Facility Fails to Maintain Clean Environment in Resident Rooms
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms, as evidenced by the presence of cobwebs and a buildup of dust. Observations conducted on various rooms revealed dust accumulation behind beds, armoires, and in corners next to cabinets. Cobwebs were also found in multiple locations, including behind chairs and in corners next to beds and armoires. These conditions were observed during a walkthrough with the Environmental Services (EVS) Director, indicating a lapse in the facility's cleaning processes. Interviews with the Lead Housekeeper revealed expectations for housekeepers to use tools such as dust mops to clean behind and under beds and to remove cobwebs. The housekeepers were instructed to move beds when possible and to take their time to ensure thorough cleaning. Despite these expectations, the presence of cobwebs and dust in numerous rooms suggests that the cleaning procedures outlined in the facility's policy were not adequately followed, potentially affecting at least 23 residents out of a census of 87.
Penalty
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Staff failed to maintain a clean, comfortable, and homelike environment and appropriate grooming on two nursing units, as evidenced by pervasive urine and feces odors in common areas and resident rooms, stained bed linens, dirty privacy curtains, damaged baseboards and furnishings, and clutter and trash on floors, including discarded wound dressings and gloves. Several residents were observed with wet pants, stained clothing, oily hair, and facial hair growth, and food particles were noted on clothing and wheelchairs. A bariatric resident reported that bariatric sheets and towels were not always available when linens needed changing, while housekeeping aides described cleaning 18–20 rooms per day, focusing mainly on floors and bathrooms and wiping tables only on request. A CNA reported that towels and bariatric sheets were sometimes insufficient at the start of shifts, requiring staff to obtain supplies from other units.
Staff failed to maintain a comfortable and homelike environment for two residents when one cognitively intact resident repeatedly reported her room was cold despite prior complaints to maintenance and ongoing issues with the PTAC heat setting, and another resident with severe cognitive impairment was found in a room with scattered personal belongings and torn wallpaper behind the bed, despite her stated preference for stored belongings and wall repair. Staff interviews revealed that a CNA responded to cold complaints only by providing extra blankets, the maintenance engineer acknowledged incorrectly switching the PTAC from cold to heat, and the assistant engineer reported multiple rooms with unrepaired accent walls damaged during bed moves, while the DON stated nursing was responsible for proper storage of residents’ belongings.
Staff failed to maintain clean, properly supplied rooms, protect personal property, and process laundry in a timely manner. A resident with complex medical needs did not consistently receive correctly sized fitted sheets for a bariatric mattress, despite an adequate central supply and 24‑hour access to laundry, and staff sometimes used whatever sheets were available instead of obtaining the proper ones. Another resident with severe cognitive impairment remained in a room with damaged walls, visible drips and spatters, trash on the floor, and a persistently dirty floor, while housekeeping and maintenance were unaware or unable to keep up with daily cleaning expectations. Two residents experienced missing personal items, including a shaving mirror and multiple laminated family photos, with incomplete or absent property inventories and grievances that were entered but never investigated or resolved. Multiple residents reported that personal clothing took more than two weeks to be returned from laundry and was often mixed up, and surveyors observed a significant backlog of soiled and clean laundry in the department, with the EVS director acknowledging delays and infrequent handling of lost‑and‑found items.
A resident with quadriplegia, multiple chronic conditions, and intact cognition was dependent on staff for ADLs and management of personal items. Facility policy required that personal belongings and clothing be inventoried at admission and as items were replenished, but no inventory for this resident could be found in the EMR or on paper. The resident later reported several missing clothing items, and the discharge instructions documented these losses without any recorded follow-up or evidence that an inventory had ever been completed. Staff interviews described general procedures for handling missing items and prior issues with laundry handling, but confirmed there was no documented personal property list for this resident, resulting in untracked and unreconciled missing clothing.
Facility staff did not ensure a safe, clean, and homelike environment for two residents, as evidenced by dirty and damaged shower rooms, resident rooms with broken furniture, dirty sinks and toilets, sticky floors, and a lack of personal items. Multiple residents reported avoiding showers due to unclean conditions, and maintenance staffing was found to be insufficient to address ongoing repairs and cleaning needs.
A resident's room was observed over several days to have a roughly plastered wall section and white plaster dust on the headboard and floor. Both maintenance and housekeeping staff confirmed the room was not in good repair or clean, contrary to facility policy requiring regular inspection and maintenance of resident rooms.
Failure to Maintain Clean, Homelike Environment and Adequate Grooming
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and appropriate grooming for residents on Units W1 and W2. Upon entering the facility lobby, surveyors noted a strong pervasive odor resembling old dried urine. On Unit W1, observations during the initial tour included privacy curtains with dark smeared substances, baseboards buckling away from the wall, and bed linens with yellow-brown halos of stains. Foul odors of feces and urine were noted at various times of the day. Residents were observed with food particles on their clothes and in their wheelchairs, as well as wearing wet pants, stained clothing, and having oily hair. On Unit W2, multiple rooms were observed to be unclean and in disrepair. In one room, the baseboard near the HVAC unit was not attached to the wall and appeared to be crumbling, window blinds were bent, and paint on the wardrobe was scuffed; both residents in that room had hair under the chin and there was a very foul odor. Another room had a bedside table with a missing drawer, yellow-orange (rust-colored) stains and various trash on the floor under the sink, including a wound dressing, glove, and straw. A different room had bedside and overbed tables with liquid spills and dried substances and a very foul odor. One resident in a bariatric bed reported that bariatric sheets were not always available when linens needed changing and that towels sometimes ran out at the start of shifts, though she confirmed her linens had been changed that day and had extra towels and washcloths at bedside. Housekeeping aides reported they typically clean 18–20 rooms per day, focusing on floors and bathrooms and only wiping tables if residents request it. A CNA stated that sometimes there were not enough towels at the beginning of a shift and that staff would go to another unit to obtain more, and that bariatric sheets were available most of the time but occasionally not.
Failure to Maintain Comfortable Room Temperatures and Homelike Room Conditions
Penalty
Summary
Facility staff failed to ensure a safe, comfortable, and homelike environment for two residents by not adequately addressing room temperature concerns and room condition issues. One cognitively intact resident with chronic kidney disease and neuralgia reported ongoing problems with her room being cold, stating during a resident meeting that maintenance had been informed but the issue was not fixed. Resident council notes documented a prior grievance from this resident about temperature, but it referenced common areas rather than her specific room. On multiple occasions, the resident reported her room felt cold, including one instance where she stated she thought she was going to freeze because she had not had heat in her room since the previous day, despite the maintenance engineer later measuring the room temperature in the low 70s Fahrenheit and acknowledging that the PTAC unit had been incorrectly switched from cold to heat. Another resident with atrial fibrillation and chronic venous insufficiency, who had severely impaired cognitive abilities per a recent MDS assessment, was observed in bed stating she did not feel well, though she could not specify what was wrong. Her room was observed to be cluttered, with personal belongings scattered on the bedside table, chair, and overbed table, and the wall behind her bed had torn wallpaper. When asked, the resident expressed a preference for having her belongings stored and for the wall beside her bed to be repaired. The DON later stated that nursing was responsible for ensuring residents' personal belongings were stored appropriately. Interviews with staff further described the circumstances contributing to these deficiencies. A CNA reported that the resident with temperature concerns had complained of being cold at night and was given two blankets. The maintenance engineer explained that the PTAC unit required switching between heat and cold modes and admitted he had switched it incorrectly, contributing to the resident’s perception of inadequate heat. The assistant engineer reported that many rooms had accent walls needing repair and attributed wall damage to direct care staff tearing walls when moving beds, noting that repairs had not been completed because residents would need to be moved out of rooms for the work. These actions and inactions resulted in residents not consistently experiencing a comfortable temperature or a homelike, well-maintained room environment.
Failure to Maintain Clean, Homelike Environment and Safeguard Residents’ Personal Property and Laundry
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and to protect residents’ personal property. One cognitively intact resident with multiple chronic conditions, including polyarthritis, chronic respiratory failure, diabetes, Crohn’s disease, and bipolar disorder, did not consistently receive properly sized fitted sheets for a bariatric mattress. Surveyors observed an ill‑fitting sheet that did not cover the entire mattress, and the resident reported that the correctly sized orange‑trimmed bariatric sheets were often unavailable on the unit. Staff interviews confirmed that the resident had voiced concerns about sheet availability, that the unit linen room sometimes lacked the needed sheets, and that CNAs sometimes used whatever sheet was available at shower time instead of obtaining the correct size from the laundry, despite 24‑hour access to clean linen and an adequate central inventory of the correct sheets. Another resident with COPD, mood disorder, chronic pain syndrome, major depressive disorder, and severely impaired cognition was found in a room where housekeeping was not maintained. Over multiple days, surveyors observed scraped and damaged drywall, missing sections of wall, brown/tan drips and spatters on the wall, paper trash and candy wrappers on the floor beside and under the bed, and a dirty floor with black/gray film, drips, footprints, and black/brown specks near the toilet. A family member reported having to pick up trash from the floor and stated that housekeeping "could be better." The maintenance director was unaware of the wall damage and reported no work order had been entered, while the housekeeping supervisor and housekeeper acknowledged that rooms and bathrooms were supposed to be cleaned daily but that room changes and deep cleans sometimes prevented the housekeeper from getting to all rooms each day, resulting in some rooms only being cleaned every other day. The facility also failed to protect residents’ personal property and to process laundry in a timely manner. One resident with moderately impaired cognition reported that pictures and other personal items were lost during room changes, particularly laminated pictures of family and pets, and that grievances had been filed without any response or apparent search for the items. Records showed two room changes and two grievances documenting missing glasses, fingernail clippers, hats, a fan, and multiple laminated pictures, with no investigation, findings, or actions recorded. Interviews with the administrator, housekeeping supervisor, social services director, and unit manager revealed that no personal belongings inventory had been completed on admission, no department had been assigned to investigate the grievances, and personal items left in a room for pest treatment were not accounted for. Another cognitively intact resident reported a shaving mirror missing for about six months; the property list did not specifically list the mirror, lacked the resident or responsible party signature, and had no dates or signatures for items added or removed, contrary to facility policy. In addition, multiple residents reported problems with timely return of personal clothing from laundry, stating that laundry sometimes took more than two weeks to be returned, was not returned in the order sent, and that they received items that were not theirs while not receiving items sent earlier. A tour of the laundry department revealed large amounts of mixed soiled facility and resident laundry in bags at the bottom of the chute, multiple bins of soiled laundry awaiting washing, tables piled high with clean facility linen to be folded, and a long rack of clean resident clothing awaiting return to units. The EVS director acknowledged that laundry sometimes became backed up, that delays occurred, and that unlabeled items were placed in lost and found, which was only brought to units about once every two months, despite a stated goal of returning resident laundry within three days.
Failure to Inventory and Track Resident Personal Property Resulting in Missing Clothing
Penalty
Summary
Facility staff failed to honor a resident's right to a safe, clean, comfortable, and homelike environment by not tracking the resident's personal property as required by facility policy. The facility's "Personal Property" policy dated 10/01/2021 stated that residents' personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. For Resident #4, the Director of Nursing and Administrator were unable to locate any record of a personal property inventory in either the electronic medical record (Point Click Care) or in paper form, and no admission inventory or subsequent updates could be found. Resident #4 was admitted with multiple diagnoses including muscle weakness, quadriplegia, urinary incontinence, Type 2 diabetes mellitus without complication, pressure ulcer of the sacral region, deep tissue damage, irritant contact dermatitis, bacteriuria, GERD without esophagitis, constipation, insomnia, lactose intolerance, moderate protein-calorie malnutrition, unsteady gait, abnormal posture, and limitation of activities due to disability. The MDS showed a BIMS score of 15, indicating the resident was cognitively intact, but functionally dependent for ADLs and required staff assistance. During the resident’s stay, there was no documented inventory of personal belongings despite the resident’s dependence on staff for daily care and management of personal items. On review of the resident’s discharge instructions, there was a documented note that the resident reported missing clothing items, including a grey hoodie, a pair of Levi’s, two pairs of grey sweatpants, and a grey shirt. There was no further documentation of follow-up regarding these missing items and no record of a personal inventory at admission or any time during the stay. Interviews with staff, including the Social Services Director, Environmental Director, housekeeping, and a CNA, described general processes for searching for and addressing missing items and acknowledged past issues with clothing being placed in incorrect laundry bags, but did not identify any existing inventory record for this resident. The DON confirmed that no personal property records for this resident could be located, and the Administrator acknowledged the absence of a system that ensured the resident’s personal belongings were inventoried and tracked as required by policy.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment for residents on two of three nursing units. Multiple residents reported that their rooms were dirty and in disrepair, and that shower areas were so unclean that they avoided using them. Direct observations by surveyors confirmed that the shower room was dirty, mildewed, foul-smelling, and littered with trash and debris. The tile was chipped, grout was black in places, and a white crusted substance was present on the floor and walls. Resident rooms were found with broken window blinds, damaged furniture, dirty sinks and toilets, clogged drains, sticky and dirty floors, peeling baseboards, and stained bed divider curtains. Some rooms lacked basic personal items such as televisions, clocks, telephones, or radios, and had holes in the walls with unfinished repairs. Two residents were specifically identified as being affected by these conditions. One resident, with a history of femur fracture, asthma, pneumonia, anxiety, depression, and Hepatitis C, required assistance with activities of daily living and was alert with mild cognitive impairment. Another resident, with a history of stroke, anemia, gout, heart attack, diabetes, asthma, and atrial fibrillation, required extensive assistance and was alert and oriented. Both residents' living environments were found to be unsafe, unclean, and not homelike. Interviews with the new Director of Maintenance revealed that maintenance staffing had been insufficient, with only three employees responsible for repairs and upkeep across two large buildings, contributing to the ongoing issues.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
Facility staff failed to maintain a homelike and clean environment in one of the resident rooms, specifically room [ROOM NUMBER]-B. Multiple observations over several days revealed a section of wall behind the head of the bed that was roughly plastered, measuring approximately 15 inches wide and 36 inches long. White plaster dust was noted coating the top of the headboard and the floor under the head of the bed during each observation. The call bell was within reach, but the room's condition remained unchanged across the observed dates. During interviews, the maintenance director acknowledged that the wall required further work, including sanding, re-mudding, and painting, and confirmed that the room was not in good repair or homelike. The housekeeping director also stated that the room should not have been left in its observed condition, describing it as neither clean nor homelike. The facility's policy requires regular inspection and maintenance of patient rooms to ensure safety and proper upkeep, including the replacement of damaged wall or floor tiles. Despite these policies, the room remained in disrepair and unclean throughout the survey period.
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