Failure to Maintain Safe Wheelchair Conditions for Residents
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the inadequate maintenance of their wheelchairs. Resident #1, a male with a history of osteomyelitis and an above-the-knee amputation, reported that his wheelchair, which was from the 1960s, could not lock properly. Despite informing the social worker and therapy staff about the issue, no maintenance work order was recorded for his wheelchair. Interviews with the physical therapy assistant and occupational therapist confirmed that the wheelchair had a loose lock and was not safe for Resident #1, who was an amputee and required a stable wheelchair for safe transfers. Resident #2, a male with cerebral infarction, visual impairments, and a history of falls, also experienced issues with his wheelchair brakes. Although a work order was documented in the maintenance logbook, it was mistakenly marked as completed without the necessary repairs being made. During an observation, Resident #2 demonstrated that his wheelchair's left wheel did not lock, posing a risk of falling when he attempted to stand. The maintenance director acknowledged the error and expressed concern for Resident #2's safety, emphasizing that wheelchair repairs should be prioritized as emergencies. The facility's policies on maintenance and resident rights were not adhered to, as evidenced by the failure to address the residents' grievances and ensure their safety. The maintenance department's oversight in marking incomplete work orders as done and the lack of timely repairs for critical equipment like wheelchairs contributed to an unsafe environment for the residents. Interviews with staff, including the maintenance director and CNA, highlighted the communication breakdown and procedural lapses that led to the deficiencies.
Penalty
Resources
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Surveyors found that multiple residents on a memory care hall were living in rooms and bathrooms with visible feces on toilets and floors, urine puddled on toilet risers, sticky and soiled floors, and strong putrid odors, despite facility policies stating that rooms and bathrooms should be cleaned daily. A resident reported that the bathroom had not been cleaned for several days. The housekeeper assigned to the hall described using a “trash and dash” method in some rooms, only removing trash and not mopping unless floors appeared obviously sticky, and acknowledged that one aggressive resident’s room was not cleaned at all the prior day. The HS had not recently checked this housekeeper’s work on the hall, and CNAs and a UM/LPN confirmed that residents had not refused housekeeping services.
Surveyors found that the facility failed to maintain safe, functional shower floors, resulting in pooled water and damaged tile surfaces in multiple resident bathrooms. Observations showed cracked, broken, and missing tiles, missing grout, and uneven surfaces, with water not draining properly and pooling after showers. A resident and a CNA confirmed that the tiles were damaged and drainage was poor, while facility policy stated that the environment should be homelike and comfortable.
A resident with multiple chronic conditions, impaired ROM, and risk for skin breakdown was observed lying on a bare bariatric mattress without a fitted sheet. The resident reported rarely having a fitted sheet because the facility lacked appropriately sized linens for bariatric beds. The Housekeeping Director confirmed ongoing difficulty obtaining fitted sheets for these beds and reliance on flat sheets, and the ADON confirmed the resident was on a bare mattress, contrary to the facility’s resident rights policy for a safe, clean, and comfortable environment.
A resident with multiple chronic conditions and documented intact cognition had a bed curtain with visible dark red splatter stains and linear black marks that remained uncleaned despite the resident’s request for cleaning. A CNA confirmed the stains, and Risk Management acknowledged there was no specific environmental policy, indicating such concerns were covered under a general resident rights policy that referenced safe and secure housing. This resulted in a deficiency related to failing to provide a safe, clean, and homelike environment.
The facility failed to maintain a sanitary, clean, and safe environment, including multiple resident rooms and common areas on a secured women’s behavioral unit and the main entrance. Several residents with impaired cognition and complex medical/psychiatric conditions were found in rooms with heavily soiled toilets, floors blackened with dirt and debris, dried blood and stool on bathroom floors, missing tiles, exposed drywall, and pest activity such as fruit flies and mouse droppings. A shared shower room used by all women on the unit was heavily soiled, with suspected mold, a broken drain, and a ceiling fan hanging from the ceiling, while the unit’s dining/activity room had a broken interior window with a sharp edge, a large hole in the wall, and non-functioning ceiling lights. One resident’s heating unit blew cold air despite reports it had been repaired, and her bathroom remained soiled and in disrepair. Another resident’s room contained evidence of mice, which she described as pets, without documented targeted pest treatment. At the main entrance, residents repeatedly smoked in a posted non-smoking area, and the entrance and surrounding landscaping were littered with cigarette butts, with no proper receptacle provided, despite a designated smoking area being located across the parking lot.
Surveyors found a strong, pervasive urine odor on one hall, traced to a cognitively intact resident with incontinence whose soiled clothing and linens were routinely placed in a pile on the floor near the room door for staff to collect. The resident reported this occurred daily and that additional soiled items were added after housekeeping cleaned. CNAs and an LPN confirmed the malodor, the presence of saturated laundry on the floor, and a bagged soiled comforter the resident refused to have laundered, noting the odor was an ongoing problem and that some residents kept their doors closed because of it. Fourteen other residents lived on the same hall, despite a facility policy requiring a safe, clean, comfortable, and homelike environment with neutral scents.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, sanitary, and homelike environment on the 300-hall memory care unit, affecting 12 residents out of 30 on that hall. During an observation period, surveyors and the Housekeeping Supervisor identified multiple resident rooms and bathrooms with visible feces on toilets, floors, and in open soiled briefs, as well as urine puddled on toilet risers, sticky floors, large amounts of food and fecal matter on floors, and strong putrid odors. Several toilets had visible buildup and rings, suggesting they had not been cleaned in some time, and fecal splatter remained in at least one toilet even after flushing. A resident reported that the bathroom was not cleaned often and that it had been a few days since the last cleaning. Interviews with housekeeping and nursing staff further described the practices that led to the unclean conditions. The housekeeper assigned to the memory care hall stated that he had cleaned all bathrooms the previous day but used a “trash and dash” approach for rooms that did not look bad to him, meaning he only removed trash and did not mop floors unless they were obviously sticky. He also reported that one aggressive resident’s room was not cleaned at all the previous day. The Housekeeping Supervisor acknowledged that all resident rooms and common areas were supposed to be cleaned seven days a week, but she had not checked this housekeeper’s work on the 300-hall and had last reviewed his work two weeks earlier on a different unit. CNAs and the Unit Manager/LPN reported that residents on the unit had not refused housekeeping services. Facility documents and the resident handbook stated that resident rooms and bathrooms were to be cleaned daily, with floors swept and mopped daily and more thorough weekly cleaning, which contrasted with the observed conditions and reported cleaning practices.
Failure to Maintain Safe and Properly Draining Shower Floors
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain resident shower floors in good repair, resulting in unsafe and non-homelike bathroom conditions for multiple residents. Observation of the shared bathroom for Residents #10 and #11 showed a large amount of water pooled on top of the shower tiles, with several tiles cracked, grout missing between multiple tiles, and an uneven tile surface. A separate observation of the bathroom used by Residents #35 and #38 revealed multiple broken and/or missing shower floor tiles and an uneven tile surface. Resident #35 confirmed that multiple tiles on the shower floor were missing or broken and that the water did not drain well. A CNA also confirmed that the shower floors in the bathrooms used by Residents #10, #11, #35, and #38 had missing, cracked, and broken tiles and that water did not drain correctly, causing pooling after residents’ showers. Review of the facility’s undated “Homelike Environment” policy showed the facility encouraged personalization and comfort of a home-like environment, but the observed shower conditions did not align with this policy. This deficiency represents noncompliance investigated under Complaint Number 2647177.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #10, #11, #35, & #38 on 04/06/2026. It was determined that there were no negative effects related to the shower tiles not being in good repair identified during Annual Survey. LNHA notified Resident #10, #11, #35, & #38's primary care provider on 03/26/2026, of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged that the resident's shower floor was not in good repair (broken uneven tile) and that there were no negative effects related to the shower floors' lack of good repair. No new orders received from primary care provider. Maintenance Director replaced shower floor tiles in room #106 on 04/17/2026. Maintenance Director will replace shower floor tiles in room #203 (resident # 11 & #12) & 206 (resident #35 & 38) on or before 04/24/2026. On or before 04/30/2026, LNHA/Designee will observe shower rooms' flooring in the rooms of like residents (all shower floors in facility) to ensure that tile is in good repair. Any tile identified flooring that is not in good repair will be repaired/replaced also on or before 04/30/2026. On or before 04/30/2026, LNHA/Designee will educate Maintenance Director as follows: §483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. On or before 04/30/2026, LNHA/Designee will review room monitoring procedures and expectations with the interdisciplinary team (IDT). This review will observe what tasks/reviews/observations are being completed during weekly room rounds. LNHA/Designee will ensure that shower room flooring observation is specifically listed on the weekly room rounds. Additionally, when a floor is found to not be in good repair, a Maintenance Request will be submitted for Maintenance to observe/address the issue noted. Such requests will be monitored electronically by the LNHA/Designee ongoing. LNHA/Designee will complete audits. The audit will observe 5 shower floors every week x4 weeks; then as determined by QAA, to determine if the floors are in good repair. Any floors observed to not be in good repair will be repaired/replaced.
Failure to Provide Fitted Sheet for Bariatric Bed
Penalty
Summary
Surveyors identified a deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment when a resident was found lying on a bare mattress without a fitted sheet. Record review showed the resident was admitted with multiple complex medical diagnoses, including fluid overload, chronic kidney disease, morbid obesity, bipolar disorder, diabetes with chronic kidney disease, atrial fibrillation, epilepsy, and other chronic conditions, and required assistance with personal care. A quarterly MDS assessment documented that the resident was alert, oriented, cognitively intact, had impaired range of motion in both upper and lower extremities, and was at risk for skin breakdown. During observation, surveyors noted that there was no fitted sheet on the resident’s bariatric bed. In an interview, the resident reported that he rarely had a fitted sheet on his bed because the facility did not have fitted sheets that fit his bariatric bed. The Housekeeping Director confirmed that there was no fitted sheet on the bed and acknowledged ongoing issues obtaining fitted sheets for bariatric beds, stating that flat sheets were usually used instead. The ADON confirmed that the resident did not have a fitted sheet on his bed and was lying directly on the bare mattress. Review of the facility’s Resident Rights policy indicated the facility was to provide resident-centered care that meets residents’ psychosocial, physical, and emotional needs and concerns.
Failure to Maintain Clean and Sanitary Bed Curtain for a Resident
Penalty
Summary
The facility failed to maintain a clean and sanitary bed curtain for one resident, compromising the resident’s right to a safe, clean, comfortable, and homelike environment. The resident had multiple medical diagnoses, including type 2 diabetes mellitus with hyperglycemia, long-term insulin use, COPD, moderate protein-calorie malnutrition, epilepsy, a right artificial shoulder joint, an above-knee right leg amputation, polyneuropathy, anemia, and generalized anxiety disorder, and was documented as cognitively intact on the MDS. During observation, surveyors noted three dark red splatter stains on the resident’s bed curtain, with the largest measuring approximately 1 cm and two others approximately 0.5 cm, along with additional linear black stains on the curtain. The resident reported having requested that the bed curtain be cleaned, but stated the facility never cleaned it. A CNA confirmed the presence of stains on the bed curtain during interview. When interviewed, the facility’s Risk Management staff member stated that the facility did not have an environment policy and indicated that environmental concerns would fall under the facility’s undated “Resident Rights” policy, which stated that residents will be treated with dignity and respect and that dignity includes providing safe and secure housing. This lack of a specific environmental policy and the failure to clean the stained bed curtain led to the cited deficiency under the resident’s right to a safe, clean, and homelike environment.
Failure to Maintain Sanitary, Safe Environment and Proper Smoking Controls
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, clean, and safe environment for residents on the secured women’s behavioral unit and for residents using the main entrance. Multiple resident rooms and common areas were observed to be heavily soiled and in disrepair. One resident with schizophrenia, COPD, hypertension, hypothyroidism, schizoaffective disorder, and osteoarthritis, who had impaired cognition and required staff assistance with ADLs and medications, was found to have a bathroom with brown splatter on the walls behind and opposite the toilet, a heavily soiled toilet, and a floor blackened with dirt and debris. Her bedroom walls were soiled, scuffed, and had exposed drywall, with unknown splatter and dried substances around the receptacle and under the light. A CNA confirmed these conditions. Another resident with essential hypertension, antisocial personality disorder, inhalant abuse, DM, schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder, who had severely impaired cognition and required supervision or set-up for ADLs and was dependent on staff for medications, was observed without sheets on her bed. Her bed contained a wadded-up blanket heavily soiled with yellow and brown substances and swarmed with fruit flies. The floor in front of the bed was blackened with dirt and debris, and a soiled incontinent brief with apparent blood and stool was on the bedroom floor, surrounded by reddish-brown droplets and brown dried splatter on the wall near the toilet. The bathroom floor was missing tiles. The CNA stated the blanket was soiled with urine and verified the room conditions. A housekeeper confirmed the presence of stool and blood on the bathroom floor and stated she does not clean up blood. Later observation showed the bathroom sink filled with brown water and cigarette butts, with no running hot or cold water, and dried blood on the floor. The maintenance supervisor acknowledged awareness of the non-functioning sink and standing brown water and stated no pest treatment had been provided to the room. On the women’s secured unit, the shared shower room used by all twelve residents had a floor blackened with dirt and heavily soiled, with unknown brown spots and splatter in the shower corners and up the walls. The toilet in the shower room was heavily soiled, the shower drain was partially broken, and the ceiling fan was hanging down with the ceiling spotted by an unknown black substance that a CNA stated appeared to be mold. The large dining/activity room on the unit had a half-broken window opening into the nurse’s station, leaving a sharp edge, and a large hole in the wall with exposed drywall beneath it. Five large ceiling lights in this room had no light bulbs. The maintenance supervisor verified the non-functioning lights and the hole in the wall and stated he was not aware of the broken window. Another resident with DM, hypertension, asthma, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and GERD, who had impaired cognition and required supervision, moderate, or set-up assistance for ADLs and was dependent on staff for medications, reported that her room was very cold. She indicated her heating unit, covered with a blanket and with another blanket at the base of the window, was blowing cold air despite being told it had been fixed. Observation confirmed the unit was running but blowing cold air, and her bathroom was soiled, missing floor tiles, and had a heavily soiled toilet with a black ring. A CNA confirmed the room had been cold for some time and verified the bathroom conditions. The maintenance supervisor later confirmed the heater was blowing cold air and noted holes in the wall beside the bed and shredded privacy curtain pieces hanging from the ceiling. A further resident with impaired cognition and diagnoses including hypertension, DM, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and cystitis was observed to have a dish of water under her sink and a large pile of what appeared to be mouse droppings under the sink. The sink did not drain correctly when water was running. The resident stated the dish of water was for mice living in a large hole in the corner under the sink and referred to the mouse as her pet. The maintenance supervisor stated he was aware of the mouse droppings and the mouse issue in the room and that the facility had been treated for mice. However, review of pest control work orders showed no specific treatments for fruit flies in the room with the soiled blanket and flies, or for mice in this resident’s room. At the main entrance, residents and staff used a double set of doors with a small concrete pad and awning. One resident was observed smoking directly outside the front doors in a posted non-smoking area. Numerous discarded cigarette butts were scattered across the ground near the front door, in the landscaping rocks on both sides of the doors, and around a trash can with a plastic liner, with no container provided for cigarette disposal. A CNA confirmed the resident was smoking in the non-smoking area and identified a designated smoking area across the parking lot, also verifying the scattered cigarette butts. The resident stated he often smoked by the main entrance doors. On a subsequent observation, two other residents were seen smoking directly outside the main entrance in the same non-smoking area, with the area still littered with cigarette butts on the ground and in the landscaping. An LPN confirmed the residents were smoking in the non-smoking area and verified the large amount of discarded cigarette butts. Facility policy stated that the maintenance department was responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, including heating/cooling systems, plumbing fixtures, and ensuring lights were in good working condition, with the maintenance director responsible for inspection of the building.
Failure to Maintain Clean, Odor-Free Environment on Resident Hall
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, sanitary, and homelike environment on one hall, particularly in the room of Resident #3. Resident #3, who was cognitively intact and admitted with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, and stage 3 chronic kidney disease, required set-up/clean-up assistance with toileting, showering, and personal hygiene and had mixed bladder incontinence. Her care plan directed staff to check frequently for incontinence, cleanse the perineum, apply barrier cream, change clothing as needed, and encourage the use of a chux pad and open brief in the chair during the day, with the resident notifying staff when she needed changing. Surveyors observed a strong, pervasive urine odor on the 600 hall during the initial tour and again on a later date, and staff confirmed the odor was coming from Resident #3’s room. Upon entering Resident #3’s room, surveyors observed a pile of laundry near the door. The resident reported that she places soiled laundry on the floor near the door every day for an aide to collect, and that the pile present had been there since earlier that morning; she also stated that when housekeeping came to clean, additional soiled laundry was added to the pile. CNAs confirmed the hall was malodorous, verified the presence of soiled clothing, and reported there was a bagged soiled down comforter in the room that the resident would not allow the facility to launder and was awaiting family pick-up. One CNA stated the odor on the hall was always a problem and that some residents had requested their doors be shut due to the odor; she also stated she had not known the soiled linen was on the floor until the survey and later verified that the collected laundry was saturated. Another resident on the hall confirmed preferring her door shut at times because of the odor. Fourteen other residents lived on the same hall, and the facility’s Homelike Environment policy required a safe, clean, comfortable environment with pleasant, neutral scents.
Plan Of Correction
F584 Safe/Clean/Comfortable/Homelike The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 3 met with the care conference team on 3-25-26 to discuss plans to manage the resident's mattress pad when soiled and a plan to manage behaviors related to toileting assistance. Nursing staff are rounding, monitoring linen placed on the floor by the resident, and removing linen when providing care. These rounds began 3-20-26. Resident # 3 has improved, clean, comfortable /homelike as of 3-26-26. The mattress pad is being laundered by the facility as of 4-9-26. Resident #3 was assessed for any negative effects from this deficient practice and she made it very clear that she is fine and does not believe she has any odor. Resident has no infection control concerns as a result of soiled linen and odor in her room. The assessment was completed by Infection preventionist nurse by 4-9-26. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents affected by the odor on the 600 hall are a total of 17. The residents involved are (#2, #4, #9, #12, #13, #17, #21, #25, #33, #34, #35, #40, #42, #49 and all per interview state, they do not notice any pervasive odors. All 600 hall residents have been interviewed by the social services/designee and none are complaining of a pervasive odor as of 3-19-2026. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Education for nursing and housekeeping to provide a clean and sanitary environment, and odor control. was completed on 4-9-2026 by DON and the housekeeping director. The mattress cover will now be laundered in the facility laundry and rounds in place by nursing and housekeeping to prevent soiled linen on the floor and to frequently mop the floor. How the corrective action will be monitored to ensure the deficient practice will not recur. Daily round audits began 3-30-26 by housekeeping 5x a week x4 weeks by housekeeping director or designee, resident #3s room, and a random 5 rooms on the 600 hall for linens on the floor or soiled floors. Nursing rounds are routinely conducted throughout the 600 hall, monitoring for soiled linen, clothes on the floor and pervasive smells. CNA rounds are routine and ongoing audits beginning 4-9-26. The social worker began 4-8-26 to interview 5 residents a day, 5 xs a week for 4 weeks, for complaints of odor. If concerns arise, the social worker will notify housekeeping and nursing managers to review what has caused the odors. If nursing or housekeeping audits reveal concerns, the room will be cleaned, and laundry pursued with staff reeducated. Results submitted to the weekly QAPI with further follow through. Random social service audits are completed daily, interviewing residents on the 600 hall 5x a week X 4 weeks
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