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F0584
E

Failure to Maintain Clean and Homelike Environment for Residents

St Joseph, Michigan Survey Completed on 04-16-2025

Penalty

Fine: $186,44029 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed multiple instances of uncleanliness and lack of maintenance in resident rooms and common areas. Dust, dirt, food, and paper debris were found along the wall and floor perimeters in several resident rooms, as well as in hallways and alcoves. Additional observations included a plastic drink lid with a red liquid and a dried red substance on the wall, as well as accumulations of personal items and debris under beds. These findings were corroborated by interviews with housekeeping staff, who described daily cleaning routines but did not provide evidence of consistent or thorough cleaning practices. Two residents were specifically noted to have unclean wheelchairs. One resident, who was cognitively intact, reported that her wheelchair was dirty and likely had not been cleaned. Observations over several days confirmed the presence of crumbs and dried food on and under the wheelchair cushion. Interviews with CNAs and LPNs revealed that while there was an expectation for night shift CNAs to clean wheelchairs, there was no specific schedule or documentation to ensure this was done. The DON acknowledged that cleaning wheelchairs was a challenge and that the process was supposed to be coordinated with resident shower days, but this was not consistently implemented. In the memory care unit, a resident reported that dining chairs needed more frequent cleaning and pointed out dust and debris on the chair frame. Observations confirmed that most dining chairs and table bases were soiled with dried liquids, crumbs, and dust. Multiple brown and yellow stains were noted on the carpets in entryways and common areas, and a heavily soiled emergency exit door was also observed. These conditions contributed to decreased satisfaction with the living environment among residents.

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