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F0584
E

Failure to Maintain Cleanliness, Odor Control, and Comfortable Environment

Springfield, Missouri Survey Completed on 08-25-2025

Penalty

No penalty information released
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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

Multiple deficiencies were identified in the facility's ability to maintain a safe, clean, comfortable, and homelike environment for its residents. Surveyors observed unclean conditions in resident rooms and bathrooms, including strong urine odors, brown and black substances on floors and walls, sticky floors, and the presence of ants. Several rooms had peeling paint, damaged drywall, and holes in doors, while some bathrooms had loose or broken fixtures. In one case, a resident's over-bed table was left soiled after a meal, and a recliner in the dementia unit's sunroom was found with dried brown substances on multiple surfaces. These issues persisted over several days and were acknowledged by housekeeping and maintenance staff, who were sometimes unaware of the duration or cause of the problems. Odors were a recurring issue in several resident rooms and hallways, with strong urine smells noted both inside and outside rooms. Staff interviews confirmed awareness of these odors, and in some cases, staff attributed them to factors such as resident incontinence, pets, or infrequent cleaning due to resident preferences. Despite daily cleaning routines, staff reported ongoing complaints about sticky floors and persistent odors. Maintenance logs revealed delays or lack of documentation regarding repairs, such as broken lights, damaged doors, and malfunctioning air conditioning units. Temperature control was also problematic, with observations of resident rooms and common areas measuring above 80 degrees Fahrenheit, despite thermostats being set lower. Residents and staff reported discomfort due to excessive heat, and temporary solutions such as mini-air conditioners and fans were provided. However, temperature logs did not always reflect the higher temperatures observed during the survey. The facility census at the time was 149, and the deficiencies affected multiple residents with varying levels of cognitive impairment, including those who were cognitively intact and those with severe cognitive deficits.

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