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F0584
D

Failure to Maintain Safe, Clean, and Homelike Resident Environment

Burlington, Wisconsin Survey Completed on 08-13-2025

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

Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for three residents. In one case, a resident's room had a wall and heat register coated with dirt and a thick layer of dust, and the curtains hanging over the heat register were also dirty and had black spots. Another resident's room had windows with a thick white film on the inside, making them appear cloudy, and the outside of the windows was dirty. There was also a cobweb with two dead flies near the window, and the window blinds were broken and not functional. In a third instance, a resident's air conditioning and heating unit was observed to be disconnected and coming off the wall on one side, with an exposed metal pipe covered in dirt and cobwebs. The shared bathroom flooring in this room was peeling off the wall, exposing dirt and the drywall behind it. The resident reported that the air/heating unit was ancient, loud, and posed a risk of injury due to its position. The maintenance director confirmed that there was no scheduled work for this room and had not inspected it since the resident moved in. Housekeeping staff described daily and monthly deep cleaning routines, including cleaning windows and sills, but acknowledged that the inside sills and windows in one resident's room had been missed during the last deep clean. The broken blind in the same room prevented proper cleaning, and there was confusion among staff regarding responsibility for cleaning the outside windows. Facility staff acknowledged the concerns when they were brought to their attention by surveyors.

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