Failure to Maintain Adequate Housekeeping, Laundry, and Maintenance Resulting in Unsanitary Environment and Equipment Issues
Summary
The deficiency involves the facility’s failure to employ and schedule sufficient maintenance, custodial, laundry, and housekeeping staff to maintain a safe, clean, comfortable, and homelike environment for all 58 residents. The facility assessment referenced support staff such as plant operations, custodians, housekeeping, and maintenance, but did not include an addendum specifying the staffing plan or number of staff needed for maintenance, housekeeping, and laundry services. Housekeeping/laundry schedules showed that only one laundry aide worked eight hours on 12 of 15 days reviewed, and only one housekeeper worked eight hours on 7 of 15 days, leaving large portions of time and shifts without coverage. Staff interviews consistently reported that there were not enough housekeepers or laundry staff, especially on second and third shifts, and that CNAs did not have time to perform laundry duties. As a result of this inadequate staffing and scheduling, the facility was not kept clean and free of odors, and there were persistent shortages of clean linens and mechanical lift slings. Multiple clean linen storage rooms were observed to be dirty, with floors covered in brown staining, trash, and debris, sinks with rust or white buildup, missing floor tiles, and overflowing trash cans. Linens stored in these rooms, including towels and sheets, were stained a light brown color and smelled of feces, and there were no clean washcloths or bed pads available in some areas. Staff and residents reported that linens frequently arrived stained, dirty, or smelling of feces, and that clean washcloths, bed pads, towels, and slings were routinely unavailable in the mornings. CNAs and nurses stated they often had to use towels instead of washcloths to clean residents, dig through dirty laundry to find the “least dirty” sling, or encountered “clean” washcloths with feces still on them. The lack of adequate housekeeping and maintenance also led to resident rooms and bathrooms not being cleaned daily and to physical plant disrepair. Observations showed resident rooms with scattered debris, overflowing trash cans, stained cubicle curtains, missing chunks of drywall, exposed unpainted drywall patches, cracked and bulging drywall above heating/cooling units, and a flickering over‑bed light that had been ongoing for weeks. Residents reported that their rooms and floors were always dirty, that their trash was always full, and that housekeepers were not able to clean their rooms every day. Several residents described toilets that overflowed into their rooms for weeks before being fixed, resulting in water and feces (“turds”) on their floors. One resident stated their sheets always smelled like feces, that they had purchased their own washcloths because they refused to use the facility’s, and that they had not had a housekeeper clean their room since early in the month. In addition, the facility failed to ensure that mechanical lifts and related equipment were adequately maintained and available. The manufacturer’s manual specified that the emergency red button is used when the control unit is not functioning and that a person can be lowered by pulling the red quick release lever in a power failure. During demonstration, the mechanical lift’s emergency button was found to be missing, and the lift’s legs were covered in debris and brown stains. The maintenance supervisor acknowledged not realizing the emergency button was missing and was unsure who was responsible for cleaning the lift, while a CNA reported that residents had been stuck in the air when batteries died and that there were not enough batteries to keep the lift functioning. Staff also reported that one of two full mechanical lifts had been broken for about a month, leaving only one working lift for multiple residents who required mechanical lift transfers, and that showers and transfers were missed when slings and clean linens were unavailable. Environmental observations further showed that the facility did not provide a homelike environment. On the memory care unit, two dining room windows lacked blinds or curtains and instead had see‑through bed sheets tacked up unevenly, covering only part of the windows. A concern form from a visitor described sheets hanging on dining room windows as “very tacky” and noted the absence of pictures on the walls. Another resident reported never having curtains and therefore hanging a bedspread over the window to block the sun. These conditions, combined with the dirty linen rooms, stained and foul‑smelling linens, unclean resident rooms, and unrepaired fixtures, demonstrate that the facility did not honor residents’ rights to a safe, clean, comfortable, and homelike environment and did not provide treatment and supports for daily living in a safe and sanitary manner.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderate cognitive impairment and extensive ADL needs was found with urine-soiled bedding, an unmade bed, and a mattress that was torn and heavily stained, with staff stating the damage had been present for a while. On the secured unit, all observed residents were served meals on plastic trays holding their plates, utensils, and drinks instead of having items placed directly on the table, and staff and the DON confirmed this was the routine practice.
A facility failed to maintain a safe, homelike environment when a resident room had broken and missing floor tile exposing the wood underneath, and two bathrooms had sinks coming away from the wall and loose enough to move when pressure was applied. One resident said the floor had been bad for some time and had been reported without being addressed, and an LPN later confirmed the damaged flooring and loose sinks.
Furniture Not Kept in Good Repair: Armchairs in multiple resident rooms and chairs in the front sitting area were observed with torn or cracked upholstery exposing cloth material. The Maintenance Director stated the furniture was not in good repair and had not been notified of the damage, while the Administrator stated staff were to remove furniture with tears.
A facility failed to maintain a clean, homelike environment when a refrigerator used for resident supplement drinks had significant ice buildup with an unknown item in it, and staff were unsure who was responsible for cleaning or reporting it. In addition, meals were repeatedly served on trays and left in front of residents during dining, which an RN and the VPS confirmed had been occurring for some time and was not homelike.
Failure to Maintain Comfortable Room Temperatures: Several residents were found in hot, stuffy rooms with weak or nonworking AC units, and room temps were measured above 81 F, including one room at 89.5 F. Residents reported feeling hot and uncomfortable, and some were not offered a room change while the issue persisted. The facility did not follow its Hot Weather policy for relocating residents to cooler areas and monitoring room temps.
Excessive ambient temperatures were observed at the 100/200 and 300/400 nurses' stations when the wall thermostat and facility temperature monitoring device both showed readings in the low 80s. The surveyor verified the readings with the Facility Maintenance Director while residents were seated in nearby common areas.
Soiled Mattress and Tray-Based Meal Service
Penalty
Summary
The facility failed to replace a torn, stained mattress and did not ensure urine-soiled bedding was changed timely for a resident who had moderate cognitive impairment and required extensive assistance with dressing, grooming, toileting hygiene, transfers, and wheelchair mobility. The resident’s diagnoses included COPD, anxiety, and schizophrenia. The resident was observed stating that his bedsheet was wet with urine and that he was looking for staff to change it. Later, his bed was observed unmade with a rumpled soiled top sheet on the mattress and a strong urine odor in the room. When a nursing assistant later changed the resident’s linens, the mattress was found to have a 6-cm tear, a large 12 x 12-inch deep brown dry stain in the center, and scattered discoloration across the remaining surface. Staff stated the mattress had been stained and ripped for a while, and maintenance said they had only received a work order that day to replace it. The facility also failed to remove residents’ meal plates, beverages, and utensils from institutional serving trays before meal service for all 27 residents on the secured unit. During multiple meal observations, residents were served and ate from plastic trays that held their plates of food, silverware, and drinks. Staff continued this practice at breakfast, lunch, and dinner observations, and one nursing assistant stated that although it looked more homelike when plates and utensils were placed directly on the table, that was not how it was done at the facility. An RN stated the facility served meals on trays and was not sure why, and the DON stated the facility had previously used a steam cart to dish up food correctly but had switched to serving meals on trays after the cart broke.
Unsafe Room Flooring and Loose Bathroom Sinks
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in one resident room and two resident bathrooms. Facility policy dated 3/23/26 stated the objective was to keep the resident environment as free of accidents and safety hazards as possible and that monthly safety walkthroughs would be completed for each resident unit. During observation of one room on 7/6/26 at 12:05 p.m., four joined flooring tiles were missing pieces measuring approximately 6 inches by 12 inches, exposing the wood underneath, and numerous other tiles throughout the room were cracked with pieces missing from the corners. Resident R16 stated the floor had been bad for some time and that although it had been reported, no one had addressed it. R16 also reported concern about the bathroom sink being loose and feared it could fall off the wall if someone leaned on it. Observation of that room's bathroom showed the sink was coming away from the wall, loose, and able to move up and down when pressure was applied. A second room's bathroom was also observed on 7/6/26 at 12:22 p.m. with the same condition: the sink was coming away from the wall, loose, and able to move up and down when pressure was applied. Resident R44 said he/she was unsure how long the sink had been that way. On 7/8/26 at 11:34 a.m., an LPN confirmed the broken and missing tile in the room and confirmed that the sinks in both bathrooms were coming away from the wall, loose, and movable when pressure was applied.
Furniture Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure furniture was in good repair for 1 of 1 facility reviewed for physical environment. During an observation with the Maintenance Director, armchairs in rooms 10, 16, 18, 42, and 44 were observed with torn fabric on the armrests and exposed cloth material, with the torn areas measuring at least one inch in diameter. In the general sitting area by the front entrance, two chairs had multiple cracks in the synthetic leather on the seat covering exposing cloth material, and one armchair had missing synthetic leather exposing cloth material. The Maintenance Director stated the furniture was not in good repair, Staff 18 stated staff were to notify maintenance when furniture was ripped, and the Maintenance Director stated he had not been notified of the torn furniture. The Administrator stated that if there were tears in the furniture, staff were to remove the furniture.
Unclean refrigerator and tray service during dining
Penalty
Summary
The facility failed to maintain a clean, homelike environment when a refrigerator used to store resident supplement drinks was observed with a large amount of ice buildup on the top freezer section and an unknown item embedded in the ice. During the kitchen tour, the cook verified the condition of the refrigerator and stated they were unsure who was responsible for cleaning, monitoring, or reporting it. Maintenance later explained that staff are supposed to place a ticket in TELS when something needs attention, and the administrator later verified the ice buildup in the dining room refrigerator. The facility also failed to eliminate the use of meal trays during dining service. During multiple observations, noon and supper meals were served to residents on trays and left in front of them in the dining room. An RN verified that the noon meal was served and left on trays and stated this had been occurring for at least two years. The VPS also verified that meals were served on trays and left in front of residents and confirmed that this was not homelike. The facility policy stated that the environment should be homelike and that meal trays should be eliminated during dining service unless otherwise requested by the resident.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to ensure resident rooms remained at comfortable temperatures and failed to offer room changes to residents whose rooms exceeded 81 F when air cooling units were not working properly. On 7/1/2026 at about 10:30 AM, R6 was in a hot, uncomfortable room and stated the floor air conditioning wall unit was not working because no air came from the vent. R8’s unit was on but only weak air came through, and R8 appeared uncomfortable and said he was hot. R9 and R10 were in a dark, warm, and stuffy room with the windows closed and curtains pulled shut, and R7 was in a very hot room with weak air blowing from the floor unit and said the room was hot. When the surveyor returned with the Maintenance Director at 10:42 AM, the room temperatures were measured at 84.5 F for R6, 89.5 F for R7, 85.2 F for R8, and 82.9 F for R9 and R10. At 4:00 PM, R7 and R8’s rooms were still hot, with temperatures of 85.6 F and 83.1 F, respectively, and both residents remained in their rooms. R6 stated a room change had been offered only a few minutes earlier, while R7 and R8 stated they had not been offered a room change during the hot room temperatures. The facility did not follow its Hot Weather policy, which stated residents would be relocated to the cooler part of the facility and temperatures and humidity would be measured in several rooms on each floor identified as the warmest area.
Excessive Ambient Temperatures at Nurses' Stations
Penalty
Summary
The facility failed to consistently maintain ambient temperatures within the required range in the 100/200 Nurses' Station and the 300/400 Nurses' Station. During direct observation, the wall-mounted thermostat at the 100/200 Nurses' Station displayed 83 F. The surveyor then requested that the Facility Maintenance Director obtain ambient temperature readings using the facility's temperature monitoring device, and the readings were verified by the surveyor as they were obtained. At that time, the Facility Maintenance Director measured 82.2 F at the 100/200 Nurses' Station and 83.0 F at the 300/400 Nurses' Station. The surveyor also observed residents seated in common areas close to both nurses' stations while the temperatures were above the recommended comfort range. The facility census was 118.
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