F0584

F

Widespread Environmental Uncleanliness and Linen Shortages Compromise Resident Living Conditions

Farmington, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, including failure to ensure clean linens and properly maintained resident care equipment and rooms. Surveyors observed multiple residents lying on worn, ripped, stained, and visibly unclean fitted sheets, with bed frames and mechanical areas under mattresses soiled with dried substances and debris. Tube feeding pumps, poles, and bases for several residents were observed with dried, splattered brown or tan substances, and some ceiling tiles and vents above beds were coated with similar debris. Privacy curtains in several rooms were heavily soiled, torn, or ripped, and some walls and ceilings showed water damage and peeling wallpaper. In one room, sharp metal poles remained attached to a bed where the resident reported sometimes grabbing them when being rolled, and the Physical Therapy Director later identified them as remnants of assist bars without a current order.

The facility’s shower rooms and bathrooms were repeatedly found in unclean and unsafe condition. In multiple shower rooms, floors were grimy, with pooled water, hair, caked-on substances in floor drains, and visibly dirty shower beds and chairs, including padding that was torn and exposing foam. One shower room toilet contained bowel movement that staff reported had been present for approximately a week due to a non-functioning flush, and the room also contained clutter such as Hoyer lifts, wheelchairs, ripped floor mats, and oxygen cylinders stored inappropriately. Several resident bathrooms and shared toilets were observed with bowel movement matter inside and outside the toilet bowls, heavily soiled floors and walls, thick dust on ceiling fans and vents, and no toilet paper available, with tissues placed along handrails instead. In some rooms, overbed lights and wall coverings were pulled away or broken, exposing sharp edges accessible to residents and staff.

Surveyors documented persistent environmental uncleanliness and lack of basic housekeeping over multiple days. Bedside tables in several rooms remained soiled with sticky, dried food and unknown substances despite being used to serve meals, and floors in those rooms were littered with food crumbs, paper debris, discarded gloves, and even a tracheostomy inner cannula, with no indication of sweeping or mopping between observations. Residents reported that their rooms were rarely cleaned, that dirty linens had been left on the floor for days, and that there were no housekeeping staff present on at least one weekend day. Window blinds in multiple rooms were damaged or missing, several wall clocks throughout resident rooms and the dining/activity room displayed incorrect times, and some trash cans lacked liners while still being used for waste.

The facility also failed to maintain adequate, clean linen supplies and to ensure linens were in good repair. Multiple linen rooms on different units were repeatedly observed with no or very limited supplies of towels, fitted sheets, flat sheets, gowns, draw sheets, or bariatric gowns, and the linens that were present were often thin, frayed, dingy, yellowed, or had holes. A resident with intact cognition reported ongoing issues with the facility running out of clean sheets, towels, and washcloths, stating that sheets were rarely changed and that they had been left in wet sheets for hours after a bed bath because no clean sheets were available. The same resident reported that staff were cutting towels in half to use for wiping and then discarding them, contributing to shortages. During a resident council meeting, several residents reported that linens were ripped and had holes, that they had to remain in chairs for hours due to lack of clean sheets, and that there were no trash bags for commodes or for dirty linens.

Storage and backup supply areas were also found in disrepair and unsanitary condition. The basement storage area used for backup linens and resident care equipment contained uncovered carts of linens and heel protectors, with visible debris on the linens. Inside a locked storage room, shelves held emergency water, backup linens, COVID tests, masks, and blankets, but the floor was heavily soiled with dark stains, debris, and trash. The ceiling showed visible water damage with broken, bubbling, and discolored areas, and ceiling particles had fallen onto the floor and onto stored items, including emergency water supplies. Cardboard boxes of blankets were stored directly under damaged ceiling pipes and were compromised by water damage, and an exposed wire protruded from the ceiling and was wrapped around a metal shelving unit. Staff interviews revealed that environmental concerns identified by surveyors had not been reported through the facility’s electronic work order system, and existing housekeeping checklists and linen policies did not address linen condition or replacement criteria.

Staff interviews further demonstrated confusion and gaps in responsibility for cleaning and environmental maintenance. The Environmental/Housekeeping Manager stated that housekeeping staff did not clean bedside carts or tube feeding poles and that maintenance or “anyone that saw it” would be responsible for cleaning inside vents, while the DON stated that housekeeping was ultimately responsible for cleaning resident equipment such as tube feeding poles and communication boards. The Environmental/Housekeeping Manager confirmed multiple observations of soiled rooms, equipment, and privacy curtains over two days and acknowledged that some areas, including the backup storage room, had not previously been inspected. Review of the electronic work order log over a two-month period showed no staff-reported concerns corresponding to the numerous environmental and safety issues observed by surveyors, despite the presence of broken handrails, unsecured wall coverings, malfunctioning toilets, and widespread uncleanliness throughout resident care areas.