Widespread Environmental Uncleanliness and Linen Shortages Compromise Resident Living Conditions
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unclean and Poorly Maintained Resident Rooms: Two residents were affected by environmental issues in their rooms. One resident’s windowpane had a crack extending the length of the window for months, and staff gave conflicting statements about awareness of the damage. Another resident reported housekeeping was not sweeping or mopping, and trash and a liquid spill remained on the floor between the beds across multiple observations. Resident council notes also documented repeated housekeeping concerns about room cleanliness.
Bathroom Sink Faucet Sprayed Water Onto Floor: A resident with RA, PTSD, and recurrent MDD had a bathroom sink faucet that sprayed water outward and onto the floor instead of downward. The resident said the problem had been present for months and had been reported to CNAs, and a CNA confirmed it had been reported to the charge nurse. Observation and interview with the MD confirmed the faucet issue and that a work order had been received but not repaired because other repairs were prioritized.
A resident with moderate cognitive impairment and dependence for ADLs was observed using a broda chair with multiple cracked cushions, exposed foam, and stuffing visible in the headrest and side areas. Staff said broken equipment should be reported for repair or replacement, but the chair remained in use and hospice had not yet been notified; the DON stated equipment was expected to stay in good repair and that the cracked cushions could not be cleaned appropriately.
Unsafe and Unclean Facility Environment: Surveyors observed multiple environmental deficiencies, including an unlocked maintenance storage room with stacked AC units, dirty vents, black substance on windowsills, walls, doors, handrails, and equipment, missing or broken light covers, holes in walls, and debris in hallways and the dining room. Staff interviews showed housekeeping cleaned vents and AC units, but filters were not changed and documentation practices were inconsistent, while the facility policy required a safe, clean, comfortable, and homelike environment.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident’s cell phone went missing and was not found or replaced, despite staff awareness and documentation that the resident’s personal effects included a phone with charger. The grievance record addressed missing clothing items but did not address the phone, and both the LPN/Resident Care Manager and Administrator stated the issue did not meet expectations.
Unclean and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-maintained resident environment for two sampled residents. Resident 112’s room was observed on two occasions to have a single crack in the right windowpane extending the length of the window. During interview, the Maintenance Director stated the window had been broken for six months, that they did not have authority to purchase a replacement window, and that facility administration was aware of the crack. The Administrator later stated they were unaware the window was cracked and said the maintenance department conducted several monthly resident room audits, during which the window should have been noted and repaired. The Administrator also stated the cracked resident window did not reflect a homelike environment. Resident 67, who was admitted with diabetes and was able to make needs known, stated during observation and interview that housekeeping did not sweep and mop and had just finished cleaning the room but left the floors dirty. Trash and a liquid spill were observed on the floor between the beds, and the same trash and spill were still present the next day. Resident council notes from March 2026 documented a request for housekeeping to ensure beds, nightstands, and surrounding areas were cleaned thoroughly, and April 2026 notes documented concerns that housekeeping was not removing trash from under the bed for three days. The Housekeeping staff member stated rooms should be swept and mopped every day, and the Administrator stated it was the expectation that resident rooms be swept and mopped daily and as needed.
Bathroom Sink Faucet Sprayed Water Onto Floor
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #53 by not ensuring the sink faucet in her bathroom was functional and did not spray water onto the floor. Resident #53 was admitted with diagnoses including rheumatoid arthritis, PTSD, and recurrent major depressive disorder. Her quarterly MDS showed a BIMS score of 15/15, indicating no cognitive impairment, and she was dependent on staff for personal hygiene. Her care plan documented an ADL self-care performance deficit related to impaired mobility and that she required assistance from one staff member for oral care management and personal hygiene. During observation and interview, Resident #53 stated she had used her power motorized wheelchair for mobility but had chosen not to get out of bed for some weeks. She reported that when she previously used the bathroom sink, the water sprayed outward instead of downward and had done so for months, and that she had told several CNAs but the faucet had not been fixed. Observation of the bathroom confirmed the faucet sprayed outward, and when the pressure was increased, water sprayed onto the floor, with a wet towel observed on the floor in front of the sink. A CNA stated she had reported the issue to the charge nurse weeks earlier and had also observed the problem herself. The MD stated he had received a work order about the faucet needing repairs but had not repaired it because other repairs were a higher priority, and he confirmed during observation that the water sprayed out of the sink and onto the floor.
Broda Chair Not Kept in Good Repair
Penalty
Summary
The facility failed to maintain a broda chair in good repair for a resident who used it for daily support and positioning. The resident’s quarterly MDS indicated moderate cognitive impairment and dependence on staff for ADLs, with diagnoses including anemia, dementia, Huntington’s disease, anxiety, depression, and bipolar disorder. On observation, the broda chair had multiple cracked areas on the headrest cushion, including vertical cracks about six inches long with inner foam visible, several cracks on the right side of the head area with foam visible, and a large cracked area on the left side with jagged breaks and exposed foam. The upper corners of the left side cushion also had stuffing and foam sticking out. A follow-up observation showed the resident continued to be placed in the same broda chair with the cracked cushions and exposed foam and stuffing. Staff interviews indicated CNA-C was not aware of the condition and stated broken equipment should be reported through maintenance or hospice if the resident was on hospice. RN-C stated the chair damage may have been caused by the resident’s helmet and that hospice would need to be notified for repair or replacement, but was not aware whether hospice had been informed. CM-B stated several chairs needed repair or replacement but hospice had not yet been notified, and identified infection control as the concern because the cracked cushions could not be cleaned appropriately. The DON stated equipment was expected to remain in good repair and that maintenance requests or hospice updates should be completed in a timely manner to maintain cleanliness and infection control. No facility policy regarding resident equipment was provided.
Unsafe and Unclean Facility Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment. During observation on 06/01/2026, surveyors found multiple environmental issues throughout the building, including an unlocked maintenance storage room on the 300 hall with seven air conditioner units stacked inside, a resident room with a black fuzzy substance on the windowsill and areas of missing paint on the walls, and a 200 hall ceiling light with no cover and two springs hanging down. The 200 hall also had a dirty cart with popcorn debris, hallway doors with black substance on the bottoms, walls with white spackle-like substance, and a broken light fixture that was missing a bulb and was dimly lit. On the 500 hall, surveyors observed six holes in the wall above the baseboard, an outside courtyard door not shut, another courtyard door unlocked, handrails with large areas of missing paint and dirt on the brackets, and a storage room with five tall boxes of supplies and one plastic-wrapped mattress sitting directly on the floor. Additional observations showed the 100 hall floor stained with a brown dirt-like substance and a blue popped balloon in the hallway, a Hoyer lift in the hallway with food debris and other black substances on the foot part, and vents near the activity room, respiratory storage room, and 100 hall with a black organic-like substance. On 06/02/2026, the dining room had a dusty floor vent and a vent cover knocked off and lying on the floor. Interviews with housekeeping, maintenance, and administrative nursing staff showed that housekeeping cleaned vents and air conditioner units, but filters were not changed, maintenance did not chart filter changes, and a housekeeping checkoff sheet had just been implemented. The facility policy stated that the environment should be safe, clean, comfortable, and homelike and that the physical layout should not pose a safety risk.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Missing Resident Cell Phone Not Addressed
Penalty
Summary
The facility failed to provide a safe environment to ensure reasonable care and protection of a resident’s personal property from loss or theft for 1 of 3 sampled residents reviewed for environment. Resident 2 was admitted with diagnoses including diabetes and high blood pressure and was able to make needs known. During an interview, Resident 2 stated their cell phone had gone missing, staff were aware, and it had not been found or replaced. The resident’s Inventory of Personal Effects, dated 04/17/2026, listed a cell phone with charger and black bag among the resident’s personal items. The facility’s grievance/concern log showed a grievance on 04/27/2026 that the resident’s family reported missing items, with the issue marked resolved on 05/08/2026. The Complaint/Grievance Report dated 05/08/2026 documented that the family reported missing clothing items and a phone on 04/26/2026; the clothing items were found and the issue was resolved, but the report did not address the missing phone. Staff interviews confirmed the phone was still missing: the LPN/Resident Care Manager stated the grievance report should have addressed the missing phone and did not meet expectations, and the Administrator stated they were not aware the resident was still without a cell phone and believed it had been found with the clothing items.
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