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 Bed Linens: A resident with hypothyroidism and chronic diastolic heart failure had a pillowcase with several dry dark brown/red areas and sheets that appeared gray and unclean. The resident could not remember the last time the linens were changed, and the DON confirmed the linens should have been changed.
Dirty Resident Room and Respiratory Equipment: A resident with dysphagia, a feeding tube, and a tracheostomy had a room observed with a dirty fan, debris on the mattress, dust and dried debris on the O2 concentrator and trach machine, and a dirty towel on the bed. A family member reported the area by the bed was often dirty from tube feeding, and an LPN Resident Care Manager agreed the room was dirty and needed daily cleaning.
A resident’s room and the second-floor hallway had missing baseboards, including under the window in the room and periodically along both sides of the hall. During interview, an Mnt. employee stated the machine must be hitting them and that they had been taken off.
A resident room wall near the window was observed damaged and in disrepair, with a crack large enough for an ink pen to be inserted through it. The Maintenance Director said he knew about the damage after the resident reported it about 2 weeks earlier and believed it was caused by an AC leak. The damaged area covered about 6 square feet, while the Administrator said she was not aware of it and that the facility did not have a specific audit for wall or structural integrity checks.
Unsafe and Deteriorated Resident Room Conditions: Surveyors observed multiple resident rooms with broken, rusted, unsecured, and deteriorated conditions, including a hanging drawer front, scuffed and chipped walls, missing wall trim/chair rails, rust on a bedframe and AC shelf, a broken bathroom tile, and a gallon of Clorox stored in a bathroom. The Maintenance Director acknowledged the environmental conditions during the walkthrough, and photographic evidence was obtained.
The facility failed to maintain a clean, safe, and homelike environment. Surveyors observed dirty hallway vents, ceiling areas with residue, damaged walls, protruding door panel edges, missing tile and cracked flooring in shower areas, and multiple unsanitary conditions in resident rooms, including cracked light covers with bugs, uncovered soiled items, and substances on floors, mattresses, bed sheets, and bedside tables. Two residents’ wheelchairs also had dried substances and hair buildup, and staff acknowledged some areas needed repair or cleaning.
Unclean Bed Linens
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain clean bed linens for one resident. Facility policy stated bed linens are to be changed at least weekly and whenever clinically indicated or requested by the resident. The resident was admitted with diagnoses including hypothyroidism and chronic diastolic heart failure, and the care plan included an intervention to keep bed linen clean due to impaired skin. During observations, the resident’s pillowcase had several dry areas of a dark brown/red substance and the bed sheets had a gray hue and appeared unclean. The resident stated he/she could not remember the last time the sheets were changed. The DON later confirmed that the pillowcase had dark brown/red areas, the sheets appeared unclean, and the bed linens should have been changed.
Dirty Resident Room and Respiratory Equipment
Penalty
Summary
The facility failed to provide a homelike environment for Resident 6, who was admitted in 2022 with diagnoses including dysphagia and whose annual MDS dated 10/25/25 showed a feeding tube for nutrition and a tracheostomy in place. During observation, the resident’s room contained a small black fan that was very dirty and dusty and appeared not to have been cleaned for a long time. The resident’s room was later observed with a mattress on the floor near the bed that appeared dirty with dried clear debris, an oxygen concentrator with dried clear debris and dust on it, a tracheostomy machine with dried white debris all over it, the black fan covered in dust, and a dirty towel on the resident’s bed. A family member stated the area next to the resident’s bed was dirty and often had liquid on it from the tube feeding and appeared gross. An LPN Resident Care Manager observed the room and agreed it was dirty and needed to be cleaned daily.
Missing Baseboards on Second-Floor Hallway and Resident Room
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the second floor. During a tour with Maintenance Employee E9, Resident R171’s room was observed to have a missing part of a baseboard under the window, and the left side of the hallway had baseboards missing periodically down the hall. The right side of the hallway also had baseboards missing periodically down the hall. During an interview, Maintenance Employee E15 stated that the machine must be hitting the baseboards and that they had been taken off.
Damaged Resident Room Wall Left in Disrepair
Penalty
Summary
The facility failed to provide maintenance services to keep a resident bedroom in good repair. In room [ROOM NUMBER], the wall near the window was observed to be damaged and in disrepair, with a crack large enough that the end of an ink pen could be inserted through the wall. The observation was made during a surveyor visit, and photographic evidence was obtained. When the wall was re-observed with the Maintenance Director, he stated he was aware of the damage and said the resident in the room had reported it about 2 weeks earlier. He stated he believed the damage was caused by the air conditioning leaking. The damaged area covered about 6 square feet and extended about 12 inches up the wall. The Administrator later stated she was not aware of the damage and said the facility had room rounds but did not have a specific audit to inspect walls and structural integrity. The facility policy stated that environmental repairs and upkeep would be addressed and corrected in a timely manner, with resident safety taking priority over cosmetic repairs.
Unsafe and Deteriorated Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple resident rooms and resident-use areas were observed in damaged, deteriorated, unsecured, or unsanitary condition in 8 of 64 rooms observed. During observations, surveyors found a broken and hanging drawer front on a built-in wall cabinet, scuffed walls with chipped and scraped paint, rusted air return vent grilles, unsecured trim adjacent to a grille, rust on a bedframe, a broken bathroom floor tile, missing wall trim/chair rail leaving unfinished wall areas, a gallon of Clorox in a bathroom, and a metal air conditioning shelf with visible rust. One room also had a dresser that was scratched and heavily exposed the wood underneath the paint. Additional observations showed more rooms with scuffed walls, chipped and scraped paint, missing wall trim/chair rail, exposed torn sheetrock, and chipped and scraped paint beneath a window. During an interview and walkthrough, the Maintenance Director acknowledged the identified environmental conditions requiring repair or correction. Photographic evidence was obtained of all the issues observed.
Cleanliness, Safety, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, and homelike environment. Surveyors observed multiple areas of disrepair and cleanliness concerns throughout the building, including shower room flooring with dark residue and chipped, open penetrations, hallway vents and ceiling areas with black, gray, and cobweb-like substances, wall gouges, and dining room ceiling vents and lights with dry splattering and rust-colored residue. The facility’s maintenance manager and maintenance director stated they were aware of some of the shower room and panel issues and knew repairs were needed. Surveyors also observed unsafe conditions in resident areas and common spaces. Plastic door panels outside two rooms had protruding edges, the south hall shower room had two large holes where tile was missing and a smaller crack, and staff acknowledged the flooring needed correction. In resident rooms, surveyors observed cracked light covers containing bugs, gouges in walls and railings, a missing bathroom door, a thick black substance at a room entrance threshold, and uncovered soiled items such as an isolation bin with soiled linen and a bedpan on the floor under the sink. Equipment cleanliness concerns were also identified. Two residents’ wheelchairs had dried substances on the cushions and wheels, with hair accumulated in the wheel mechanisms, and a CNA stated night shift should have cleaned the wheelchairs. In another room, surveyors observed mattresses with dried brown and white substances, a mattress leaning against the wall with dried white substance, dried substances on the floor and bed sheets, and a bedside table with dried brown substance. Facility logs reviewed did not document cleaning of hallway vents, mats, or mattresses at the bedside, and the Housekeeping Supervisor stated vents should have been cleaned and that nurse aides were responsible for cleaning body fluids from mattresses and mats before housekeeping cleaned them.
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