F0921

E

Unsanitary Resident and Vacant Rooms, Soiled Linens, and Pest Activity

The Woodlands, Texas Survey Completed on 12-12-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, clean, and sanitary environment in resident-occupied and vacant rooms. One complaint resident (CR#1), a woman admitted with spinal stenosis of the lumbar region with neurogenic claudication and prior lumbar-sacral fusion, was admitted to a room that had urine-stained sheets, brown fecal matter on the toilet seat and toilet bowl, and wheelchair leg-rest equipment left on the closet floor from a previous resident. CR#1, who was alert and oriented x4, reported that the room was unsanitary upon admission, stating that her family had to clean the room and that they observed urine stains on the bed linens. Photographs taken by CR#1 on the day of admission showed brown fecal matter on the bottom of the toilet seat and directly underneath the toilet seat, short black hair in the bathroom soap dish, and wheelchair leg rests left on the closet floor.

Another resident, identified as Resident #1, had a room with multiple small black bugs crawling on the kitchenette counter and inside a plastic bag containing a cookie. Resident #1’s family member reported that the move-in process had gone fine but stated there had been a lot of bugs by the kitchenette sink and counter and that the bugs had been present in the room for an unspecified period of time. Resident #1’s medical record showed she was admitted with noninfective gastroenteritis and colitis and a perforation of the intestine, and her care plan documented an ADL self-care performance deficit related to activity intolerance and impaired balance due to declined health. The presence of bugs in her room was directly observed by the surveyor during the interview with the family member.

Two vacant rooms were also found to be in unsanitary condition. In vacant room A, which appeared empty of personal belongings but still had a resident’s name on the door, there were spider webs along the baseboards with a dead centipede caught in the web, a faint urine stain on the fitted sheet when the bed covers were pulled back, and dried fecal matter splatter inside the back of the toilet bowl. In vacant room B, hairballs and food residue were observed along the floor baseboards, and when the bed sheets were pulled back, over 30 strands of short black hair were seen on the fitted sheet. Staff interviews revealed that housekeeping staff were responsible for cleaning both occupied and vacant rooms and that some CNAs reported receiving linens from laundry that were stained with urine or bowel movement and that they would return visibly stained linens to the dirty pile. A CNA reported receiving complaints from residents about bugs and having seen roaches, and another CNA reported finding a roach in the hallway. A laundry aide described separating heavily soiled linens for special washing and sometimes re-washing items multiple times, and the DON stated that her expectation for new admissions and discharges was that housekeeping would perform a deep clean of the room, with the harm of an unclean environment identified as an infection control concern.

Record review of the facility’s “Homelike Environment” policy, revised February 2021, showed that residents were to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment and clean bed and bath linens in good condition. Despite this policy, the observations, interviews, and record reviews documented that CR#1 was admitted to a room with visibly soiled linens and bathroom fixtures, Resident #1’s room had visible bugs on the kitchenette counter and food packaging, and two vacant rooms contained dirty linens, pest evidence, and unclean bathroom fixtures and baseboards. These conditions formed the basis of the cited deficiency for failure to maintain a safe, functional, and comfortable environment for residents, staff, and the public.