F0584

E

Widespread Environmental and Housekeeping Failures Affecting Resident Living Areas and Shower Rooms

Southfield, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a clean, safe, comfortable, and homelike environment throughout multiple resident care areas, including shower rooms and resident rooms on several units. During a building tour, surveyors observed shower rooms with vinyl fabric liners under shower beds filled with cloudy liquid that smelled of urine; when tipped, the liquid drained through a liner drain hole with attached tubing. These liners were visibly soiled and stained brown, and the Director of Housekeeping & Laundry stated they were not laundered and that CNAs were responsible for cleaning them. In multiple shower rooms, floors were visibly soiled with buildup under and around therapy tubs, caulk at the floor/wall juncture was torn or missing and soiled with a black substance, and a lower plastic shelf under a shower bed was visibly soiled. The Director of Housekeeping acknowledged the need for re‑caulking and cleaning and reported that shower rooms were supposed to be cleaned daily with monthly deep cleaning, but the observed conditions did not reflect that schedule.

Additional observations in resident rooms showed widespread uncleanliness and lack of routine housekeeping. One resident’s room had a floor littered with debris and numerous stains near the head of the bed and around the nightstand. Another resident’s room had dried purple streaks on the closet door and adjacent walls. A different room was cluttered, with a sticky floor scattered with debris that appeared not to have been mopped. A shared room had dirty floors with food crumbs, including scrambled eggs, and trash around both beds, and these conditions persisted on re‑observation the following day, when the bathroom was also found with two wheelchairs stored inside, a pink stain on the toilet seat, discolored toilet water with a film, and black stains in the bowl. In another room, the bed linens had been stripped and thrown on the floor under the window, and the floor at the foot of the bed had copious skin flakes and light brown sticky stains near the nightstand. One resident reported that housekeeping used to sweep and mop daily but recently only came about once a week, described the environment as not sanitary, and stated that unpleasant odors were frequent and sometimes prompted them to go to dialysis just to get away from the smell.

Common areas and hallways also showed environmental deficiencies. Surveyors noted very strong urine and bowel movement odors throughout hallways on two units, including near a central shower room where no specific source was identified. Flooring outside and inside one resident’s room was covered with a clear, sticky substance that remained in place on subsequent observation, with a mechanical lift stored directly over it. The same room had a strong urine odor, heavily damaged walls with deep grooves, peeling floor molding with exposed debris, and scattered food debris and trash. Wallpaper throughout the hallways was heavily soiled with purple and brown splatters and peeling away from the walls. Handrails across from a housekeeping closet and near a main lounge had separated sections and missing end caps, exposing sharp metal and plastic edges; a resident was observed propelling their wheelchair by pulling along the exposed area. A housekeeping closet containing several cleaning chemicals was found open and unsecured with no housekeeping staff nearby, and a housekeeper acknowledged it should have been locked. The Maintenance Director confirmed the presence of sharp handrails, missing end caps, peeling wallpaper, and peeled floor molding, and identified a broken pin under a shower bed that should have secured a bed rail, stating it should have been reported and the bed should not have been available for use. The Director of Housekeeping, in place for about a month, reported staffing vacancies, stated that rooms were supposed to be cleaned daily using a checklist, acknowledged housekeeping concerns and the stained hallways, and confirmed that the housekeeping closet should remain locked. Review of the facility’s electronic reporting system from late September through early February showed no entries for the observed environmental issues, despite facility policies requiring a clean, sanitary, orderly environment, pleasant neutral scents, and safe chemical storage.

The facility’s own policies on a homelike environment and chemical storage state that staff are to provide a clean, sanitary, and orderly environment with pleasant, neutral scents, and that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Staff are directed to report lingering odors, bathrooms needing cleaning, and unresolved environmental concerns to administration, and chemicals are to be stored safely. Despite these policies, surveyors documented persistent odors of urine and bowel movements, visible dirt and debris in resident rooms and hallways, stained and soiled surfaces, improperly maintained shower equipment, unsecured chemicals, and unreported maintenance issues such as damaged handrails, peeling wallpaper, and broken shower bed components. Residents interviewed reported decreased frequency of housekeeping services and dissatisfaction with cleanliness and odors in the facility, aligning with the environmental conditions observed during the survey.