F0584

E

Failure to Maintain Sanitary and Clean Resident Environment

Buffalo, Missouri Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior environment in resident-use areas, despite written policies requiring routine and cycle cleaning. Surveyors observed multiple instances of unclean conditions throughout several halls and rooms. On Buffalo Blvd. Hall, there was a large dried splatter stain with a white crust on the floor, a large pile of dried leaves accumulated at an exit door, and a resident room with a pillow on the floor amid food crumbs, napkins, tissues, a clear cup, and an empty food box. Between two rooms, an orange medication cart cap and a single blue plastic glove were on the floor.

On Memory Lane Hall/Unit, surveyors noted a strong urine odor upon entering. The dining room trash can at the end of the serving counter was overflowing, with trash and napkins on the surrounding floor. In the TV/visiting area, a resident was reclined in a chair next to a wheeled side-table cart heaped with trash, including soda cans, rolled tissues, and wrappers, with food crumbs, tissues, and an elastic hair band on the floor under the recliner. Multiple rooms on this unit had tissue and food crumbs on the floor, large stained discolorations on the floor, popcorn and wadded trash items on the floor, overflowing trashcans, splatter-like stains across the floors, and various discarded items such as straws, wrappers, tissues, Q-tip wrappers, and bottle caps under beds. On a later observation date, one room had a strong urine odor, wadded trash under the bed, and dried, hardened wads of paper splattered onto the floor.

On Prairie Lane Hall, a wadded-up piece of paper was observed on the floor outside a room and appeared to remain in the same location several days later. A cognitively intact resident reported usually cleaning the room independently because it took too long for staff to do it, stating that housekeeping staff were good but too few, and that other staff did not help with cleaning. This resident’s room had a strong bowel odor, and the resident pointed out a pile of soiled bedding under the sink counter that had been removed from the bed two days earlier and not picked up, causing embarrassment. Another cognitively intact resident stated that staff would empty trash but took a long time to do so, and that weekdays were better because housekeeping came to help clean rooms.

Staff interviews further described ongoing cleanliness issues. A COTA reported noticing the facility in disarray at times and personally cleaning gum wrappers from under a resident’s bed because they had been there so long. A CNA stated the facility was dirty at the start of shifts, that night shift staff were the worst about throwing trash around, and that there was no current housekeeping department head after the prior Maintenance Director left. This CNA also reported that some residents were incontinent and that urine-containing items in trash contributed to odors, and that plumbing issues caused sewer smells, especially after showers. Another CNA reported the facility was filthy on Monday mornings and after weekends, with weekend staff leaving trash in rooms instead of disposing of it. A housekeeper stated it was normal to arrive each day to find trash all over floors, shower rooms with clothes, bedding, and towels scattered, and overflowing trashcans. Another CNA said housekeeping tasks completed depended on who was working, that housekeepers were supposed to clean every room daily and deep clean monthly, and that they always carried trash bags because someone’s room was always dirty. The DON reported there were three or four housekeeping staff, was unsure if housekeeping worked weekends, and stated housekeeping should empty trash, sweep, and wipe surfaces daily, with aides also able to perform these tasks. The Administrator stated an expectation that all staff pick up after any mess they make and that staff try to clean when they notice cleanliness or odor issues.