F0921

E

Widespread Environmental and Linen Deficiencies Affecting Resident Care and Cleanliness

Richmond, Virginia Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The facility failed to provide a functional, sanitary, and comfortable environment on all three units, beginning with inadequate linen supplies necessary for resident care. An alert and oriented resident with a BIMS score of 15/15 reported having to wait long periods, sometimes hours, for incontinence care because staff did not have enough linen. Observations on multiple days showed linen carts on all units with only a scarce amount of linen, including limited blankets, gowns, wash cloths, towels, fitted sheets, incontinence pads, and pillowcases. CNAs reported they frequently did not have enough linen and often had to go to other units to find supplies, with one CNA stating the facility did not have adequate linens to meet resident care needs.

The facility also failed to maintain clean and sanitary common areas and resident rooms. On the East Wing, hallway floors were dirty with debris and dirt buildup in the corners, and several hand sanitizer dispensers outside resident rooms were dirty with white debris caked on the bottom dish, with some dispensers empty and their casings dirty. In one resident’s room, wet towels with dark orangish-brown stains were observed under bins by the window and remained in place with the stains appearing larger over two days. A water fountain near the East Wing nurses’ station had a brownish stain around the drain, and when the button was pressed, gnats emerged from the drain while gnats were also flying over the fountain and landing on the walls. The Unit Manager stated the stain looked like a nutritional supplement used during medication pass and acknowledged that nurses were expected to ensure residents consumed medications and supplements.

Individual resident rooms were observed to be unclean and cluttered. One resident with diagnoses including metabolic encephalopathy, aphasia, hemiplegia, and hemiparesis, and a BIMS score of 6 indicating severely impaired cognitive skills, had a room with clothes piled on the floor, debris scattered on the floor, dirty dishes on the overbed table, and a brown substance on the floor at the doorway and in the bathroom. This resident required assistance with ADLs and had behaviors with an intervention of 1:1 until seen by a provider, and did not have a roommate at the time. Another shared room on the west wing occupied by two residents was in disarray with refuse throughout the floor, a pile of paper trash in front of bedside tables, soiled floors, and debris in the bathroom; one resident reported it had been four days since someone cleaned, and the other stated cleaning did not occur every day and depended on who was working.

Additional environmental concerns included cobwebs and a spider web in a window across from the therapy gym that remained present throughout the survey. Housekeeping staff reported that the number of housekeepers had been reduced from 5–6 per day to about 3–4 per day, and one housekeeper stated she sometimes worked until late in the evening to get to every room and that after weekends the facility looked very unkempt. The regional housekeeping director stated there were only three housekeepers per day recently, described that each room was supposed to be cleaned daily according to a defined task list, and acknowledged that the observed conditions were not sanitary or comfortable. Facility policy for daily resident room cleaning outlined tasks such as straightening rooms, dusting, cleaning vents and surfaces, sweeping and mopping floors, emptying and cleaning trashcans, and wet mopping with disinfectant, which contrasted with the observed state of multiple areas and rooms.