F0584

D

Failure to Maintain Clean, Homelike Resident Rooms After Cleaning and Turnover

Fort Pierce, Florida Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to provide a safe, clean, comfortable, and homelike environment in multiple resident rooms, including both occupied and unoccupied rooms. A grievance from the spouse of Resident #2, who had been admitted and later discharged, documented that the floor in the resident’s room was not clean. When Resident #2’s room was observed after a reported deep cleaning, both beds had dated papers indicating recent cleaning, yet one mattress remained stained, the privacy curtain was dirty, trash was present in the trash can, crumpled paper towels were on the floor under the privacy curtain, a previous resident’s personal items were still in a labeled bag in the closet, and the floor and wood molding were stained near the closet and bathroom.

Another grievance from a family member of Resident #3 reported that housekeeping failed to clean up a spill and that the floor had not been sufficiently cleaned. During observation of this room, the floor appeared clean, but wallpaper was peeling behind both beds. Additional room observations revealed discolored floors and walls with drywall damage in one room, and discolored and missing flooring with dirty wall areas in another. In a further room, despite signs indicating both beds had been cleaned and clean sheets were present, surveyors observed an adaptive reacher, a pad from a wheelchair leg rest, and a folded red plastic bag on the countertop, trash in both bedroom and bathroom trashcans, a hole in the wall under the A/C unit, a dirty privacy curtain, and a blue mat with ripped areas behind the bedside table.

Record review showed that Resident #1, admitted with a diagnosis including acute respiratory failure and later discharged, had a family member who reported the room appeared unclean on admission. The family member stated that the previous resident’s clothing and paperwork were left in the closet, there was a mold-like substance around an electrical outlet and in the A/C unit, and hair was present on the bedding. Observation of this room later showed an electrical outlet with drywall open around the outlet cover and dark blackish stains on the wood molding around the A/C unit. In interviews, the Housekeeping Manager described the deep-cleaning process and confirmed that a signed paper on the bed signifies the whole room is deep cleaned and ready for a new resident, but agreed that Resident #2’s room still had a dirty privacy curtain, trash, mattress residue, and stained floors and moldings despite being marked as cleaned. The Maintenance Director stated he only checks rooms when he has the opportunity and focuses on call lights, bathrooms, televisions, and A/C units, and he did not routinely identify mold in A/C units, while the Nursing Home Administrator acknowledged difficulty accessing rooms for repairs and agreed with the survey findings.