F0584

D

Failure to Maintain Clean, Organized, and Dignified Resident Room Environments

Grand Rapids, Michigan Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a clean, orderly, and comfortable environment in multiple resident rooms, as well as failure to ensure safe and appropriate management of resident belongings and care-related supplies. One resident, R8, was cognitively intact but dependent on staff for transfers and unable to get out of bed independently. Over three consecutive days of observation, surveyors noted that a dresser behind this resident’s bed had dust and debris under a bottle of stoma powder lying on its side, along with a jar of chicken bouillon, various wound and ostomy supplies, and scissors with plastic wrap hanging from the blades. These items remained in the same disorganized and unclean condition across all three days, with visible dirt, dust, and debris and supplies piled on top of each other. The resident stated that staff took care of things in his room because he could not get out of bed on his own.

Another resident, R108, was severely cognitively impaired, dependent on staff for all ADLs, and had a feeding tube with a resident-specific treatment plan for enteral feeding. Observations on three separate days showed that her room remained in a persistently unclean and cluttered state. Under the heat register was a purple container of deodorant that was not removed. A chair next to the enteral feeding pole held a wadded-up fleece jacket and a tube of ointment, all splattered with a dried sticky substance resembling enteral feeding, which also covered the pump, pole, pole base, floor underneath, and the chair. Dirt, dust, and debris were noted along the floorboards and dressers, and the resident’s personal belongings were partially in tote bags and partially spilled out onto the floor, as if someone had gone through them and left items scattered. The resident’s high-backed wheelchair had the rubber missing completely around the right rear wheel. These conditions were observed repeatedly without change over the three days.

Family concerns further highlighted the issues in R108’s environment and hygiene. Her family member reported ongoing concerns about the resident’s personal hygiene and room condition, stating that despite staff-provided showers, the resident complained of still feeling unclean and having body odor. The family member described that linens were not consistently changed with bed baths, that she often had to change the sheets herself, and that the resident’s hair and skin showed signs of inadequate hygiene care, including dry, flaky skin and buildup of hair oil. She also reported finding used gloves on the floor, dirty wipes in drawers, spilled hair conditioner under the bed, and enteral feeding drippings on the visitor chair and floor, which she had previously observed and addressed. The unit manager later confirmed that floors were the responsibility of housekeeping, while aides and nursing staff were responsible for keeping rooms and belongings neat and tidy and for reporting equipment issues.

A third resident, R12, was cognitively intact but dependent on staff for bed-to-chair transfers and had limited physical mobility related to bilateral total shoulder arthroplasties and removal of the right shoulder. Over three consecutive days, surveyors observed that his room was crowded with a bedside dresser, walker, wheelchair, bedside commode, and dresser against the wall, leaving no clear path to the bathroom and little space to move around. Under the bedside commode, there was a cookie in a wrapper, a plastic hanger, and the lid from the bedside commode, which remained in the same place on subsequent days. A broken picture frame was also observed on the floor, and along the floorboards there was an accumulation of dirt and debris that persisted across all three days. The only noted change was that the packaged cookie that had been on the floor appeared to have been moved to the bedside table, while the rest of the clutter and dirt remained unchanged.