F0584

E

Failure to Maintain Clean Resident Rooms and Proper Temperature Control

Saginaw, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a clean, safe, and comfortable environment and to perform daily room cleaning as outlined in its March 2021 “Maintaining a Clean Environment” policy. That policy required daily cleaning of resident rooms, including all horizontal and contact surfaces, high-touch items, and daily wet mopping of floors with a detergent germicide. During a confidential resident group meeting, four of six attendees reported frustration and anger that staff were not cleaning their rooms daily or, in some cases, at any time since admission. During the initial tour, surveyors observed five resident rooms with unclean conditions and, through resident interviews, confirmed that routine cleaning such as vacuuming, bathroom cleaning, and disinfection of touchable surfaces was not occurring as required.

In one room, a resident with a BIMS score of 15 had small pieces of dried food and paper on the floor, dirty bathroom floor corners, and dried BM inside the toilet rim; the resident stated the room was cleaned only once a week. Another alert resident reported never seeing staff clean, vacuum, or clean the bathroom, and surveyors observed dirty floors with food crumbs and tissue under the bed and wheelchair. A resident with a BIMS of 14 stated staff did not clean the room at all, and surveyors noted paper on the floor, dust under the bed, and dust on the bathroom floor. A resident with a BIMS of 10 reported the vacuum had been used only once since admission and that the toilet had never been cleaned; surveyors observed dirty floors, paper on the floor, dirt in bathroom corners, and dried BM on the inside of the toilet rim and bowl. Another resident with a BIMS of 15 reported vacuuming only once or twice and bathroom mopping once a week, with surveyors observing many small tissue and paper pieces on the floor. Additionally, in one room, cold air was coming from the heater during snowy weather, and staff had placed three large bath blankets over the heater vents to block the cold air while the resident complained of being cold. Maintenance staff reported that second-shift staff were changing heater/AC settings, and the Director of Maintenance acknowledged the system switched from heat to AC and that he had to lock the heaters to prevent staff from turning them down. The Infection Control RN stated he was new and had not conducted or documented environmental rounds.