Environmental Cleanliness, Maintenance, and Supply Failures Affect Resident Rooms and Common Areas
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in multiple resident rooms and common areas, as well as failures in basic housekeeping, maintenance response, and supply availability. Surveyor observations over several days showed food debris, used tissues, and other trash accumulated along the inner bottom portions of handrails throughout a second-floor hallway, and multiple resident room and private dining room doors were heavily soiled with dirt, debris, and dried liquid splatter. One resident’s room had a corner wall with missing drywall crumbled onto the floor and an exposed metal brace with sharp edges, and the resident’s dresser had a thick layer of dust across the top. In another room, drywall was peeling away from the walls in multiple areas, exposing the underlying cardboard, and this condition persisted on re-observation two days later. During a confidential resident council interview, several residents reported housekeeping and maintenance concerns. One resident stated their carpet was so dirty that their wheelchair wheels turned their hands black when propelling, and another reported their room was only cleaned twice a week. A resident described a roommate who used a urinal and frequently missed, leaving urine on the floor and between the room divider that remained for a long time and smelled strongly of urine. Other residents reported a thick, foul-smelling heater filter, a leaking toilet that required the resident to dump collected water every night, and a broken toilet seat that had been reported about a month earlier without repair. One resident reported having no toilet paper in their bathroom since the previous night despite informing two CNAs, resulting in the resident using paper towels to clean themselves, which caused discomfort; the bathroom was observed to have no toilet paper. Additional observations showed environmental and safety issues related to call systems and room conditions. In one bathroom, the call light pull cord was wrapped around a grab bar, making it non-functional for the resident. In another room, the resident’s call button was on the floor and out of reach. A room with a leaking toilet had a small plastic basin under the pipes that was nearly full of water; when the toilet was flushed, the leak worsened. Another room had a loose toilet seat that slid easily from side to side. The facility’s maintenance worker later confirmed that the peeling drywall in one resident’s room would need repair and painting and stated they had not been made aware of the issue, despite the facility having a notification system that should have been used. The facility’s housekeeping and laundry operations also contributed to the deficiency. The Director of Housekeeping and Laundry acknowledged staffing issues and that housekeeping staff did not work weekends, resulting in accumulated housekeeping concerns by Monday. The director confirmed the observed debris along the hallway handrails and the damaged wall and debris in the resident’s room. Laundry observations showed both washers and dryers running and large amounts of clean linens awaiting folding, with housekeeping staff pulled from their usual duties to help catch up on laundry. CNAs reported frequent shortages of clean linens, particularly towels, which disrupted shower schedules. Clean linen rooms on both floors were observed with limited supplies of washcloths, bath towels, and disposable briefs in certain sizes, while soiled linen rooms contained heaping, unemptied bins of bagged soiled linens and personal laundry. Record review of the facility’s work order log from a several-month period showed only completed items, with no documentation of existing environmental concerns, no dates of when issues were reported, and no dates of correction. The log did not include any of the specific resident-reported concerns such as leaks, broken toilet seats, or wall damage. Staff interviews indicated that housekeeping was responsible for restocking toilet paper in resident rooms and public restrooms, including on weekends, and that central supply maintained adequate stock of linens, briefs, and toilet paper. However, the observed lack of toilet paper in at least one resident’s bathroom, the low levels of linens and briefs in clean supply rooms, and the reported disruptions to shower schedules due to linen shortages demonstrated that supplies were not consistently delivered to resident care areas as needed, contrary to the facility’s housekeeping policy requiring daily cleaning of surfaces and regular carpet care, as well as prompt response to visible soiling and spills.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unclean Bed Linens: A resident with hypothyroidism and chronic diastolic heart failure had a pillowcase with several dry dark brown/red areas and sheets that appeared gray and unclean. The resident could not remember the last time the linens were changed, and the DON confirmed the linens should have been changed.
Dirty Resident Room and Respiratory Equipment: A resident with dysphagia, a feeding tube, and a tracheostomy had a room observed with a dirty fan, debris on the mattress, dust and dried debris on the O2 concentrator and trach machine, and a dirty towel on the bed. A family member reported the area by the bed was often dirty from tube feeding, and an LPN Resident Care Manager agreed the room was dirty and needed daily cleaning.
A resident’s room and the second-floor hallway had missing baseboards, including under the window in the room and periodically along both sides of the hall. During interview, an Mnt. employee stated the machine must be hitting them and that they had been taken off.
A resident room wall near the window was observed damaged and in disrepair, with a crack large enough for an ink pen to be inserted through it. The Maintenance Director said he knew about the damage after the resident reported it about 2 weeks earlier and believed it was caused by an AC leak. The damaged area covered about 6 square feet, while the Administrator said she was not aware of it and that the facility did not have a specific audit for wall or structural integrity checks.
Unsafe and Deteriorated Resident Room Conditions: Surveyors observed multiple resident rooms with broken, rusted, unsecured, and deteriorated conditions, including a hanging drawer front, scuffed and chipped walls, missing wall trim/chair rails, rust on a bedframe and AC shelf, a broken bathroom tile, and a gallon of Clorox stored in a bathroom. The Maintenance Director acknowledged the environmental conditions during the walkthrough, and photographic evidence was obtained.
The facility failed to maintain a clean, safe, and homelike environment. Surveyors observed dirty hallway vents, ceiling areas with residue, damaged walls, protruding door panel edges, missing tile and cracked flooring in shower areas, and multiple unsanitary conditions in resident rooms, including cracked light covers with bugs, uncovered soiled items, and substances on floors, mattresses, bed sheets, and bedside tables. Two residents’ wheelchairs also had dried substances and hair buildup, and staff acknowledged some areas needed repair or cleaning.
Unclean Bed Linens
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain clean bed linens for one resident. Facility policy stated bed linens are to be changed at least weekly and whenever clinically indicated or requested by the resident. The resident was admitted with diagnoses including hypothyroidism and chronic diastolic heart failure, and the care plan included an intervention to keep bed linen clean due to impaired skin. During observations, the resident’s pillowcase had several dry areas of a dark brown/red substance and the bed sheets had a gray hue and appeared unclean. The resident stated he/she could not remember the last time the sheets were changed. The DON later confirmed that the pillowcase had dark brown/red areas, the sheets appeared unclean, and the bed linens should have been changed.
Dirty Resident Room and Respiratory Equipment
Penalty
Summary
The facility failed to provide a homelike environment for Resident 6, who was admitted in 2022 with diagnoses including dysphagia and whose annual MDS dated 10/25/25 showed a feeding tube for nutrition and a tracheostomy in place. During observation, the resident’s room contained a small black fan that was very dirty and dusty and appeared not to have been cleaned for a long time. The resident’s room was later observed with a mattress on the floor near the bed that appeared dirty with dried clear debris, an oxygen concentrator with dried clear debris and dust on it, a tracheostomy machine with dried white debris all over it, the black fan covered in dust, and a dirty towel on the resident’s bed. A family member stated the area next to the resident’s bed was dirty and often had liquid on it from the tube feeding and appeared gross. An LPN Resident Care Manager observed the room and agreed it was dirty and needed to be cleaned daily.
Missing Baseboards on Second-Floor Hallway and Resident Room
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the second floor. During a tour with Maintenance Employee E9, Resident R171’s room was observed to have a missing part of a baseboard under the window, and the left side of the hallway had baseboards missing periodically down the hall. The right side of the hallway also had baseboards missing periodically down the hall. During an interview, Maintenance Employee E15 stated that the machine must be hitting the baseboards and that they had been taken off.
Damaged Resident Room Wall Left in Disrepair
Penalty
Summary
The facility failed to provide maintenance services to keep a resident bedroom in good repair. In room [ROOM NUMBER], the wall near the window was observed to be damaged and in disrepair, with a crack large enough that the end of an ink pen could be inserted through the wall. The observation was made during a surveyor visit, and photographic evidence was obtained. When the wall was re-observed with the Maintenance Director, he stated he was aware of the damage and said the resident in the room had reported it about 2 weeks earlier. He stated he believed the damage was caused by the air conditioning leaking. The damaged area covered about 6 square feet and extended about 12 inches up the wall. The Administrator later stated she was not aware of the damage and said the facility had room rounds but did not have a specific audit to inspect walls and structural integrity. The facility policy stated that environmental repairs and upkeep would be addressed and corrected in a timely manner, with resident safety taking priority over cosmetic repairs.
Unsafe and Deteriorated Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple resident rooms and resident-use areas were observed in damaged, deteriorated, unsecured, or unsanitary condition in 8 of 64 rooms observed. During observations, surveyors found a broken and hanging drawer front on a built-in wall cabinet, scuffed walls with chipped and scraped paint, rusted air return vent grilles, unsecured trim adjacent to a grille, rust on a bedframe, a broken bathroom floor tile, missing wall trim/chair rail leaving unfinished wall areas, a gallon of Clorox in a bathroom, and a metal air conditioning shelf with visible rust. One room also had a dresser that was scratched and heavily exposed the wood underneath the paint. Additional observations showed more rooms with scuffed walls, chipped and scraped paint, missing wall trim/chair rail, exposed torn sheetrock, and chipped and scraped paint beneath a window. During an interview and walkthrough, the Maintenance Director acknowledged the identified environmental conditions requiring repair or correction. Photographic evidence was obtained of all the issues observed.
Cleanliness, Safety, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, and homelike environment. Surveyors observed multiple areas of disrepair and cleanliness concerns throughout the building, including shower room flooring with dark residue and chipped, open penetrations, hallway vents and ceiling areas with black, gray, and cobweb-like substances, wall gouges, and dining room ceiling vents and lights with dry splattering and rust-colored residue. The facility’s maintenance manager and maintenance director stated they were aware of some of the shower room and panel issues and knew repairs were needed. Surveyors also observed unsafe conditions in resident areas and common spaces. Plastic door panels outside two rooms had protruding edges, the south hall shower room had two large holes where tile was missing and a smaller crack, and staff acknowledged the flooring needed correction. In resident rooms, surveyors observed cracked light covers containing bugs, gouges in walls and railings, a missing bathroom door, a thick black substance at a room entrance threshold, and uncovered soiled items such as an isolation bin with soiled linen and a bedpan on the floor under the sink. Equipment cleanliness concerns were also identified. Two residents’ wheelchairs had dried substances on the cushions and wheels, with hair accumulated in the wheel mechanisms, and a CNA stated night shift should have cleaned the wheelchairs. In another room, surveyors observed mattresses with dried brown and white substances, a mattress leaning against the wall with dried white substance, dried substances on the floor and bed sheets, and a bedside table with dried brown substance. Facility logs reviewed did not document cleaning of hallway vents, mats, or mattresses at the bedside, and the Housekeeping Supervisor stated vents should have been cleaned and that nurse aides were responsible for cleaning body fluids from mattresses and mats before housekeeping cleaned them.
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