F0584

E

Environmental Cleanliness, Maintenance, and Supply Failures Affect Resident Rooms and Common Areas

West Bloomfield, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

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.