F0584

E

Failure to Maintain Sanitary, Safe Environment and Proper Smoking Controls

Cincinnati, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a sanitary, clean, and safe environment for residents on the secured women’s behavioral unit and for residents using the main entrance. Multiple resident rooms and common areas were observed to be heavily soiled and in disrepair. One resident with schizophrenia, COPD, hypertension, hypothyroidism, schizoaffective disorder, and osteoarthritis, who had impaired cognition and required staff assistance with ADLs and medications, was found to have a bathroom with brown splatter on the walls behind and opposite the toilet, a heavily soiled toilet, and a floor blackened with dirt and debris. Her bedroom walls were soiled, scuffed, and had exposed drywall, with unknown splatter and dried substances around the receptacle and under the light. A CNA confirmed these conditions.

Another resident with essential hypertension, antisocial personality disorder, inhalant abuse, DM, schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder, who had severely impaired cognition and required supervision or set-up for ADLs and was dependent on staff for medications, was observed without sheets on her bed. Her bed contained a wadded-up blanket heavily soiled with yellow and brown substances and swarmed with fruit flies. The floor in front of the bed was blackened with dirt and debris, and a soiled incontinent brief with apparent blood and stool was on the bedroom floor, surrounded by reddish-brown droplets and brown dried splatter on the wall near the toilet. The bathroom floor was missing tiles. The CNA stated the blanket was soiled with urine and verified the room conditions. A housekeeper confirmed the presence of stool and blood on the bathroom floor and stated she does not clean up blood. Later observation showed the bathroom sink filled with brown water and cigarette butts, with no running hot or cold water, and dried blood on the floor. The maintenance supervisor acknowledged awareness of the non-functioning sink and standing brown water and stated no pest treatment had been provided to the room.

On the women’s secured unit, the shared shower room used by all twelve residents had a floor blackened with dirt and heavily soiled, with unknown brown spots and splatter in the shower corners and up the walls. The toilet in the shower room was heavily soiled, the shower drain was partially broken, and the ceiling fan was hanging down with the ceiling spotted by an unknown black substance that a CNA stated appeared to be mold. The large dining/activity room on the unit had a half-broken window opening into the nurse’s station, leaving a sharp edge, and a large hole in the wall with exposed drywall beneath it. Five large ceiling lights in this room had no light bulbs. The maintenance supervisor verified the non-functioning lights and the hole in the wall and stated he was not aware of the broken window.

Another resident with DM, hypertension, asthma, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and GERD, who had impaired cognition and required supervision, moderate, or set-up assistance for ADLs and was dependent on staff for medications, reported that her room was very cold. She indicated her heating unit, covered with a blanket and with another blanket at the base of the window, was blowing cold air despite being told it had been fixed. Observation confirmed the unit was running but blowing cold air, and her bathroom was soiled, missing floor tiles, and had a heavily soiled toilet with a black ring. A CNA confirmed the room had been cold for some time and verified the bathroom conditions. The maintenance supervisor later confirmed the heater was blowing cold air and noted holes in the wall beside the bed and shredded privacy curtain pieces hanging from the ceiling.

A further resident with impaired cognition and diagnoses including hypertension, DM, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and cystitis was observed to have a dish of water under her sink and a large pile of what appeared to be mouse droppings under the sink. The sink did not drain correctly when water was running. The resident stated the dish of water was for mice living in a large hole in the corner under the sink and referred to the mouse as her pet. The maintenance supervisor stated he was aware of the mouse droppings and the mouse issue in the room and that the facility had been treated for mice. However, review of pest control work orders showed no specific treatments for fruit flies in the room with the soiled blanket and flies, or for mice in this resident’s room.

At the main entrance, residents and staff used a double set of doors with a small concrete pad and awning. One resident was observed smoking directly outside the front doors in a posted non-smoking area. Numerous discarded cigarette butts were scattered across the ground near the front door, in the landscaping rocks on both sides of the doors, and around a trash can with a plastic liner, with no container provided for cigarette disposal. A CNA confirmed the resident was smoking in the non-smoking area and identified a designated smoking area across the parking lot, also verifying the scattered cigarette butts. The resident stated he often smoked by the main entrance doors. On a subsequent observation, two other residents were seen smoking directly outside the main entrance in the same non-smoking area, with the area still littered with cigarette butts on the ground and in the landscaping. An LPN confirmed the residents were smoking in the non-smoking area and verified the large amount of discarded cigarette butts. Facility policy stated that the maintenance department was responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, including heating/cooling systems, plumbing fixtures, and ensuring lights were in good working condition, with the maintenance director responsible for inspection of the building.