Widespread Environmental, Pest, and Cleanliness Failures Across All Units
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment across all three units, as evidenced by widespread pest infestations, environmental disrepair, and unclean resident care areas. Multiple cognitively intact residents reported large flying roaches in their rooms and throughout the building, including on walls and ceilings, making it difficult to sleep and causing some to question whether they should avoid showering. Residents also reported that pest control had not treated their rooms. Surveyors directly observed roaches in resident bathrooms and rooms, including live and dead roaches on floors, and facility leadership acknowledged that a gap at a courtyard threshold served as an entry point for bugs. A wasp nest with egg sacs and a live wasp was observed between a resident room window and screen, with a gap allowing air and insects into the room; residents stated the nest had been present for about three weeks and that staff were aware. The physical environment on the Fine Unit and other areas was in disrepair and not maintained in a clean or homelike condition. Numerous ceiling tiles in halls and resident rooms were stained, bulging, loose, or missing, including heavily stained tiles over residents’ beds. Walls, doors, and thresholds were damaged, including a wall in disrepair between rooms, a resident room door with frayed and swollen edging, and a courtyard threshold removed in a way that left a gap and uneven flooring. Bathrooms had leaking toilet cisterns with pans catching actively dripping water, heavily stained and loose tiles, and containers under valves collecting standing water that staff acknowledged likely attracted roaches. In several rooms, floors were described and observed as filthy, sticky, and covered with trash, food debris, and accumulated brown or yellowish substances on floors, walls, and cove bases. In at least two rooms, staff and the Housekeeping Director stated that residents frequently spit on the floor, and that encrusted brown substances could not be removed with current cleaning methods. Resident rooms on the Fine Unit were small, with many semi-private rooms having one bed abutted directly against the wall near the door, leaving no space on one side of the bed. Residents were observed lying in beds with body parts resting on the walls, and stains were noted on walls where residents’ heads rested. Staff, including CNAs and housekeeping, reported difficulty providing care and cleaning around beds placed against walls, and a family member reported feeling cramped and lacking privacy when visiting a loved one in such a room. Visitors and residents commented that the Fine Unit rooms were much smaller and older than rooms on other units and that they had seen roaches in the building. The State Life Safety Inspector stated that beds should not be abutted against the wall, that the rooms were small, and that there should be enough room for stretchers to enter to assist either resident in an emergency. Shared and unit shower rooms were observed to be cluttered and unclean. On one unit, the shower room bathroom contained multiple shower chairs, a pair of shoes on the floor, a toilet covered in black plastic with a sign indicating it needed repair or replacement, and used latex gloves on the plastic and floor. A commode bucket with dried brown-looking substance and used items was found on a commode chair, and the shower area had brown substances on walls and floors, wet hair near the drain, and a wet washcloth on a shower bed. On another unit, the shower room was full of clutter, including shower chairs with bags of soiled clothing, and a bathtub filled with incontinence products, towels, shirts, dust, and sheets. The shower floor and tiles appeared soiled and dusty, water was constantly dripping from the shower head, and a used saturated dressing with pink and yellow secretions was observed at the shower drain. The water closet in that shower room was extremely cluttered, and the toilet was sealed with plastic and tape with an “out of order” note. Hallways and common areas were not maintained free of clutter and obstructions. On the Fine Unit, furniture, equipment, and supplies were stored on both sides of a hallway near resident rooms, including a mattress, rollator, multiple cardboard boxes, pallets of boxed items, a large trash can, and a rolling hamper. On another hall, wheelchairs, a shower bed, chairs, oxygen concentrators, mats, positioning devices, a laundry cart, a Hoyer lift, and a wheelchair were stored in the corridor across from resident rooms and near a shower room. A family member reported concern that hallway clutter would make it hard to evacuate a resident in an emergency and that her visually impaired loved one, who ambulates and may wander, could fall or be injured due to the clutter. Emergency call systems were not consistently functional in resident-accessible bathrooms. In a shared bathroom used by several rooms, including one resident who ambulated independently to the bathroom, the emergency alarm pull cord did not light up or send an alert to the nurse’s station when tested on two separate days. A CNA at the nurse’s station stated he was not aware whether the emergency pull-cord alarm sent an alert. This non-operable emergency call system remained in use by a resident who was observed throughout the survey ambulating independently to that restroom. Individual resident rooms showed repeated failures to maintain cleanliness and a homelike environment. One resident’s room was repeatedly observed with a filthy floor, trash debris, and an exposed outlet with sharp edges near the HVAC unit; a reddish substance resembling vomit was seen on the floor until housekeeping was called to clean it. Another resident’s room had a sticky floor, food accumulated around the perimeter, dark yellow/brown substances on the floor, and copious brown drippage behind the headboard down to the floor; the resident stated she had informed housekeeping about the dirt and roaches in her room and bathroom. In another room, a resident was observed with a fall mat between beds that had debris and footprints, a soiled glove on the floor, and a floor that was noticeably dirty and in need of mopping. In yet another room, the wall under the window was dirty and needed painting, and crusty material was present on the floor, wall, and baseboard behind the bed; the resident stated staff never cleaned the room and that she had to look out at the “nasty mess.” Support service areas were also not maintained in a clean, orderly condition. The laundry room contained washed clothing left in washers, dryers full of clothing waiting to be folded, and tables piled halfway to the ceiling with unfolded clothing. Shelves held many plastic bags of clothing identified by the laundry aide as personal belongings to be donated. The laundry room floors were grossly soiled, and a large bin of soiled laundry contained pillows with yellowish-brown substances mixed in with soiled bed linens. In the kitchen, floor tiles were missing at the entrance, and the removed tiles were placed on a pellet warmer next to the missing area. The Director of Maintenance stated the tiles had been removed a couple of months earlier and acknowledged that the missing tiles could be an area where staff could trip and fall. Throughout the survey, residents, family members, visitors, and staff consistently reported concerns about roaches, room size and layout, clutter, and cleanliness. Residents described roaches crawling on ceilings and walls, flying roaches present day and night, and worsening infestations since construction began. Staff interviews confirmed difficulty providing care and cleaning in cramped rooms with beds against walls and acknowledged environmental issues such as gaps at thresholds that allowed insect entry and leaking plumbing that contributed to standing water. Despite these observations and reports, during multiple debriefings and final interviews, the administrative team either made no comments, voiced no concerns, or did not provide additional information regarding the identified environmental and cleanliness deficiencies.
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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