Dirty HVAC units and an unclean laundry area were observed throughout the facility. A resident reported moldy air conditioners, and surveyors found a dining room mini split with a mildew odor, black debris, and black stains in the vents, along with multiple unit ACs with heavy dust and debris despite maintenance logs showing recent cleaning. In the laundry area, surveyors observed dirty and dusty surfaces, uncovered clean linens and resident clothing, soiled equipment, cobwebs, and other cluttered items; staff said housekeeping was responsible for the area and that some stored items belonged to expired residents.
Resident rooms were not kept in good repair, with many second-floor rooms showing spackled but unpainted walls, peeling baseboard molding, wall damage, and exposed sheetrock. The Director of Maintenance said repairs and painting had fallen behind due to staffing changes, competing priorities, and delayed corporate approval.
Excessive Unit Temperatures: Two residents were found in an excessively hot unit when the HVAC was not working and the thermostat read 90 degrees F. EMS documented one resident as weak, unable to stand, with slowed speech, dry skin, and tenting, and the hospital noted possible heat exhaustion. The other resident was lethargic with poor intake, weight loss, and was hot to the touch; EMS reported the floor was exceptionally hot and the resident had a fan at the bedside.
Environmental maintenance and hand hygiene supplies were not maintained. Surveyors observed widespread damage and poor upkeep in resident rooms and bathrooms, including torn wallpaper, damaged walls, broken blinds, missing tile, dirty floors, insects, and stained curtains. A resident who was working toward using the toilet instead of a commode reported that the bathroom toilet would not flush and the sink leaked into a bucket, and surveyors confirmed both problems remained unresolved during the survey. Several resident bathrooms also lacked hand soap, and staff acknowledged that some dispensers were not working and soap was not available in those bathrooms.
Resident room fans in multiple rooms were observed with gray, fuzzy material on the blades, enclosure, and grills over 3 consecutive survey observations, while several fans were running. Staff gave conflicting accounts of whether Housekeeping or Maintenance was responsible for cleaning the fans, and the room routine audit form and cleaning policy did not direct fan cleaning.
Soiled Upholstered Chairs in Common Areas: The facility failed to maintain a clean and homelike environment when surveyors observed heavily stained upholstered chairs in the solarium and dining room. The Administrator acknowledged the chairs were heavily soiled and said he had been researching replacements because they were costly, but no documentation of progress toward replacement was provided. A policy on maintaining a clean homelike environment was not provided.
Unclean resident room and soiled wheelchair: A resident with chronic respiratory failure, tracheostomy, COPD, stroke, and a g-tube was observed in a room with a dirt-covered wheelchair, rusty soiled overbed tables, hardened drippings on the walls and radiators, and dirt buildup on the floor and corners. The Administrator acknowledged the buildup and said the room needed deep cleaning, while the DOR of Housekeeping could not verify completion of monthly deep cleaning or wheelchair cleaning rosters.
Soiled Privacy Curtain Not Reported for Replacement: A resident’s bedside privacy curtain had a visible soiled area that was observed during one room check and was still present days later when a housekeeper was working in the room. The HSKP supervisor stated soiled curtains are to be removed and replaced when identified, but this resident’s room was not included on the list of curtains needing replacement.
Unsafe and Uncomfortable Facility Temperatures: An LPN and residents were observed in cold rooms and common areas, with temperatures measured as low as 53 F in the lobby, 57.6 F at the nurses' station, and low 60s in hallways and dining areas. A resident in bed said, "I'm freezing," while the facility acknowledged awareness of the heating issue and had only been closing resident doors to preserve heat. Residents later reported they had complained about being uncomfortable and needing heat for at least two weeks before the survey.
Two residents were affected when the facility failed to maintain a safe and sanitary environment. A resident with a history of falls and limited mobility, who was allowed to self-transfer, used a bathroom grab bar that detached from the wall during a wheelchair-to-toilet transfer, resulting in a fall and later-confirmed rib fractures; facility environmental rounds did not include checking grab bar stability. Another dependent, severely cognitively impaired resident with CHF, prior UTIs, and pressure-ulcer risk was found to have a mattress emitting a strong urine odor beneath clean linens, despite reports from a visitor about urine smells and the absence of any mattress-cleaning schedule in facility checklists.
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