A facility failed to maintain a clean and homelike environment when black, fuzzy substance was observed in window AC units and on surrounding trim and walls in two resident rooms. One resident with a BIMS of 14 reported the room was musty and believed mold was in the unit, while another resident with a BIMS of 15 said the unused window AC remained in place despite using a wall unit. The MDS, resident statements, and staff acknowledgment confirmed the condition, and the facility could not provide a policy for maintaining a clean/homelike environment.
Dirty Carpets and Damaged Resident Room Closet: A resident with intact cognition reported large stains in the hallways and a damaged doorway strip, while observations found stained carpets throughout the facility, missing doorway termination plates, and a resident room closet with cracked, flaking debris, missing wall material, and black fuzzy discoloration. Staff confirmed the carpet concerns and described the closet findings as mildew, and the Administrator stated the closet doors on the floor were unacceptable and embarrassing.
Failure to maintain a homelike environment: a sunroom ceiling had hanging drywall tape and visible water damage, and two residents had unresolved room damage including scuffed drywall, drywall powder on the floor, and a baseboard heater coming off the wall with a large crack. The residents had intact cognition and reported the issues had been present for weeks to months, while the MDS and maintenance interviews confirmed the repairs had been delayed.
Unsafe and Unclean Resident Environment: Surveyors observed cluttered hallways, stained and discolored carpet in multiple hallways, and damaged walls, doors, and door frames. In a resident room, the sink was broken with a jagged edge and the bathroom floor had black stains around the toilet, which the resident also reported. The DON and Administrator acknowledged multiple unfinished repairs and stated the facility did not have a policy related to a homelike environment.
A facility failed to keep resident rooms, shower rooms, and hallways clean and homelike, with surveyors noting missing transition strips, stained and dirty flooring, black marks on doors and walls, scrape marks, missing tiles, holes, broken drywall, loose conduit boxes, peeling anti-slip strips, and strong urine odors in multiple bathrooms and hallways. Cognitively intact residents reported long-standing issues such as weekly room cleaning, damaged ceilings from a leak, and missing flooring and wall damage, while staff described limited housekeeping coverage, weekend cleaning of the whole facility, and a month-long shortage of enzyme spray for urine odors. The ADM, housekeeping, and maintenance staff also described staffing gaps, incomplete repairs, and limited maintenance rounding.
Missing Belongings Not Properly Tracked or Followed Up: Two residents with intact cognition reported missing clothing and other personal items, and one resident’s family reported repeated loss of clothes, shoes, and a walker. Grievance forms showed staff looked in laundry, rooms, and lost and found, but no inventory forms were found for either resident and the record did not show a reliable system for tracking or following up on the missing belongings concerns.
Worn dining chairs were observed in the entrance area and North DR, with faded varnish, loose arms, and cracked or peeling vinyl upholstery. A resident with COPD and DM reported that housekeeping only swept and cleaned toilets, not tables, and sticky rings were observed on the table in the resident’s room; staff also reported there was no current housekeeping manager amid budget cuts and staff changes.
A resident with moderate cognitive impairment reported peeling paint in her room, and surveyors observed multiple areas of bubbled, peeled, and damaged paint on the walls, including a framed picture used to cover one area. A plastic strainer that had reportedly been used months earlier was also found on the bathroom floor and appeared soiled, while staff said the room was on a repair list.
Soiled body pillow case left in use: A cognitively intact resident with stroke, hemiplegia, and hemiparesis used a large u-shaped body pillow because she feared falling out of bed. Surveyors observed yellow and brown discoloration on the pillow case on consecutive days, and staff later found two soiled pillow cases on the pillow before replacing them with a clean one. Staff said the pillow case was supposed to be changed weekly or when visibly dirty, and the DON said it should be changed on shower day and if soiled between shower days.
Surveyors found that multiple residents were living in unclean and uncomfortable conditions, including sticky bedside tables, discolored toilet seats, and bathrooms with used washcloths, clothing, incontinent pads, paper towels, and gloves on the floor, as well as unflushed toilets with strong odors. Staff interviews confirmed that CNAs were expected to remove soiled linens and incontinent products and keep items off the floor, but these practices were not consistently followed, resulting in failure to maintain a safe, clean, and homelike environment.
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