Surveyors found holes in hallway walls and multiple shower rooms being used to store resident equipment, belongings, and supplies in addition to bathing residents. The shower areas contained plugged-in electrical equipment, dirty linens, personal items, and disorganized storage, while the shower stall floors had peeling, chipped, and worn non-skid coating. The DON and Administrator acknowledged concerns about the condition of the shower rooms, the wall damage, and the unsafe storage of equipment.
Unsanitary Kitchen Environment: The facility failed to keep the kitchen clean and sanitary. Surveyors observed grime on pantry and refrigerator doors, food crumbs in refrigerator seals, black grime on the ice machine, brown splatters on walls, grimy floors, soiled garbage cans, and splatters around the sink area. The DM stated he did not regularly monitor kitchen cleaning, and staff reported cleaning duties were assigned but not consistently completed.
The facility failed to maintain a safe, clean, and sanitary laundry environment and to properly manage a resident’s clothing. A resident with COPD, heart failure, type 2 DM, and ESRD had most of their clothing lost during a short stay, and the family member who searched for the items described the laundry room as extremely hot, messy, dirty, with clothes everywhere and overflowing trash. Staff interviews confirmed the laundry room had long‑standing issues with excessive heat and clutter. Surveyor observations found floors between and behind washers covered with dirt, a dry flaky substance, loose concrete, and residue on piping and chemical tubing, alongside buckets of corrosive chemicals. Interviews with housekeeping, EVS, a chemical vendor, and maintenance showed that a chemical spill behind the washers had occurred over a year earlier and was never properly cleaned up, with conflicting accounts over whether maintenance or EVS was responsible and no effective system to ensure cleaning behind the machines.
The facility failed to maintain a safe, clean, and well‑maintained environment as required by its own policy, with surveyors observing loose kitchen handrails, damaged doors and wood paneling, exposed concrete and stained flooring in resident rooms and bathrooms, bubbling and chipped paint, rusted door frames, water‑stained ceiling tiles, scuffed walls and baseboards, damaged tiles, and deteriorated outdoor structures such as a raised garden bed. Additional issues included a broken cabinet and taped wall corner guard in shower rooms, an unsecured wall clock, a missing floor tile, dried paint splatter, rusted heating/cooling units with chipped paint, and a pool table with a missing corner guard. A resident reported a heating/air unit in her room with a missing bottom panel exposing dust and debris. Staff interviews revealed that some items had been broken for years, concerns about the safety of the handrails had not resulted in repairs, housekeeping did not consistently log issues for maintenance, and there was no formal system to track and ensure completion of maintenance work orders, as acknowledged by the DON, the Maintenance Director, and the Administrator.
Surveyors found the facility failed to maintain a safe, clean, and well-repaired environment, with unsecured kitchen handrails, damaged doors and wood paneling, holes and stained flooring in resident rooms and bathrooms, bubbling paint, rusted door frames, water-stained ceiling tiles, and scuffed walls and baseboards. Common and shower areas had missing cabinet hardware, taped wall guards, an improperly mounted clock, a pool table with a missing corner guard, and a structurally deteriorated raised garden bed. Flooring defects, rusted heating/cooling units, and exposed dust and debris in a resident’s HVAC unit were also observed, and a resident reported dissatisfaction with the cleanliness. Staff interviews revealed that some items, such as a broken shower cabinet and unsafe handrails, had been problematic for years, that housekeeping did not consistently log issues for maintenance, and that there was no formal system to track and ensure completion of maintenance work orders despite leadership expectations for a safe and clean environment.
Housekeeping and maintenance failed to keep multiple resident rooms clean and in good repair. Observations found scuffed and missing paint, wall holes, a black substance in a shower, and a broken bathroom light dangling from the ceiling. Staff, including the Maintenance Director, DON, and Housekeeping Aide, stated that work orders could be submitted by staff, but the observed issues remained present.
Housekeeping and maintenance failures left resident rooms and common areas unclean and damaged. Observations found cracked tile, broken toilet paper holders with sharp edges, broken wall bumpers, a black stain around a toilet, uncovered bedpans with yellow liquid, and debris under shower mats in men's shower rooms. The DON described one shower room as filthy, and interviews with the Maintenance Director, DON, Housekeeping Manager, and Administrator confirmed that staff were expected to report needed repairs, while the Maintenance Director said no active work orders were pending.
Housekeeping and Environmental Maintenance Deficiencies: The facility failed to maintain a clean, sanitary, and safe environment for several residents. Observations found cracked and broken ceiling tiles, stains in bathrooms, chipped paint and wood near resident beds, a raised bathroom floor surface, and holes in a hazardous material doorframe. Staff interviews showed maintenance issues were tracked through books and TELS, but the Maintenance Director said he mainly checked the books and did full walk-throughs only monthly, while the Housekeeping Manager said rooms were deep cleaned weekly with spot cleaning on other days.
Unsafe and poorly maintained resident areas were observed throughout the facility, including cracked and broken floor tiles, chipped paint, a loose baseboard, a hole in a resident room floor, and a damaged door frame with exposed sharp metal. A resident reported a wheelchair wheel getting stuck in the floor hole, and another said the room did not feel like home because the wall behind the bed needed painting. The dining room also had cracked and uneven tiles, scratched walls, and rust exposed on the kitchen door. The DON said he was unaware of the cracked tiles, and the facility had no housekeeping or maintenance policies available for review.
Unpleasant Odors and Fecal Contamination in Common and Shower Areas: The facility failed to keep the Men's locked dementia unit free from persistent urine odors and fecal contamination. Surveyors repeatedly observed a strong stale urine odor in the day room and halls, and staff acknowledged ongoing incontinence, refusals of showers, and urine-soiled fabric chairs that were not consistently disinfected. Surveyors also found feces smeared on toilet surfaces and floors in shower rooms used for resident toileting, along with soiled clothing and blood on a sink lip, while staff stated there was no set cleaning schedule for those rooms.
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