Surveyors found multiple maintenance and housekeeping issues, including water-stained ceiling tiles, missing or damaged room fixtures, exposed drywall, a broken wheelchair armrest, and trash and food debris in a unit dining area. A resident with dementia was also observed in a room without a sheet on the bed, with ant and roach spray on the bedside table, and the UM confirmed the spray belonged to the family and that the bed had been cleaned earlier but not yet made up.
Inconsistent resident room temperatures led to a deficient homelike environment when multiple rooms were documented above the acceptable range and residents reported repeated episodes of excessive heat. Survey findings included portable AC units throughout the units, resident complaints that the building and rooms were hot, and temperature logs showing several rooms reaching the 80s and even the 90s. The ADM stated thermostats were reset when they tripped, but no documentation was provided showing residents with elevated room temperatures were accommodated.
Facility maintenance services were not provided to keep resident rooms and equipment in proper condition. Surveyors observed multiple residents’ wheelchairs with torn vinyl, missing padding, and missing armrests, along with two unattended wheelchairs with damaged or missing armrests. They also found water-stained ceiling tiles in the lobby, hallway, and several resident rooms, plus missing and loose wood trim around a sink. Staff interviews identified a breakdown in the repair reporting process, with one housekeeper using verbal reports instead of the electronic system and the DON noting staff were expected to use the system for non-emergency repairs.
A facility failed to maintain a clean, safe, and comfortable environment in 3 of 4 rooms reviewed. A bathroom had no airflow, felt warm, and retained an odor because the exhaust fan was nonfunctional, and two other rooms had damaged bed footboards and water-damaged closet doors with swelling, warping, and bubbling paint.
Facility staff failed to maintain a clean, homelike environment on multiple units. Surveyors observed discarded gloves on floors and at a room entrance, food and crumbs scattered in hallways, a discarded mask on a PPE cart, dirty dishes piled on a cart, linen carts in disarray with briefs, wipes, trash bags, and gloves, and a black cart outside a resident room holding partially eaten food, dirty dishes, silverware, and exposed food. Hallway flooring on one unit also had blackened drip-like stains that remained visible over several observations, and an LPN/Supervisor stepped over gloves left on the floor.
Homelike Environment Not Maintained on Unit D: Surveyors observed thick debris on a lobby vent, severely worn and stained Unit D carpeting, a cracked dining room window, damaged parking lot pavement, worn resident furniture, disrepair in room signage and doors, unfinished ceiling lights near the nurse station, and debris on the bird enclosure glass. The Maintenance Director acknowledged the concerns, and the Administrator was informed before survey exit.
Unsafe and deteriorated room and bathroom conditions were observed for two residents. One resident’s bathroom had a flickering light, cracked and pitted wall surfaces, peeling baseboards with a mold-like buildup, and a damaged nightstand with a missing drawer and detached cabinet door. Another resident’s bathroom was missing a towel rack, and hygiene items were stored on top of a trashcan, obstructing access to the hand sink.
Bathroom environmental conditions were not maintained in a shared resident bathroom. Surveyors observed a missing light fixture cover, unfinished wall repairs with visible patching material and gaps, and ceiling tiles that were displaced and stained brown from water. The Maintenance Director confirmed the concerns during interview.
Resident rooms on the unit were observed with marred walls, cracked and peeling paint, loose cove base, missing or loose floor tile, damaged bathroom door frames, and a privacy curtain that did not provide full privacy. A black bug was also seen in cracked bathroom floor tile during the tour, and the Maintenance Director acknowledged the concerns.
Unsanitary and Damaged Resident Care Areas: A resident’s overbed table had food or drink residue, several bathrooms had extremely rusted towel racks, and a room used for resident equipment was also set up as a shower room while being used for storage. Other shower areas had missing fixtures, damaged drywall, cracked tiles, stained curtains, a nonworking vent, and soiled items on the floor. Ice scooper containers in nourishment areas contained cloudy liquid or water with no drainage, and one nourishment room had a temperature log but no thermometer was observed.
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