Housekeeping failed to keep a shared resident room, bathroom, and multiple unit areas clean and sanitary. A room occupied by two residents had a strong urine odor, stained flooring, a dirty toilet, and heavy clutter from cups and food containers, while other rooms on Units 4, 5, and 6 had debris, unmade beds, and floors needing cleaning. Staff and the ADM said one resident’s hoarding and resistance made cleaning difficult, but the bathroom and room condition showed the area had not been cleaned for an extended period.
Laundry Area Maintenance Deficiencies: During a complaint survey, water was observed dripping from a hose behind the first washer and later dripping onto the floor, with the MD stating the fitting needed tightening. The surveyor also found an uncovered vent in the folding room and a hole in the wall, while the MD could not verify that a vent cover had been ordered.
Unsafe and unsanitary hallway conditions were observed throughout 8 of 8 hallways on both floors, including broken, missing, sagging, and damaged ceiling tiles; missing access panel covers; patched but unfinished drywall; black stains; and dirty or damaged vents, light fixtures, and speaker covers. Air handler units in multiple wings, including the Solarium, had thick dust on intake panels and black substance on louvers and surrounding surfaces. In the 1st floor A wing, a dried black substance was seen on the wall and fire exit door, which the Maintenance Assistant said was old oil and sediment from an HVAC leak after a pipe burst; the DON also observed an air handler unit and said it needed cleaning.
Unsanitary conditions were observed in the dish machine room during the annual survey. Steam was escaping from both ends of the high temperature conveyor dish machine and scattering throughout the room, and excessive black buildup was seen on the vent stacks, dropdown ceiling tile edges, and drywalls. Staff confirmed the dish machine room would be scheduled for deep cleaning and maintenance review.
Damaged doors and a loose ceiling screen cover were observed in the Rehab Dept and on the 300 hall. A surveyor found a ceiling speaker screen hanging loose at the Rehab entrance and resident room doors with marred, chipped, and splintered wood, including rooms 300 and 304. The DOR and Regional Maintenance Director both observed the conditions during the survey.
Laundry room environmental maintenance deficiencies were observed, including a ceiling leak dripping onto the wall and floor, black staining, peeling paint, torn pipe insulation, visible dust on vents and equipment, and a leaking washer with a puddle behind it. Staff reported the leak had been occurring for a while, maintenance was not consistently aware of the issue, and the Laundry area relied on verbal reporting rather than a documented system.
Facility staff failed to maintain a clean, safe, and well‑maintained kitchen environment, as evidenced by surveyor observations of different colored particles on the base of a food lid rack, copious black dust on the exhaust fan, and a detached front panel on a PTAC heat/air conditioning unit. The Maintenance Director reported reliance on a TELS app and scheduled inspections but acknowledged not identifying the observed issues during a recent kitchen inspection, while a Certified Dietary Manager stated that dietary staff are supposed to enter maintenance concerns into TELS but admitted seeing the problems and not reporting them due to being focused on other tasks.
Kitchen Sanitation Deficiencies Observed: Surveyors found multiple sanitation-related issues in the kitchen, including torn flooring with exposed red brick, a rusted bait trap under the triple sink, chipped flooring near the walk-in freezer and refrigerator, detached and chipped baseboards in the dishwashing area and behind the ice machine, and peeling ceiling paint above the walk-in refrigerator. The NHA and Maintenance Director confirmed the conditions and acknowledged they were concerns for facility sanitation.
Staff failed to maintain appropriate shower water temperatures on the Wye Oak Unit, where one of two showers was found to have water at 87°F and a faucet that could not be turned toward the hot setting, while the other shower measured 110°F. The Director of Maintenance and Housekeeping confirmed the low temperature, acknowledged that shower temperatures should be between 100°F and 120°F, and reported being unaware of the problem. No signage was posted to prevent staff from using the malfunctioning shower, and this issue was identified during a complaint survey of one of four nursing units.
Staff failed to maintain multiple interior and exterior areas in a safe, clean, and homelike condition. Surveyors observed damaged drywall, a broken cabinet hinge, and water-damaged cabinetry in a nourishment room; uncapped electrical wires hanging from a box in a shower room; supplies and plumbing tools stored on a blanket under a sink in a supply room; and a broken soap dispenser in another shower room. Dining room windows had large gaps that allowed cold air to enter. Interviews with an LPN, the DON, and the Maintenance Director showed that maintenance concerns were not consistently documented in unit maintenance books, nourishment and supply rooms were not part of routine preventive checks, and there was no checklist to confirm repairs. Outside, the parking lot, tree line, and building entrance areas were littered with masks, gloves, bottles, plastic bags, and other debris, despite EVS leadership stating that housekeeping was assigned and monitored to clean these areas.
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