A resident room had a strong urine odor, a stand fan heavily covered in dust, dirty floors, and a disorganized appearance. The room also had large black markings on the wall next to the bed, and the DON confirmed the findings.
Bathroom Setup and Sanitation Deficiency: A resident reported urine running down the leg when using the bathroom because of the gap between the raised seat and toilet. Surveyors observed the toilet installed facing a wall, a commode seat positioned perpendicular to the toilet creating a large gap, and excrement splatter around the rim. The setup was confirmed by the surveyor and Maintenance Director to be non-homelike and not sanitary or dignified.
Housekeeping and maintenance services were not adequately provided on multiple units, with surveyors observing unbagged and unlabeled bedpans, a dirty unlabeled bed pan with dried urine, an unbagged commode lid, dirty bathroom floors, a dusty exhaust vent, a stained ceiling tile, chipped and missing paint, unlabeled urine care items and creams, used gloves on a sink counter, and other marked or marred bathroom surfaces. Facility leadership, including the Administrator, Maintenance Director, and ES staff, confirmed the findings during the tours.
Environmental Maintenance and Housekeeping Deficiencies: Surveyors observed widespread use of heavy adhesive tape as a permanent repair method on floors, handrails, a sink fixture, and other surfaces in multiple resident rooms and common areas, creating sticky, frayed, un-cleanable surfaces. They also found chipped and missing flooring, sagging wet ceiling tiles, a heavily soiled Whirlpool Room shower area, and a dirt-covered sit-to-stand mechanical lift in the corridor.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. A surveyor observed dirty and stained floors, rust, chipped or missing paint, stained ceiling tiles, damaged privacy curtains, cracked and stained sink and toilet areas, exposed sheetrock, and untreated or broken surfaces in resident rooms and the laundry area; the ES Director and Housekeeping/Laundry Supervisor confirmed the findings.
Failure to maintain a clean, odor-free environment on the Acadia Unit. Surveyors repeatedly observed a strong, foul urine odor lingering throughout the locked dementia/Alzheimer's unit over multiple days. The RN-Charge Nurse acknowledged the unit has a strong odor and said windows are opened when possible, housekeeping cleans daily, and air freshener sprays are used; the DON was informed of the findings.
Housekeeping and maintenance services were not adequately provided in multiple areas, including the North and East wings, a common area, a dining/sitting room, and the laundry room. The surveyor observed broken and cracked floor tiles, chipped and missing paint, dirty surfaces, damaged privacy curtains, rust, dirty equipment, and other disrepair in resident rooms, bathrooms, hallways, and shared spaces; the DSES confirmed the findings.
Housekeeping and maintenance services were not adequately provided on the East and West units and in the laundry room. Surveyors observed a gel cushion and wash basin stored on the floor, privacy curtains missing hooks, stained and broken ceiling tiles, chipped paint, dried residue on a dining room wall, resident dressers with worn surfaces, an unlabeled graduated cylinder in a shared bathroom, and multiple uncleanable or damaged surfaces in the whirlpool and laundry areas. The Maintenance Director confirmed the findings.
Unsafe and Unsanitary Ice Machine Areas: Multiple unit kitchenette and dining/common areas were observed with ice machine-related environmental concerns, including an improper air gap, warped and damaged cabinet surfaces with dark substance on exposed wood, a drain tube with a large black buildup, and a cabinet storing urinals, an incontinence brief, gloves, and loose garbage bags. Another kitchenette area was heavily soiled with dark unknown substances, and the counter behind the ice machine had exposed cut edges and discoloration from spilled coffee.
Housekeeping and maintenance services were not adequately provided in the laundry room and medication storage room. Surveyors observed chipped wood, broken floor tiles, rusted and damaged surfaces, dirt and debris behind washers, and stained, lifting wall and trim materials in the laundry area. In the medication room, dust and debris and a dried pink substance were found on the floor, and later observations still showed debris plus chipped, missing paint and stains on the wall; the DON and an RN confirmed the findings.
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Citations used to create this checklist
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