Inadequate clean linens were available on the second floor, affecting a resident’s bed and the linen supply for the unit. A resident representative was changing linens and found no pillowcases available, and later a resident was observed without a top sheet, lying on a fitted sheet under a bedspread. A CNA confirmed there were no linens available in the linen closet and said it was not unusual for the closet to be empty. The DON acknowledged ongoing issues with maintaining clean linens, and the Laundry Supervisor and Administrator confirmed laundry staff were responsible for stocking the clean linen closets.
Obstructed Shower Drain Caused Repeated Flooding: A shower room drain was backed up, and water pooled on the floor and overflowed into the hallway and near the nurse's station. A resident reported fearing she might fall, another resident said the clog had been ongoing for months, and an LPN confirmed repeated overflow events that were not reported. Maintenance acknowledged the drain was backed up, and the DON said an outside company had been called to assess the flooding issue.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
Failure to Maintain a Homelike Environment: A resident’s wall behind the bed had a large area of missing paint with exposed sheetrock, and the condition was described as ongoing. The Maintenance Supervisor said staff and family had been told not to push the bed against the wall, but the issue continued and had not been reported through work orders. The Administrator confirmed the condition did not meet the expectation for a home-like environment. The resident had a hx of moderate protein-calorie malnutrition and a BIMS score of 10, indicating moderately impaired cognition.
Leaky Faucet Not Repaired in Resident Room: A resident with COPD and intact cognition had a leaking sink in her room that remained unrepaired after she had previously reported it. The Maintenance Director confirmed the work order was overdue, and the Administrator acknowledged the repair request had not been completed; the resident reported the dripping water interrupted her sleep.
A resident’s room air conditioning vent was observed to have visible dust and debris, and it remained dirty on a later observation. The resident’s wife said she had told an LPN about the issue about a month earlier and was told maintenance had been notified, but it was not addressed. The LPN said she spoke with maintenance staff but did not submit a maintenance request ticket, and the Maintenance Director confirmed no request had been logged.
Damaged bedroom walls were observed in three resident rooms, including exposed sheetrock, heavy scuffing, and chipped paint behind beds and a recliner. One resident was cognitively intact, while two others had severe cognitive impairment; staff confirmed the wall damage and noted several rooms needed repair and repainting, with the Administrator stating the facility had difficulty hiring a painter.
Dirty and rusted overbed tables were observed in three resident rooms, with a thick black substance on the metal bases that was readily visible upon entering the rooms. CNAs reported the tables appeared very rusty and in poor condition, one CNA had not noticed the issue or submitted a work order, and the DON stated the tables looked bad and did not represent a homelike environment. The Maintenance Supervisor said no work orders had been received and noted multiple overbed tables on the wing were rusted and in need of replacement.
Broken Window Blinds in Resident Rooms: The facility failed to keep window coverings intact and in good repair in two resident rooms. Surveyors observed blinds with broken and missing slats, leaving a large gap at the bottom and exposing the outside elements. A CNA confirmed the issue had been reported, and the Administrator stated the blinds were unsightly and did not meet the facility's homelike environment expectation. The Maintenance Director said repairs depend on a work order and was only notified about one room.
The facility failed to maintain a clean, comfortable, and homelike environment when ongoing shortages of towels, washcloths, sheets, and bed pads left staff without adequate linens for resident care. Surveyors observed empty linen closets, and CNAs reported repeated morning shortages over several days, leading them to use wipes or pillowcases for hygiene and perineal care, which delayed care. A resident reported daily linen shortages, late bed-making, and lack of bed pads or linens at night. The Housekeeping Supervisor cited limited laundry hours and staffing issues, while the DON and Administrator acknowledged persistent shortages over several weeks, with concerns that staff were discarding heavily soiled linens instead of laundering them and documentation showing closets consistently low during morning inventories.
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