Surveyors found that the facility failed to maintain a clean, sanitary, and homelike environment on both floors, including black discoloration and chipped tiles in a first-floor shower stall, ripped wallpaper behind a bed in one room, and a gap with black vegetative substance between an AC/heater unit and drywall in another room. On the second floor, surveyors observed cracked tiles, a clump of hair in a shower room corner, a black substance on the shower floor, and a bathroom sink with cracked, peeling caulk and a gap between the sink and wall. The ADON acknowledged the need for attention to the shower tiles and stated housekeeping handled major shower room cleaning, while the LNHA reported that maintenance and an ambassador team tour the facility daily to promote a homelike environment, consistent with the facility’s Homelike Environment policy requiring a clean, sanitary, and orderly setting.
Improper Disposal of Soiled Materials and Unclean Linen Storage: Surveyors observed soiled linen, PPE, and gloves discarded on top of a trash receptacle and on the floor in a room with EBP signage. For a resident with dementia, muscle weakness, and an unhealed stage 4 pressure ulcer, surveyors also found clean linens and incontinence supplies sitting on top of a trash bin cover. The CNA, LPN, DON, and IP all confirmed that PPE and linen were not being stored or discarded as required by facility practice.
Disrepair and staining were observed in a resident room and in HP unit common areas, including peeling and missing wallpaper, broken wall protection, stained ceiling tiles, and a baseboard heater with a crusty brown substance and dents. The DBS, DON, Assistant Administrator, and Administrator acknowledged the areas were in disrepair and detracted from the homelike environment.
Homelike Environment Not Maintained: Surveyors observed a cracked bedroom window, patched walls, stained ceiling tiles, cracks above doorways, debris on a shower bed, and stored items on the shower room floor on the 200 Unit, along with stained ceiling tiles on the hallway leading to the 300 Unit. The MD said several repairs were ongoing, including a delayed window replacement, and the HKD stated shower rooms were cleaned daily by housekeeping and after each resident use by nursing staff, but the shower room condition was not consistent with infection control standards or a homelike environment.
Surveyors found that the facility did not maintain required environmental standards in multiple resident-accessible areas. Dining/activity rooms on upper floors were documented at temperatures below the acceptable range, and a dining room that leadership described as decommissioned had no signage and remained accessible. In resident rooms, a loose pipe was found on the floor, privacy curtains were not properly hooked, and a ceiling vent had visible grayish buildup. A hallway linen cart was left partially uncovered with dried substances and stains on its cover. On two upper floors, hallways, rugs, walls, handrails, and dining rooms showed large dark stains, peeling wallpaper, and worn surfaces, with nursing and housekeeping leadership acknowledging that these conditions had persisted despite repeated cleaning and prior verbal reports. These findings conflicted with the facility’s own policy requiring a safe, clean, comfortable, and homelike environment in all resident areas.
Surveyors identified extensive environmental deficiencies, including unsanitary ice machines, food debris, soiled linens, and broken furniture, along with a persistent cockroach infestation affecting resident rooms, personal belongings, and common areas. Multiple residents and staff reported ongoing pest sightings and distress, with measures such as wrapping belongings in plastic and blocking beds with towels. Delayed removal of soiled items and strong odors from unaddressed incontinence episodes further contributed to an environment that was neither clean nor homelike.
Surveyors identified multiple deficiencies in the Memory Care Unit, including missing or broken furniture components, damaged surfaces, and unaddressed maintenance issues in both resident rooms and common areas. Staff interviews confirmed these problems and described a logbook system for reporting repairs, but the environment was not maintained in good repair as required by facility policy.
Surveyors found that the facility failed to maintain a clean, safe, and homelike environment, with observations of dirty and damaged equipment, unclean and sticky floors, broken furniture, missing or damaged window screens, and inadequate cleaning of shower rooms and vents. Residents and staff confirmed these issues, and review of facility policies and logs showed a lack of effective cleaning and maintenance systems.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with observations including soiled and damaged carpets, dust and debris accumulation, broken exposed pipes, leaking and stained air conditioner covers, missing window treatments, and unsanitary kitchen and dumbwaiter areas. Facility staff were unaware of some issues and could not provide documentation of recent environmental rounds.
Multiple environmental deficiencies were observed, including a broken window blind in a family room, damaged door frames in a dining area, torn carpet and a sharp broken plastic piece in a resident room, and loose ceiling tiles in another room. A resident with multiple health conditions reported the ceiling tiles had been loose for months and expressed concern for their safety. Facility staff were either unaware of these issues or unable to provide documentation of maintenance requests, and no policy for maintaining a homelike environment was available.
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