Unsafe and Unclean Resident Environment: A resident was observed in bed with an emptied, needleless saline syringe left on top of the blanket, and a soiled paper towel was found inside a drawer outside a room that contained PPE gowns. The LNHA stated that saline syringes should not be left in a resident’s bed. The facility policy requires a clean, sanitary, and orderly environment.
A resident’s floor mat was repeatedly observed dirty, stained, and wet, and a CNA said housekeeping had been called but the mat was still dirty. In addition, a resident council member reported a morning towel shortage, and the 4th floor unit had 63 residents but the 7-3 cart listed only 60 towels; the supply closet had no towels while the laundry room had towels being processed and folded.
A resident was observed in bed with a bed controller cord that had a broken sheath in several areas and exposed wires. The resident said the cord had been that way for many months and had been reported to the facility, but it was never fixed. An LPN and the DON both stated they had not noticed the damage.
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.
Unclean and Damaged Resident Room Environment: A resident’s room had an unlabeled open food container and debris inside a personal refrigerator, ice in the freezer with no thermometer, debris on the bedroom floor, and damaged walls and bathroom trim with visible residue. The DOM, D of Housekeeping and Laundry, IP, and DON gave differing accounts of responsibility for cleaning the refrigerator and maintaining the room, while the facility policy required a clean, sanitary, and orderly environment and labeled refrigerated foods.
Sticky Floor and Soiled Table in Memory Care Dining/Activity Area: The memory care dining/activity room floor was repeatedly observed to be sticky while residents and staff were present, and a large rectangular table was visibly soiled with fingerprints, smudges, and a thick dried substance. The AA stated housekeeping typically cleaned the area, the DES said the floor was swept and washed each morning, and review of records showed the cleaning schedule did not document the memory unit dining/activity area. A later document confirmed the floor chemical dispenser was out of alignment and required replacement and calibration.
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.
Unsafe and Unclean Resident Areas: Surveyors observed peeling wood on CNA charting station drawers used by residents, stained rugs in family rooms, a broken floor tile, stained ceiling tiles, and dust or blackish buildup on vents, window sills, baseboards, and hallway lights in resident rooms, bathing areas, dining areas, hallways, and a soiled utility room. Staff, including an LPN, CNA, RN/UM, housekeeping, and maintenance, acknowledged several of the conditions and were unsure how long some had been present or who was responsible for cleaning certain areas.
Bathroom Light Out for Resident Room: A resident in a semiprivate room on the C Wing reported that the bathroom light was not working, and the surveyor observed the light switch did not turn on the ceiling light and there was no cover on the fixture. The resident, who used a rolling walker, said maintenance knew about the issue but had not fixed it, and later stated it was hard to use the bathroom at night. The maintenance log documented the problem, but the repair section was blank, and staff could not provide documentation of the ordered light or a homelike environment policy.
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