Insufficient clean linen and bedding were available, and staff could not state the facility par level for linens. Linen closets and carts were found with no towels, washcloths, flat sheets, or blankets, and staff reported daily trouble getting linen and problems with linen looking dirty and not clean. A resident was observed in bed with no linens while eating lunch, another resident said the facility runs out of linen, and a resident council member reported being bathed with towels and dried with pillowcases when standard items were unavailable.
Unsanitary and cluttered common areas were observed throughout the facility, including a dirty cabinet with trash, crumbs, and a soiled brief in the 3rd floor dining room, broken items and medical supplies left on the floor in a 2nd floor lounge, and a plate with leftover food plus a dirty refrigerator in the Homestead unit. The Administrator, DON, and Homestead Program Director confirmed the conditions.
The facility failed to maintain a clean, safe, and homelike environment. Surveyors observed a soiled wheelchair with cracked vinyl, a sling draped on an STS lift, torn and peeling wallpaper, and multiple resident rooms with damaged plaster and exposed gypsum behind the beds. A resident’s recliner also had dried white substance smears, and the Administrator did not have the requested policies for wheelchair cleaning, maintenance, or wall repair.
Lack of Clean and Adequate Linen Supply: Staff and surveyors found stained, worn linen and an inadequate supply of clean linen in multiple storage areas. On one unit, towels, washcloths, sheets, and blankets were limited, with several items stained, frayed, or faded, while a Housekeeper reported new linen was not being put out. In another area, no blankets, sheets, or pillowcases were available and only minimal towels and washcloths were present.
Unsanitary bathroom conditions were observed in resident rooms 312 and 313, including missing caulking around sinks and toilets, stained tile, a yellow substance on a wall near a shower, and dirty buildup at wall bases. Two residents reported leaking toilets with water around the base, and an IP later acknowledged issues in the bathrooms of rooms 310, 312, and 313.
The facility failed to maintain safe, comfortable room temperatures and a clean, homelike environment. Two residents reported being cold, with one and a family member observed wearing coats in a room measured at about 63°F, while staff stated room heat could not be individually adjusted and the boiler heat had been turned off despite a policy requiring 71–81°F. Multiple rooms had sticky substances on floors, debris along walls and under beds, trash on floors, trash cans without liners, excessive dust on A/C filters, and a damaged A/C unit with rust and peeling paint. Housekeeping was reported to appear only every other day, and staff did not recall recent maintenance visits. Pantries contained dirty microwaves and a soiled refrigerator, with unclear responsibility between housekeeping and dietary for cleaning them. Persistent odors of stagnant water, body odor, and urine were noted on one unit, reflecting ongoing environmental cleanliness problems.
Unfinished drywall, peeling paint, loose or cracked caulking, stained flooring, scuff marks, and hanging baseboard trim were observed in resident rooms #100, #102, and #205. The Administrator and Environmental Manager acknowledged the room and bathroom issues during a walkthrough, and the Environmental Manager stated she would send a list to maintenance for repairs.
Dirty air conditioner/heater filters were observed in three of eight resident rooms, including rooms 202, 204, and 206. During a walk-through, the surveyor noted about one-quarter inch of dust on the filters, and an LPN later verified the filters were covered with a dust layer.
Homelike Environment Deficiencies in Resident Rooms and Hallways: The facility was cited after the surveyor observed missing and disrepaired caulking around a toilet in one resident room, torn floor molding near a sink in another room, and bug lights in the 100 and 200 hallways with multiple dead insects visible on sticky paper. The findings were reviewed and confirmed with the Administrator.
Unclean room fixtures and improper closet storage. Surveyors observed dust buildup on air vent filters in two residents’ rooms, and in another resident’s room the closet door would not close and a plastic bag with items was hanging out. The DON confirmed the closet condition and the resident gave permission for the closet to be straightened.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.