Unsafe and unsanitary resident rooms were observed with clutter, uncovered food, and rodent activity. A resident with schizophrenia and depression had food crumbs and meat under the bed, while another resident reported mouse droppings and hoarded food in a crowded room. Other rooms had overflowing bins, bags of belongings, and uncovered food, and staff reported that some residents refused housekeeping access and that pest control service in resident rooms was inconsistent.
Failure to maintain bedroom ceiling lights for two residents. One resident had impaired cognition, dementia, and was enrolled in hospice, while the other had intact cognition and diagnoses including fibromyalgia, anxiety, depression, and chronic pain. The second resident reported a flickering ceiling light that had not worked for a long time, caused headaches, and left the room dark unless she used the pull-string light. Staff said maintenance requests were supposed to be entered in TELS, but the DON and MT-D confirmed no request had been submitted for the issue.
Surveyors found that the facility did not maintain a clean and odor-free environment, as evidenced by persistent musty and urine odors in hallways and resident rooms, stained and inadequately cleaned carpets, and improper cleaning of urine spills. Multiple residents and family members reported unpleasant smells and unclean conditions, and staff confirmed challenges with housekeeping due to staffing shortages.
Surveyors found a beauty salon ceiling vent with black, mold-like and rust substances, which had not been cleaned as scheduled. The maintenance director confirmed the vent was dirty and should have been addressed during routine checks, while a salon technician failed to report a resident's concern about the vent. Maintenance records for the required cleaning were missing.
A resident's personal refrigerator was found without temperature monitoring, a thermometer, or maintenance logs, and contained expired and improperly stored food items. Facility staff confirmed that there was no process in place to ensure food safety in personal refrigerators, despite the vulnerability of residents and the facility's responsibility to provide care.
Surveyors observed orangish blackish substances on top of the dish machine, identified as rust sediment falling from the hood above. Dietary and maintenance staff were aware of the issue, but cleaning routines and maintenance had not resolved the accumulation. The facility's warewashing policy lacked specific guidance on cleaning frequency for the dish machine.
Surveyors observed that the kitchen floor in the dishwashing area had missing tile chunks, missing grout, and a green substance on the subfloor. The dietary director acknowledged these issues and identified them as a cleaning concern, but no maintenance work orders or relevant cleaning and maintenance policies were found.
A dietary aide used a dusty fan to blow directly on clean, wet dishes during air drying, despite facility policy prohibiting such devices in the dish drying area. Multiple staff, including the dietary director and infection preventionist, were unaware of the fan's condition or cleaning schedule, and the fan had visible dust and debris on its blades and cage.
Surveyors found that a shared resident refrigerator contained open, undated food items and a freezer with melted popsicles and sticky residue, with no recent cleaning documented. The medication refrigerator had water inside insulin storage containers due to ice buildup and leaking, and temperature logs for both refrigerators were incomplete for several months. The CDM, LPN, DON, and administrator confirmed these unsanitary conditions and lapses in required monitoring.
A resident with severe cognitive and physical impairments had a personal refrigerator in their shared room that was found to be unsanitary, containing multiple unlabeled and undated food items. Temperature logs were incomplete or missing, and staff interviews confirmed that required monitoring and cleaning procedures were not followed, despite facility policy mandating regular checks and cleaning.
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