Staff failed to maintain a clean, safe, and homelike environment for a resident whose room remained crowded with boxes and plastic containers, scattered clothing, and multiple open and partially eaten food items left unrefrigerated, creating a sour, spoiled food odor. The resident was observed sitting on a soiled bed encrusted with spilled food while wearing a shirt heavily stained with dried food and liquids. The roommate largely avoided the room and did not explain why when asked. The DON stated that the resident was very resistant to room cleaning and became belligerent when items were moved or trash was discarded, and that the resident had since refused to speak with her.
Staff failed to maintain a safe, clean, and homelike environment across all units, with multiple residents reporting large flying roaches in rooms and common areas, difficulty sleeping due to pests, and unclean shower rooms. Surveyors observed live and dead roaches in bathrooms, a wasp nest at a resident window with a gap into the room, leaking toilets with pans catching water, stained and bulging ceiling tiles over beds, damaged doors and thresholds, and filthy floors with food debris and encrusted brown substances in several rooms. On one unit, many semi-private rooms were very small, with one bed abutted against the wall, limiting access for care and cleaning and reducing privacy for residents and visitors; staff and visitors confirmed these concerns. Hallways were cluttered with equipment, furniture, and supplies, and an emergency bathroom pull cord used by an independently ambulating resident did not activate the nurse call system. Shower rooms and the laundry area were cluttered and soiled, with used dressings, soiled items, and large amounts of unfolded and soiled laundry present, and the kitchen had missing floor tiles at the entrance, creating a trip hazard.
Staff failed to maintain a clean and sanitary environment in a first-floor dining room, where a light fixture and bug light above a dining table used by a resident were observed to be covered with cobwebs and dead insects. A CNA acknowledged the buildup had likely been present for some time. Interviews with housekeeping and dietary staff showed conflicting understandings of who was responsible for deep cleaning the dining room, and the housekeeping supervisor could not produce records or a schedule showing when deep cleaning was last performed. Facility policy required regular cleaning and disinfection of environmental and housekeeping surfaces when visibly soiled.
Staff failed to maintain a safe, clean, and homelike environment throughout the facility, with multiple resident rooms found cluttered with hoarded items, spoiled food, soiled linens, and stained privacy curtains, and one resident observed lying on a heavily soiled bed partially unclothed. Shower rooms and hallways had black buildup, broken tiles, trip hazards, and grime, while dining and dirty linen rooms contained dirty surfaces, overflowing soiled linens, and unsecured sharps and chemicals accessible near cognitively impaired and ambulatory residents. Housekeeping and laundry services were severely understaffed, resulting in excessive piles of soiled and wet laundry, minimal clean linen on unit carts, and residents lacking adequate bedding and room cleaning for extended periods, as confirmed by a resident, an LPN, and facility records of grievances and Resident Council concerns.
Surveyors found that multiple rooms on one unit had heavy dirt and debris on floors, including food items, medical waste, and a bug, and that a bathroom floor was also dirty. A cognitively intact resident reported that housekeeping came about once a week, often left debris on the floor, and that the resident had to clean up spills. The Environmental Services Director stated that one housekeeper is assigned per unit to complete daily cleaning by midday, with no further housekeeping cleaning afterward and light cleaning left to unit staff, despite a written policy requiring daily trash removal, disinfection of high-touch surfaces, full bathroom cleaning, dusting, sweeping, mopping, and supply replenishment.
Staff failed to maintain a clean, comfortable, and homelike environment and appropriate grooming on two nursing units, as evidenced by pervasive urine and feces odors in common areas and resident rooms, stained bed linens, dirty privacy curtains, damaged baseboards and furnishings, and clutter and trash on floors, including discarded wound dressings and gloves. Several residents were observed with wet pants, stained clothing, oily hair, and facial hair growth, and food particles were noted on clothing and wheelchairs. A bariatric resident reported that bariatric sheets and towels were not always available when linens needed changing, while housekeeping aides described cleaning 18–20 rooms per day, focusing mainly on floors and bathrooms and wiping tables only on request. A CNA reported that towels and bariatric sheets were sometimes insufficient at the start of shifts, requiring staff to obtain supplies from other units.
Staff failed to maintain a comfortable and homelike environment for two residents when one cognitively intact resident repeatedly reported her room was cold despite prior complaints to maintenance and ongoing issues with the PTAC heat setting, and another resident with severe cognitive impairment was found in a room with scattered personal belongings and torn wallpaper behind the bed, despite her stated preference for stored belongings and wall repair. Staff interviews revealed that a CNA responded to cold complaints only by providing extra blankets, the maintenance engineer acknowledged incorrectly switching the PTAC from cold to heat, and the assistant engineer reported multiple rooms with unrepaired accent walls damaged during bed moves, while the DON stated nursing was responsible for proper storage of residents’ belongings.
Unsafe and Unsanitary Resident Environment: Surveyors found multiple resident rooms and bathrooms with no hot water, toilets that would not flush, foul odors, and heating problems. Several cognitively intact residents reported these issues, and staff confirmed the conditions during interviews. Surveyors also observed roaches and mice in resident areas, and residents described ongoing pest activity in their rooms.
Staff failed to maintain clean, properly supplied rooms, protect personal property, and process laundry in a timely manner. A resident with complex medical needs did not consistently receive correctly sized fitted sheets for a bariatric mattress, despite an adequate central supply and 24‑hour access to laundry, and staff sometimes used whatever sheets were available instead of obtaining the proper ones. Another resident with severe cognitive impairment remained in a room with damaged walls, visible drips and spatters, trash on the floor, and a persistently dirty floor, while housekeeping and maintenance were unaware or unable to keep up with daily cleaning expectations. Two residents experienced missing personal items, including a shaving mirror and multiple laminated family photos, with incomplete or absent property inventories and grievances that were entered but never investigated or resolved. Multiple residents reported that personal clothing took more than two weeks to be returned from laundry and was often mixed up, and surveyors observed a significant backlog of soiled and clean laundry in the department, with the EVS director acknowledging delays and infrequent handling of lost‑and‑found items.
A facility failed to maintain a clean, homelike environment for two residents. One resident had a fan in the room with dust fibers and dried residue inside the cage while it was being used at bedside, and staff said housekeeping only cleaned the outside unless maintenance took it apart. Another resident’s room smelled strongly of urine on admission, with a stained carpet and repeated attempts by EVS to scrub the room, but the odor remained and the room was described as not homelike.
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