Failure to Maintain Sanitary Resident Room Due to Persistent Gnat Infestation
Summary
The facility failed to maintain a clean and sanitary environment in a resident's room, as evidenced by persistent and significant gnat infestation. The resident, who had diagnoses including schizoaffective disorder, chronic respiratory failure, and end stage renal disease requiring dialysis, was observed to have multiple gnats flying, landing, and crawling on his breakfast tray, drink cups, straws, bedside table, and bed. Staff interviews confirmed that the gnats were always present in the resident's room, with estimates of over 40 to 50 gnats at a time. Observations on consecutive days revealed leftover food and supplement drink containers with gnats crawling on them, and gnats were also seen on the resident and his bedding. Despite repeated observations and staff awareness of the issue, there was no evidence that the facility had a pest control policy or that effective action was taken to address the infestation. The resident's care plan did not address hoarding or concerns related to room cleanliness, and staff, including nursing, housekeeping, and maintenance, either did not know what was being done about the gnats or had not been notified of the problem. Housekeeping staff noted that the resident kept food in his room but did not refuse cleaning, and the maintenance director was unaware of the infestation until informed by surveyors. The administrator confirmed the absence of a pest control policy.
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Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Surveyors found multiple resident rooms with significant environmental issues, including dirty floors with stains, dirt, debris, and food particles, damaged walls with holes, scrapes, missing paint, and crumbling material, and equipment problems such as an AC unit with detached covers, a missing electrical outlet cover powering a television, and loose vent covers. Doors to two rooms were difficult to open or close, with one door dragging and gouging the floor. A RN, the DOM, and the housekeeping supervisor all verified these conditions, which were inconsistent with the facility’s policy requiring housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment.
Surveyors found that multiple resident rooms and common areas were not maintained in a safe, sanitary, and homelike condition. Observations showed stained and water-damaged ceiling tiles, cracked and stained flooring, a severely chipped bathroom door with rough, unpainted hinges, loose or improperly attached bathroom fixtures, and hallway floor boards that were stained and not fully attached. These conditions persisted on re-observation and were confirmed by facility leadership, despite a facility policy requiring a clean, sanitary, and orderly homelike environment.
Surveyors found that the facility did not maintain a homelike environment in good repair, with three burnt-out ceiling lights creating a darker section of a hallway and widespread physical disrepair throughout the building. Observations with the Administrator revealed holes in walls, peeling and missing paint, missing baseboards, and extensive scuff marks on doors, pillars, and walls, including on multiple occupied resident rooms and common areas such as the dining room, nurse’s station, and central bathing room. A resident’s heating unit lacked a cover, and the Administrator and Maintenance Director acknowledged the general disrepair and need for painting, while facility policy required an orderly, well-kept environment with adequate, even lighting in hallways and common areas.
Surveyors identified multiple environmental deficiencies, including severely damaged walls and floorboards around a nursing station, exposed drywall and hot water pipes, missing privacy curtains at toilets, and shower fixtures held together with disposable gloves in two shower rooms. Additional findings included soiled grout, missing tiles exposing bare wall, and an unsecured lightbulb hanging from exposed wiring above a shower. A maintenance director acknowledged being unaware of some issues and confirmed the disrepair, while a regional maintenance leader verified that a loose handrail and crumbling concrete at a handicapped ramp and upper walkway were known problems, even though residents rely on the rail for support.
Surveyors found that a resident’s bed remote was taped, non-functional, and reported by the resident to have an electrical short, preventing the resident from adjusting the bed, and that the blinds in the same room were broken, as confirmed by the DON. In the dining room, there was a noticeable tobacco odor and most windows lacked screens despite being open, allowing bugs to enter. The Maintenance Director stated that measurements for replacement blinds had been sent to corporate and that bariatric bed remotes varied by bed style and needed to be purchased through corporate, but he could not provide documentation that the blinds had been ordered.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in multiple resident rooms, as observed during surveyor rounds and confirmed by staff interviews and policy review. In one room, there was a large hole in the wall behind the head of the bed, with multiple scrapes, scratches, and areas of missing paint. The walls, floors, and nightstand in that room had large brown- and yellow-colored dried splatter stains of unknown origin, and the floor was visibly dirty and covered with food particles and debris. A RN verified these environmental conditions at the time of observation. Additional observations in two other resident rooms showed further environmental deficiencies. One room had an air conditioner unit with the front cover hanging off and the vent cover detached and lying on the floor, a floor with dirt marks and debris, and a long curved gouge in the floor by the entrance door caused by the door dragging, making the door very difficult to close. Another room had a door that was difficult to open, a dirty floor with stains, dirt, and debris, a missing outlet cover supplying power to the television, a partially detached vent cover, and a small dent with crumbling wall material above the baseboard near the entrance. The Director of Maintenance verified the damaged doors, missing outlet cover, dented wall, and loose vent covers, and the Housekeeping Supervisor verified the dirty floor conditions, noting prior staffing issues. These conditions occurred despite a facility policy stating that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain the resident environment and equipment in a safe, sanitary, and homelike manner for multiple residents in Building B. During an observation on 04/23/26 with the Administrator, surveyors noted that one resident’s room had ceiling tiles with large brown stains and dried brown liquid that had dripped from the ceiling. Another resident’s room had multiple cracks in the floor, yellow stains throughout the flooring, and multiple cracked tiles. A third resident’s bathroom door had severe wood chipping along the entire width of the inside door, and another resident’s bathroom ceiling tiles had water stains. In a different resident’s bathroom, the paper towel holder was not fully attached to the wall and paper towels were found on the toilet. Another resident’s room had three ceiling tiles with brown water stains. The second-floor dining room also had water-stained ceiling tiles, and on the first floor of Building B, the floor boards along the hallway were stained and not fully attached. The Administrator confirmed these observations. A follow-up observation on 04/27/26 with the Corporate Administrator and Maintenance Director confirmed that many of these environmental issues persisted. The same resident’s room continued to have ceiling tiles with large brown stains and dried brown liquid stains, and the same other resident’s room still had cracked flooring, yellow stains, and multiple cracked tiles. The resident’s bathroom door that was previously chipped now had hinges that were unpainted and rough to the touch. The resident’s bathroom ceiling tiles with water stains remained unchanged, and the bathroom paper towel holder in another resident’s room was still not fully attached and was very loose. The same resident’s room continued to have three ceiling tiles with brown water stains, and the second-floor dining room now had fourteen ceiling tiles with water stains. The Corporate Administrator and Maintenance Director confirmed these findings. Review of the facility’s “Homelike Environment” policy dated February 2021 showed that the facility was expected to maintain a clean, sanitary, and orderly environment, which was not met in these observations.
Failure to Maintain Homelike Environment and Adequate Lighting
Penalty
Summary
The facility failed to maintain a comfortable, homelike environment in good repair for all 32 residents, as evidenced by multiple areas of disrepair and inadequate lighting. During an observation of the 300 hallway, surveyors identified three burnt-out ceiling lights from outside one resident room to the end of the hallway, resulting in that end of the corridor being darker than the rest. An LPN and the Maintenance Director confirmed the presence of the three non-functioning lights and the darker lighting conditions in that section of the hallway. Review of the facility’s Safe and Homelike Environment policy showed that the facility was required to provide and maintain adequate and comfortable lighting levels in all areas, with even light levels in common areas and hallways to avoid patches of low light. Additional observations during a tour with the Administrator revealed widespread physical disrepair throughout the building. This included a three-inch hole in the wall near the reception window, dark scuff marks on the Administrator’s door, and scuff marks on multiple occupied resident room doors (rooms 104, 105, 110, 111, 113, 114, and 116). There was missing and chipping paint on other occupied resident room doors, a hole in the wall near the conference room door, scuff marks on the central bathing room door on the 100 hall, peeling paint and scuff marks on pillars in the main dining room, missing baseboards and damaged paint at the nurse’s station on the west 200 unit, and a closet door with multiple scuff marks on the west 200 unit. The heating unit in one resident’s room lacked a cover, and the kitchenette door entering the 300 unit had multiple scuff marks on its lower half, along with dark scuff marks on additional occupied resident room doors. The Administrator acknowledged that the building was in general disrepair and attributed the scuffed doors and walls to resident wheelchairs, noting recent ownership change and a new Maintenance Director. The Maintenance Director confirmed that the entire building was in need of paint. The facility’s policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, defining “orderly” as an uncluttered, neat, and well-kept physical environment, and directing unresolved concerns to be reported to the Administrator.
Environmental Disrepair and Safety Hazards in Resident Care Areas and Entrances
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment for residents, staff, and the public, with the potential to affect all 91 residents. On one hall, surveyors observed that the walls, paneling, and floorboards around the C hall nursing station were severely damaged and in significant disrepair, including exposed drywall and missing floorboards. In the B hall shower room, there were exposed hot water shutoff pipes visible through missing drywall or door covering, ripped or missing drywall immediately outside the shower, no privacy curtain around the toilet, plumbing fixtures at the shower head held together by disposable gloves, and soiled grout with approximately one foot of missing tile exposing bare wall at the bottom of the shower. The Maintenance Director confirmed that the hot water pipes should be covered, was unaware of the gloves holding the shower head together, and acknowledged the other conditions, stating they would not want their own home to appear as the shower room did. Further observations showed similar issues in the C hall shower room, including no privacy curtain around the toilet, a shower head held together by disposable gloves, and a lightbulb not securely installed or covered, hanging from exposed electrical wiring directly above the shower. During a concurrent interview, the Maintenance Director stated that nobody informs them about such issues and verified the disrepair, including the exposed lightbulb and wiring. The Maintenance Director also confirmed that the walls around the C hall nurse's station were in significant disrepair. Outside the facility, surveyors observed a loose railing at the bottom of the handicapped ramp entrance/exit that moved easily with regular force, as well as crumbling and broken concrete below the railing on the upper-level walkway near the main entrance steps. The Regional President of Maintenance verified the loose railing, acknowledged that residents use it for assistance, and confirmed awareness of the crumbling concrete. These findings were investigated under Complaint Numbers 2979015 and 2784905.
Failure to Maintain Safe and Functional Resident Equipment and Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain resident-use equipment and the physical environment in a safe, clean, sanitary, and well-functioning condition. During an observation and interview, Resident #7 was found with a bed remote that had been taped and was non-functional; the resident reported there was an electrical short in the remote and that he was unable to adjust the bed. In the same room, the blinds were observed to be broken, and the DON confirmed these findings at the time of observation. In a separate observation with the DON in the dining room, surveyors noted a noticeable smell of tobacco. Although the windows were open due to warm outdoor temperatures, four of the five dining room windows were missing screens, allowing bugs to enter the facility; the DON verified these observations. During an interview, Maintenance Director #224 stated that measurements for replacement blinds for Resident #7’s room had been sent to the corporate office and blinds were ordered, but he could not provide documentation that the blinds had actually been ordered. He also reported that attempts had been made to repair bariatric bed remotes, but the beds varied in style and new remotes needed to be purchased, with all ordering required to go through corporate. This deficiency was investigated under Complaint Number 2987038.
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