Health inspection·August 13, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for two (2) of 3 three sampled residents (Resident 1 and 2) by failing to:1. Ensure toilet was free from brownish to reddish color dry substants on the toilet seat.2. Ensure that the floor was free of clutters and food stains.3. Ensure that the dirty white towel with brownish colored substance was not placed on top of the covered linen barrel.4. Ensure that the old food tray from dinner was picked up.These deficient practices caused an unsanitary and unsafe environment potentially put residents in contamination and at risk for serious illness and/ or injury.During a record review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted on [DATE] with diagnosis which included but not limit to anxiety (common mental health condition characterized by excessive and persistent worry, fear, and nervousness), history of falling, unspecified visual loss and Type II diabetes (body cannot use insulin properly, leading to high blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/1/2025, the MDS indicated Resident 1 cognitive skills (processes of thinking and reasoning) for daily decision making was intact. During a record review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted on [DATE] with diagnosis which included but not limited to hypertension (high blood pressure), history of falling, hyperlipidemia (a condition where there are elevated levels of fats (lipids) in the blood) and Type II diabetes (body cannot use insulin properly, leading to high blood sugar). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (potentially requiring significant assistance with daily activities). During a concurrent observation and interview on 8/12/2025 at 8:00 AM at Resident 1 and 2's room, with the house keeping (HK1), HK1 stated the room was dirty. The toilet seat cover was not clean, there were dry urine from yesterday. HK 1 also stated the room was dirty. During a concurrent observation and interview on 8/12/2025 at 8:06 AM in Resident 1 and 2's room, the assistant administrator (AADM), AADM stated the room's floor was cluttered with empty cups, cup covers, and food wrappers. The floor was also crusted with dirt. The toilet bowl needed cleaning, dry feces (stool) were on the toilet seat. During the same concurrent observation and interview on 8/12/2025 at 8:06 AM with the AADM, AADM stated a dirty white towel with brownish, dry substance was on top of the white covered linen barrel. The AADM stated it should be inside the covered white barrel. The AADM also stated the leftover food from last night should have been picked up. The AADM also stated the room needs to be clean, as this can harbor bacteria and attract insects, ants, cockroaches, and rodents. During an interview on 8/12/2025 at 10:30 AM with the infection preventionist nurse (IPN1), IPN 1 stated food from night shift should have been taken out after eating. The dirty white towel with brown crusted color substance should be inside the white barrel for infection control. Other residents might get it and wipe themselves with it. IPN 1 stated the floor should be free of clutter and clean. IPN 1 also stated dirty toilet was not acceptable. These conditions can cause sickness that can be harmful to residents. During an interview on 8/13/2025 at 11:20 AM with Resident 1, Resident 1 stated that he was worried about the bathroom toilet not being clean. Resident 1 also stated he's worried that he might get sick because of that. During a review of the facility's policy and procedures (P&P,) titled Resident Room and Environment, revised on 11/1/2017, the P&P indicated Purpose: to provide residents with a safe, clean comfortable and homelike environment. The P&P also indicated the facility staff aim to create a personalized, homelike atmosphere, paying close attention to the cleanliness and order. Event ID: Facility ID: 055293 If continuation sheet Page 2 of 2