Resident 67 has severe cerebral palsy with extreme stiffness in all limbs and cannot move. The resident scored zero on cognitive assessments, indicating severe impairment with no discernible consciousness.
On December 15, inspectors found the resident's bedside fan covered in a thick layer of dust and cobwebs. The fan was turned off but pointed directly at the resident's face.
The next day, the same fan was running and still aimed at Resident 67's face. The dust remained. The resident's mouth was open.
On December 17, inspectors returned at 9:04 AM to find the fan still operating, still dusty, still pointed at the resident's open mouth.
When confronted about the conditions, nursing staff said they only cleaned bodily fluids from resident rooms. Lead CNA Staff 39 told inspectors on December 17 that nursing personnel had no responsibility for cleaning fans.
Housekeeping staff also refused accountability. Staff 37 from housekeeping said she and her colleagues were not responsible for cleaning residents' personal fans.
The housekeeping manager doubled down on that position. Staff 38 entered Resident 67's room at 1:35 PM on December 17, acknowledged the thick dust coating the fan, and stated housekeeping was not responsible for cleaning personal fans in resident rooms.
Even maintenance disclaimed responsibility. Maintenance Director Staff 15 came to the room at 3:14 PM the same day, saw the dusty fan, and said maintenance was not responsible for cleaning residents' personal fans.
The director of nursing finally acknowledged the problem. Staff 2 entered Resident 67's room at 3:26 PM on December 17 and admitted the fan was on, dirty, and pointed directly at the resident's face.
But by then, the quadriplegic resident had endured at least three days of a contaminated fan blowing dust and debris toward their open mouth while conscious of nothing.
The facility's departments had created a perfect circle of neglect. Nursing said it wasn't their job. Housekeeping said it wasn't their job. Maintenance said it wasn't their job. The director of nursing could only acknowledge what inspectors had documented.
For Resident 67, the bureaucratic finger-pointing meant breathing air filtered through layers of accumulated dust and cobwebs. The resident cannot speak, cannot move, cannot turn away from the contaminated air stream.
Federal inspectors cited the facility for failing to maintain a sanitary environment. The violation affected few residents but demonstrated how institutional indifference can compound the vulnerability of the most defenseless patients.
The inspection occurred following a complaint. The facility has not yet submitted its plan of correction for the deficiency.
Resident 67 remains at Gresham Post Acute Care and Rehabilitation, still quadriplegic, still in a vegetative state, still unable to advocate for basic cleanliness in their immediate environment.
Full Inspection Report
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