Facility Fails to Maintain Clean and Safe Environment
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations made by surveyors. In one instance, a resident's bathroom had a crooked and loose toilet paper dispenser, stains on the floor near the window, and stains on the wall outside the bathroom door. Another resident's room was found with a disconnected bed rail and a bed remote control left on the floor. Additionally, the smoking area grounds were littered with discarded cigarettes, and an outdoor bench was cracked. Further observations revealed issues in the nourishment rooms across various units. In one unit, a water bottle with an unlabeled blue substance and an open sponge were found under the sink, while the ice machine had white stains and rust. Paper cups were improperly stored facing up, exposing them to germs. Another unit had a kitchen cabinet in poor condition with missing knobs and paperclips used to open doors, along with peeling paint. In yet another unit, cabinets were nailed shut, and there was visible dirt, dust, and a dead bug in the open cabinets. Interviews with staff, including registered nurses, the Director of Housekeeping, and the Maintenance Director, confirmed awareness of these issues. The staff acknowledged that personal items and cleaning supplies were improperly stored, and that the nourishment rooms required cleaning and maintenance. The Licensed Nursing Home Administrator also recognized the need for appropriate storage solutions and replacements for the damaged cabinets, indicating ongoing efforts to address these deficiencies.
Plan Of Correction
F584 Homelike Environment What corrective action will be accomplished for those residents affected by the deficient practice? The following residents were identified as being affected by the deficient practice: resident #11, resident #319, and resident #20. Resident #11 toilet paper dispenser in the bathroom was secured to the wall. The bedroom walls were repainted, and the floor was stripped and buffed. Resident #319 NJ EX Order 26 on the left side was immediately reconnected to NJ Ex Order 26.4. The bed remote control was immediately picked up, wiped clean, tested to be in working condition and placed within residents reach. Resident #20 room was immediately swept and mopped discarding the medication cup, straw and liquid on the floor. The unidentified tablet was discarded via drug buster. The clean left bedside were put away per residents request. The following areas were identified as being affected by the deficient practice: The cigarettes on the ground in the grass and sidewalk area of the designated smoking area were discarded. The cracked outdoor bench in the courtyard was removed and discarded. The pillowcases in room B8 bathroom window were removed. The window was checked by maintenance and is in good working order. Room B4 (A) wall was repainted. The water bottle with blue substance and sponge were immediately removed from Unit C/D nourishment room. The white stains on the ice machine were removed and the rust was removed off the rack. The stack of 3 paper cups observed facing up and open to room air were discarded. The nourishment room cabinet On Unit G/H was discarded and a new cabinet was installed. Cabinet doorknobs were placed on the Unit B nourishment room cabinet doors under the counter. The tied plastic bag with a mop head in it was immediately removed and discarded. The open bag of clothes on the chair was removed. The inside of the upper cabinets in Unit E/F nourishment room were cleaned. The bottom cabinets on Unit E/F nourishment room were replaced. The counter tops in Unit E/F nourishment room were cleaned. Six tied bags of clothes on the counters in Unit E/F nourishment room were removed. The missing paint around the soap dispenser in Unit E/F nourishment room was repainted. The layer of dirt and debris behind the sink in Unit E/F nourishment room was cleaned. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A facility audit was conducted to identify rooms/areas with the following: Resident bathroom toilet paper dispensers were audited for secure placement. The condition of resident bedroom walls and floors were audited. Resident bed rails were audited to ensure proper placement. Unit ice machines were audited for descaling and cleanliness. Unit nourishment rooms were audited for repairs. Nourishment rooms were audited for employee personal belongings. Resident wearing briefs were identified and asked regarding their preference of storing incontinence products. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Housekeeping Director began re-education on January 6, 2025, to the housekeeping staff reviewing the following: Resident room cleaning procedures. Nourishment room cleaning procedures. Smoking area cleaning procedures. The Housekeeping Director or Designee will conduct random audits of the following areas: Resident rooms for cleanliness of floors and walls by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Nourishment rooms for cleanliness of counter tops, cabinets and sinks by rounding and visually observing all nourishment rooms 5 days a week x4 weeks, then all nourishment rooms 3 days a week x4 weeks and then all nourishment rooms 2 days a week x4 weeks. Smoking area for cleanliness and removal of cigarettes by rounding and visually observing the smoking area 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. The Director of Maintenance began re-education on January 6, 2025, to the maintenance staff reviewing the following: Resident room repairs and preventative maintenance. Resident bathroom repairs and preventative maintenance. Nourishment room repairs and preventative maintenance. Equipment repairs and preventative maintenance ie. Bed rails, ice machines. The Director of Maintenance and or Designee will conduct random audits of the following areas: Resident rooms for identified maintenance repairs by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Resident bathrooms for identified maintenance repairs by rounding and visually observing 5 resident bathrooms 5 days a week x4 weeks, then 3 bathrooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Nourishment room for identified maintenance repairs by rounding and visually observing all nourishment rooms 5 days a week x4 weeks, then all nourishment rooms 3 days a week x4 weeks and then all nourishment rooms 2 days a week x4 weeks. Bed rails to ensure proper placement on the bed frame by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. All Unit Ice machines to ensure descaling and tray maintenance by rounding and visually observing the ice machines 5 days a week x4 weeks and then 3 days a week x4 weeks. The Unit Managers began re-education on January 6, 2025, to the nursing staff on proper storage location of personal items and resident preference of location to store incontinent products. The Unit Managers and or Designee will conduct random audits for employee personal belongings by rounding and visually observing nourishment rooms 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. The Unit Managers and or Designee will conduct random audits of residents who use incontinence products for proper storage in rooms by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. How will the corrective action be monitored to ensure the deficient practice will not recur? The Director of Housekeeping and/or designee will report on all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads. The Director of Maintenance and/or designee will report on all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads. The Unit Managers and/or designee will report all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unclean and Poorly Maintained Resident Rooms: Two residents were affected by environmental issues in their rooms. One resident’s windowpane had a crack extending the length of the window for months, and staff gave conflicting statements about awareness of the damage. Another resident reported housekeeping was not sweeping or mopping, and trash and a liquid spill remained on the floor between the beds across multiple observations. Resident council notes also documented repeated housekeeping concerns about room cleanliness.
Bathroom Sink Faucet Sprayed Water Onto Floor: A resident with RA, PTSD, and recurrent MDD had a bathroom sink faucet that sprayed water outward and onto the floor instead of downward. The resident said the problem had been present for months and had been reported to CNAs, and a CNA confirmed it had been reported to the charge nurse. Observation and interview with the MD confirmed the faucet issue and that a work order had been received but not repaired because other repairs were prioritized.
A resident with moderate cognitive impairment and dependence for ADLs was observed using a broda chair with multiple cracked cushions, exposed foam, and stuffing visible in the headrest and side areas. Staff said broken equipment should be reported for repair or replacement, but the chair remained in use and hospice had not yet been notified; the DON stated equipment was expected to stay in good repair and that the cracked cushions could not be cleaned appropriately.
Unsafe and Unclean Facility Environment: Surveyors observed multiple environmental deficiencies, including an unlocked maintenance storage room with stacked AC units, dirty vents, black substance on windowsills, walls, doors, handrails, and equipment, missing or broken light covers, holes in walls, and debris in hallways and the dining room. Staff interviews showed housekeeping cleaned vents and AC units, but filters were not changed and documentation practices were inconsistent, while the facility policy required a safe, clean, comfortable, and homelike environment.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident’s cell phone went missing and was not found or replaced, despite staff awareness and documentation that the resident’s personal effects included a phone with charger. The grievance record addressed missing clothing items but did not address the phone, and both the LPN/Resident Care Manager and Administrator stated the issue did not meet expectations.
Unclean and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-maintained resident environment for two sampled residents. Resident 112’s room was observed on two occasions to have a single crack in the right windowpane extending the length of the window. During interview, the Maintenance Director stated the window had been broken for six months, that they did not have authority to purchase a replacement window, and that facility administration was aware of the crack. The Administrator later stated they were unaware the window was cracked and said the maintenance department conducted several monthly resident room audits, during which the window should have been noted and repaired. The Administrator also stated the cracked resident window did not reflect a homelike environment. Resident 67, who was admitted with diabetes and was able to make needs known, stated during observation and interview that housekeeping did not sweep and mop and had just finished cleaning the room but left the floors dirty. Trash and a liquid spill were observed on the floor between the beds, and the same trash and spill were still present the next day. Resident council notes from March 2026 documented a request for housekeeping to ensure beds, nightstands, and surrounding areas were cleaned thoroughly, and April 2026 notes documented concerns that housekeeping was not removing trash from under the bed for three days. The Housekeeping staff member stated rooms should be swept and mopped every day, and the Administrator stated it was the expectation that resident rooms be swept and mopped daily and as needed.
Bathroom Sink Faucet Sprayed Water Onto Floor
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #53 by not ensuring the sink faucet in her bathroom was functional and did not spray water onto the floor. Resident #53 was admitted with diagnoses including rheumatoid arthritis, PTSD, and recurrent major depressive disorder. Her quarterly MDS showed a BIMS score of 15/15, indicating no cognitive impairment, and she was dependent on staff for personal hygiene. Her care plan documented an ADL self-care performance deficit related to impaired mobility and that she required assistance from one staff member for oral care management and personal hygiene. During observation and interview, Resident #53 stated she had used her power motorized wheelchair for mobility but had chosen not to get out of bed for some weeks. She reported that when she previously used the bathroom sink, the water sprayed outward instead of downward and had done so for months, and that she had told several CNAs but the faucet had not been fixed. Observation of the bathroom confirmed the faucet sprayed outward, and when the pressure was increased, water sprayed onto the floor, with a wet towel observed on the floor in front of the sink. A CNA stated she had reported the issue to the charge nurse weeks earlier and had also observed the problem herself. The MD stated he had received a work order about the faucet needing repairs but had not repaired it because other repairs were a higher priority, and he confirmed during observation that the water sprayed out of the sink and onto the floor.
Broda Chair Not Kept in Good Repair
Penalty
Summary
The facility failed to maintain a broda chair in good repair for a resident who used it for daily support and positioning. The resident’s quarterly MDS indicated moderate cognitive impairment and dependence on staff for ADLs, with diagnoses including anemia, dementia, Huntington’s disease, anxiety, depression, and bipolar disorder. On observation, the broda chair had multiple cracked areas on the headrest cushion, including vertical cracks about six inches long with inner foam visible, several cracks on the right side of the head area with foam visible, and a large cracked area on the left side with jagged breaks and exposed foam. The upper corners of the left side cushion also had stuffing and foam sticking out. A follow-up observation showed the resident continued to be placed in the same broda chair with the cracked cushions and exposed foam and stuffing. Staff interviews indicated CNA-C was not aware of the condition and stated broken equipment should be reported through maintenance or hospice if the resident was on hospice. RN-C stated the chair damage may have been caused by the resident’s helmet and that hospice would need to be notified for repair or replacement, but was not aware whether hospice had been informed. CM-B stated several chairs needed repair or replacement but hospice had not yet been notified, and identified infection control as the concern because the cracked cushions could not be cleaned appropriately. The DON stated equipment was expected to remain in good repair and that maintenance requests or hospice updates should be completed in a timely manner to maintain cleanliness and infection control. No facility policy regarding resident equipment was provided.
Unsafe and Unclean Facility Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment. During observation on 06/01/2026, surveyors found multiple environmental issues throughout the building, including an unlocked maintenance storage room on the 300 hall with seven air conditioner units stacked inside, a resident room with a black fuzzy substance on the windowsill and areas of missing paint on the walls, and a 200 hall ceiling light with no cover and two springs hanging down. The 200 hall also had a dirty cart with popcorn debris, hallway doors with black substance on the bottoms, walls with white spackle-like substance, and a broken light fixture that was missing a bulb and was dimly lit. On the 500 hall, surveyors observed six holes in the wall above the baseboard, an outside courtyard door not shut, another courtyard door unlocked, handrails with large areas of missing paint and dirt on the brackets, and a storage room with five tall boxes of supplies and one plastic-wrapped mattress sitting directly on the floor. Additional observations showed the 100 hall floor stained with a brown dirt-like substance and a blue popped balloon in the hallway, a Hoyer lift in the hallway with food debris and other black substances on the foot part, and vents near the activity room, respiratory storage room, and 100 hall with a black organic-like substance. On 06/02/2026, the dining room had a dusty floor vent and a vent cover knocked off and lying on the floor. Interviews with housekeeping, maintenance, and administrative nursing staff showed that housekeeping cleaned vents and air conditioner units, but filters were not changed, maintenance did not chart filter changes, and a housekeeping checkoff sheet had just been implemented. The facility policy stated that the environment should be safe, clean, comfortable, and homelike and that the physical layout should not pose a safety risk.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Missing Resident Cell Phone Not Addressed
Penalty
Summary
The facility failed to provide a safe environment to ensure reasonable care and protection of a resident’s personal property from loss or theft for 1 of 3 sampled residents reviewed for environment. Resident 2 was admitted with diagnoses including diabetes and high blood pressure and was able to make needs known. During an interview, Resident 2 stated their cell phone had gone missing, staff were aware, and it had not been found or replaced. The resident’s Inventory of Personal Effects, dated 04/17/2026, listed a cell phone with charger and black bag among the resident’s personal items. The facility’s grievance/concern log showed a grievance on 04/27/2026 that the resident’s family reported missing items, with the issue marked resolved on 05/08/2026. The Complaint/Grievance Report dated 05/08/2026 documented that the family reported missing clothing items and a phone on 04/26/2026; the clothing items were found and the issue was resolved, but the report did not address the missing phone. Staff interviews confirmed the phone was still missing: the LPN/Resident Care Manager stated the grievance report should have addressed the missing phone and did not meet expectations, and the Administrator stated they were not aware the resident was still without a cell phone and believed it had been found with the clothing items.
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