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 Bed Linens: A resident with hypothyroidism and chronic diastolic heart failure had a pillowcase with several dry dark brown/red areas and sheets that appeared gray and unclean. The resident could not remember the last time the linens were changed, and the DON confirmed the linens should have been changed.
Dirty Resident Room and Respiratory Equipment: A resident with dysphagia, a feeding tube, and a tracheostomy had a room observed with a dirty fan, debris on the mattress, dust and dried debris on the O2 concentrator and trach machine, and a dirty towel on the bed. A family member reported the area by the bed was often dirty from tube feeding, and an LPN Resident Care Manager agreed the room was dirty and needed daily cleaning.
A resident’s room and the second-floor hallway had missing baseboards, including under the window in the room and periodically along both sides of the hall. During interview, an Mnt. employee stated the machine must be hitting them and that they had been taken off.
A resident room wall near the window was observed damaged and in disrepair, with a crack large enough for an ink pen to be inserted through it. The Maintenance Director said he knew about the damage after the resident reported it about 2 weeks earlier and believed it was caused by an AC leak. The damaged area covered about 6 square feet, while the Administrator said she was not aware of it and that the facility did not have a specific audit for wall or structural integrity checks.
Unsafe and Deteriorated Resident Room Conditions: Surveyors observed multiple resident rooms with broken, rusted, unsecured, and deteriorated conditions, including a hanging drawer front, scuffed and chipped walls, missing wall trim/chair rails, rust on a bedframe and AC shelf, a broken bathroom tile, and a gallon of Clorox stored in a bathroom. The Maintenance Director acknowledged the environmental conditions during the walkthrough, and photographic evidence was obtained.
The facility failed to maintain a clean, safe, and homelike environment. Surveyors observed dirty hallway vents, ceiling areas with residue, damaged walls, protruding door panel edges, missing tile and cracked flooring in shower areas, and multiple unsanitary conditions in resident rooms, including cracked light covers with bugs, uncovered soiled items, and substances on floors, mattresses, bed sheets, and bedside tables. Two residents’ wheelchairs also had dried substances and hair buildup, and staff acknowledged some areas needed repair or cleaning.
Unclean Bed Linens
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain clean bed linens for one resident. Facility policy stated bed linens are to be changed at least weekly and whenever clinically indicated or requested by the resident. The resident was admitted with diagnoses including hypothyroidism and chronic diastolic heart failure, and the care plan included an intervention to keep bed linen clean due to impaired skin. During observations, the resident’s pillowcase had several dry areas of a dark brown/red substance and the bed sheets had a gray hue and appeared unclean. The resident stated he/she could not remember the last time the sheets were changed. The DON later confirmed that the pillowcase had dark brown/red areas, the sheets appeared unclean, and the bed linens should have been changed.
Dirty Resident Room and Respiratory Equipment
Penalty
Summary
The facility failed to provide a homelike environment for Resident 6, who was admitted in 2022 with diagnoses including dysphagia and whose annual MDS dated 10/25/25 showed a feeding tube for nutrition and a tracheostomy in place. During observation, the resident’s room contained a small black fan that was very dirty and dusty and appeared not to have been cleaned for a long time. The resident’s room was later observed with a mattress on the floor near the bed that appeared dirty with dried clear debris, an oxygen concentrator with dried clear debris and dust on it, a tracheostomy machine with dried white debris all over it, the black fan covered in dust, and a dirty towel on the resident’s bed. A family member stated the area next to the resident’s bed was dirty and often had liquid on it from the tube feeding and appeared gross. An LPN Resident Care Manager observed the room and agreed it was dirty and needed to be cleaned daily.
Missing Baseboards on Second-Floor Hallway and Resident Room
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the second floor. During a tour with Maintenance Employee E9, Resident R171’s room was observed to have a missing part of a baseboard under the window, and the left side of the hallway had baseboards missing periodically down the hall. The right side of the hallway also had baseboards missing periodically down the hall. During an interview, Maintenance Employee E15 stated that the machine must be hitting the baseboards and that they had been taken off.
Damaged Resident Room Wall Left in Disrepair
Penalty
Summary
The facility failed to provide maintenance services to keep a resident bedroom in good repair. In room [ROOM NUMBER], the wall near the window was observed to be damaged and in disrepair, with a crack large enough that the end of an ink pen could be inserted through the wall. The observation was made during a surveyor visit, and photographic evidence was obtained. When the wall was re-observed with the Maintenance Director, he stated he was aware of the damage and said the resident in the room had reported it about 2 weeks earlier. He stated he believed the damage was caused by the air conditioning leaking. The damaged area covered about 6 square feet and extended about 12 inches up the wall. The Administrator later stated she was not aware of the damage and said the facility had room rounds but did not have a specific audit to inspect walls and structural integrity. The facility policy stated that environmental repairs and upkeep would be addressed and corrected in a timely manner, with resident safety taking priority over cosmetic repairs.
Unsafe and Deteriorated Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple resident rooms and resident-use areas were observed in damaged, deteriorated, unsecured, or unsanitary condition in 8 of 64 rooms observed. During observations, surveyors found a broken and hanging drawer front on a built-in wall cabinet, scuffed walls with chipped and scraped paint, rusted air return vent grilles, unsecured trim adjacent to a grille, rust on a bedframe, a broken bathroom floor tile, missing wall trim/chair rail leaving unfinished wall areas, a gallon of Clorox in a bathroom, and a metal air conditioning shelf with visible rust. One room also had a dresser that was scratched and heavily exposed the wood underneath the paint. Additional observations showed more rooms with scuffed walls, chipped and scraped paint, missing wall trim/chair rail, exposed torn sheetrock, and chipped and scraped paint beneath a window. During an interview and walkthrough, the Maintenance Director acknowledged the identified environmental conditions requiring repair or correction. Photographic evidence was obtained of all the issues observed.
Cleanliness, Safety, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, and homelike environment. Surveyors observed multiple areas of disrepair and cleanliness concerns throughout the building, including shower room flooring with dark residue and chipped, open penetrations, hallway vents and ceiling areas with black, gray, and cobweb-like substances, wall gouges, and dining room ceiling vents and lights with dry splattering and rust-colored residue. The facility’s maintenance manager and maintenance director stated they were aware of some of the shower room and panel issues and knew repairs were needed. Surveyors also observed unsafe conditions in resident areas and common spaces. Plastic door panels outside two rooms had protruding edges, the south hall shower room had two large holes where tile was missing and a smaller crack, and staff acknowledged the flooring needed correction. In resident rooms, surveyors observed cracked light covers containing bugs, gouges in walls and railings, a missing bathroom door, a thick black substance at a room entrance threshold, and uncovered soiled items such as an isolation bin with soiled linen and a bedpan on the floor under the sink. Equipment cleanliness concerns were also identified. Two residents’ wheelchairs had dried substances on the cushions and wheels, with hair accumulated in the wheel mechanisms, and a CNA stated night shift should have cleaned the wheelchairs. In another room, surveyors observed mattresses with dried brown and white substances, a mattress leaning against the wall with dried white substance, dried substances on the floor and bed sheets, and a bedside table with dried brown substance. Facility logs reviewed did not document cleaning of hallway vents, mats, or mattresses at the bedside, and the Housekeeping Supervisor stated vents should have been cleaned and that nurse aides were responsible for cleaning body fluids from mattresses and mats before housekeeping cleaned them.
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