Facility Fails to Maintain Safe and Homelike Environment
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as observed during a recertification survey. Multiple deficiencies were noted across several units, including mismatched paint patches, discolored blinds, worn window treatments, torn wallpaper, damaged furniture, and dirty, dusty areas. These issues were evident in four out of five units, indicating a widespread problem with the facility's maintenance and housekeeping practices. On Unit 1 North, the baseboard and door corners in the shower room were in disrepair, and several rooms had large unpainted areas near the radiator. Unit 1 East had unpainted patches on hallway walls and ceilings, dirty windows, cracked plaster, missing privacy curtain hooks, and damaged walls. The 2nd Floor had mismatched paint, peeling paint, unpainted patches, tattered window treatments, and loose air conditioner units. Unit 1 West had stained and worn furniture, broken window blinds, dusty and dirty window sills, and broken plaster. Interviews with maintenance and housekeeping staff revealed that repairs and cleaning were not being completed in a timely manner. Maintenance workers acknowledged delays in painting and repairing damaged areas due to other priority assignments. Housekeepers reported challenges in cleaning certain areas due to resident presence and the inability to clean certain items effectively. The Director of Housekeeping and Maintenance and the Administrator acknowledged the issues and stated that efforts were being made to address them, but the deficiencies remained uncorrected at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **Immediate Correction:** 1) As of 12/31/24, The Maintenance Department will prioritize the immediate repair of all areas identified in the survey, including the unpainted walls, mismatched paint patches, cracks, and damaged areas in Rooms 40, 38, 37 (Unit 1 North), Rooms 25, 28, 18, 16/17 (Unit 1 East), Rooms 206, 210, 203, 211, 215, 217 (2nd Floor), and Rooms W49, W65, W47b, W52 (Unit 1 West). 2) As of 12/31/24, All areas observed with visible dirt, dust, or staining (e.g., air conditioner units, windowsills, walls, and bathroom tiles) were thoroughly cleaned and sanitized by the Maintenance/Housekeeping team. 3) As of 12/31/24, the windows in room [ROOM NUMBER], the air conditioners in multiple rooms (e.g., W49b, W65), and the bathrooms with stained tiles were cleaned by the Maintenance/Housekeeping team. 4) As of 12/31/24, The Housekeeping staff performed a detailed cleaning of the affected areas and provided documentation of completion. 5) As of 12/31/24, In Room W49b, the stained and worn mattress, broken bed frame, and broken closet were repaired. 6) As of 12/31/24, The missing door handle in Room W49b was replaced by the Maintenance team. **Identification of Others:** 1) Units 1 North, 1 East, 2nd Floor, and 1 West will have their rooms assessed for cleanliness and safety, and corrective actions will be taken as needed. All affected rooms will be given priority for repairs and cleaning. 2) The Director of Housekeeping and Maintenance will oversee that the rooms are returned to a safe, clean, and comfortable environment. 3) A facility-wide audit will be conducted to identify any additional rooms or common areas that may require repair, cleaning, or redecoration. This includes assessing all floors, any unpainted walls, damaged window treatments, and necessary repairs to ensure that all areas meet the facility’s safety and comfort standards. **Systemic Changes:** 1) The facility’s Safe, Clean, Comfortable and Homelike Environment policy will be revised to include clearer guidelines on maintaining rooms, common areas, and the timely reporting of repairs or maintenance concerns. 2) The updated policy will also specify the roles and responsibilities of the Housekeeping and Maintenance departments in ensuring a safe and homelike environment. 3) The Director of Maintenance and Maintenance and housekeeping workers will undergo additional training to understand the updated standards and expectations for maintaining a safe, clean, and homelike environment. 4) A clear protocol will be implemented for housekeeping staff to immediately report issues to the Maintenance Director, including a system for tracking repairs and ensuring all issues are addressed in a timely manner. 5) The facility will implement daily environmental rounds with the Administrator, Assistant Administrator, Director of Housekeeping, and Maintenance Director to assess the cleanliness, safety, and comfort of resident rooms and common areas. 6) A formal audit checklist will be developed to ensure the environment meets the facility's standards for cleanliness, maintenance, and homelike qualities. 7) Any issues identified during the rounds will be documented, and corrective actions will be taken immediately. Any issues that cannot be resolved during the rounds will be logged and addressed within a defined timeframe (e.g., 24-72 hours). 8) A Maintenance Log will be implemented, where maintenance and housekeeping staff will be required to record and report any issues they notice during cleaning. This log will be reviewed daily by the Maintenance Director to ensure timely action is taken. 9) The facility will ensure all maintenance issues reported in the log are tracked through completion, with clear timelines for resolution and documentation. 10) Staff will be instructed to immediately report any areas of concern in resident rooms or common areas, ensuring that all repairs and cleanliness issues are promptly addressed. **Quality Assurance:** 1) The Director of Maintenance/Housekeeping will conduct weekly audits for the next 3 months to ensure that all repairs, cleaning, and updates have been completed as per the standards outlined in this plan. The audits will also assess whether the facility is maintaining a safe, clean, comfortable, and homelike environment for residents. 2) The facility administration will establish a feedback mechanism for residents and their families to provide input on the condition of the environment. A survey or comment box will be placed in common areas to allow for anonymous feedback on cleanliness, safety, and comfort. 3) Feedback will be reviewed by the Administrator and the QAPI team, and corrective actions will be taken based on the feedback received. 4) Weekly audits will be completed by the Maintenance and Housekeeping weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. **Person Responsible for this Ftag:** 1) The Administrator.
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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