Facility Fails to Maintain Safe and Homelike Environment
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of deficiencies across various units. Resident rooms were found with scratched and damaged furniture, mismatched paint, holes in drywall, and duct tape on floors. Additionally, enteral feeding pumps and poles were observed with cream-colored stains, and shared bathrooms and whirlpool tubs were noted to be dirty and in disrepair. The kitchen area also exhibited several issues, including leaking kettles, cracked tiles, and grease residue on metal shelves. Interviews with staff revealed that maintenance and cleaning protocols were not consistently followed or effectively communicated. Dietary aides reported broken kitchen tiles and leaking kettles, while housekeeping staff were unsure of reporting procedures for damaged furniture. Maintenance staff acknowledged the need for repairs and replacements but indicated that matching paint and replacement doors were still pending. The Director of Maintenance confirmed ongoing remodeling efforts but did not provide specific timelines for completion. The facility's policies on cleaning and disinfecting resident care items and equipment were not adequately implemented, as evidenced by dusty and stained medical equipment and furniture. Staff interviews highlighted a lack of clarity regarding cleaning responsibilities and the frequency of maintenance checks. Despite some efforts to address these issues, the facility's environment remained substandard, compromising the residents' right to a homelike and safe living space.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F584 Element 1 Immediate Corrective Action:** The Maintenance Director and Food Service Director immediately took action to correct the deficiencies identified in the kitchen. A 1/2-inch quick valve was replaced to correct the leak on the kettle. The Quarry floor tile has been ordered, and all cracked kitchen tiles will be replaced throughout the kitchen. The gap in the wall edge by refrigerator #3 will be repaired. Metal shelving in the kitchen holding washed dishes was immediately cleaned. Cracked flooring and baseboard tiles in the dish room were replaced. The cracked floor tile identified in freezer #2 has been removed and will be replaced with quick-dry cement and epoxy. Next, work will begin on Refrigerator #1, and the floor will be replaced. The dish room handwashing sink opening has been closed in the tile surrounding the pipe. The metal stairs identified by the compactor were replaced on (MONTH) 14, 2025, and the wheelchair parts stored were removed. The Housekeeping and Maintenance Directors immediately acted to correct the deficiencies identified in the nursing units. **2 East:** The Director of Housekeeping audited to ensure that all feeding pumps were cleaned. Any pumps with stains, including E209, W203, and W238, were immediately cleaned or replaced. In E206, the floor tile was replaced, the duct tape was removed, and the garbage can was replaced with a new one. The drywall on the elevator bank on 2 East elevators #1, #2, and #3 was repaired and replaced with corner guards. The fan was cleaned and removed. **2 East:** The 3 areas identified with a gap around the piping in the shower rooms under the sink were filled, the shower drain cleaned, and the drain cover replaced. All debris noted in the century tub was removed and cleaned. Hoyer canvas was removed for routine cleaning. The Director of Maintenance did a whole house audit to ensure all a/c units were clean and dust-free. Areas identified were immediately cleaned to include the following rooms: W238, W203, W208, E318, E302, E311, E308, E315, E306, E302, E317, and the 4 units on 4 West Dayroom. **2 West Medication Room:** The company who built the cabinets was contacted to replace the peeling veneer on the upper middle cabinet door. The kitchenette and refrigerator/freezer in the staff lounge were cleaned immediately. **2 W room [ROOM NUMBER]:** The call light box was replaced on the wall. **room [ROOM NUMBER]:** The chip noted in the barn door was filled in, and the door was repainted. The medication cart on 2 West was removed and cleaned. **2 West Main shower room:** Debris identified in the century tub was removed, and the tub was cleaned. The bariatric shower chair was removed and cleaned, and any rusty wheels will be replaced. The cracked tile under the sink was replaced. The sharps container on the Wound Care Cart was adhered correctly to the cart to ensure it was closing. **2 West Lobby Area:** The baseboard heater cover had fallen off and was clipped back on. The ice machine vent was cleaned immediately. The hole in the wall behind the refrigerator was repaired, and the gap between the fridge and the false pantry will be repaired as we proceed. **3 East:** Brookstone Developers will begin renovating the following rooms starting (MONTH) 20, 2025: 3 East Rooms 300, 318, 306, 339, 303, 311, 308, 317, 309, 315, 305, 304, 302, 308. This will include replacing ceiling tiles and grids, flooring, painting walls, nightstands, overbed tables, wardrobe closets, a handwashing sink inside resident rooms, and new tile and showers inside each resident's bathroom. **3 West:** Brookstone Developers completed the renovation of the 3 West Main Shower Room and removed the Century Tub. This renovation includes new ceiling tiles, lighting and grids, fixtures, tile, and flooring. All old equipment, such as commodes, has been discarded. **Pantry:** All areas within the pantry were cleaned, and the metal ladle in the drawer under the microwave was discarded. **3 West Medication carts:** In (MONTH) 2023, Specialty Pharmacy provided Crown Heights Center with new medication carts; each unit has 2 medication carts and 1 treatment cart. The housekeeping department schedules the monthly cleaning of medication carts using a pressure washer. During this process, the Director of Housekeeping will in-service the staff to clean the bottom of the medication cart. All medication carts identified as being dusty or soiled were immediately cleaned. **4 West:** The 4th-floor hallway and the opposite side of the elevators were repainted. Room [ROOM NUMBER] was completely renovated and painted. W 417 Resident Room chair was replaced. The 5 Tier Linen cart with a cracked left edge was repaired. Bedside tables will be replaced in the following rooms: W400, 414, 406, 403, 408, 407, 409, 417, 421, 432, 428, 405. **Element 2 Residents at Risk:** All residents have the potential to be affected by this practice. The Food Service Director immediately audited all trays. Any cracked trays will be removed. The Director of Maintenance and the Director of Housekeeping conducted a visual inspection of the entire facility, and no other issues were identified. **Element 3 Systemic changes:** Policies and procedures were reviewed, and no revisions were necessary. On (MONTH) 6, 7, and 8th, maintenance and housekeeping staff were in-serviced to maintain a safe, clean, and comfortable environment. The housekeeping director is responsible for ensuring all equipment is clean and operable. The director of maintenance is responsible for ensuring preventative environmental rounds are routinely conducted and any identified issues are corrected immediately. An audit tool has been developed to monitor compliance. **Element 4 Monitoring of Corrective Action:** On a weekly basis for 6 months, Maintenance and Housekeeping directors will conduct environmental audits. The maintenance and housekeeping director will report findings to the administrator monthly. Any issues identified will be corrected as soon as possible. Maintenance and housekeeping directors will report findings to the QAPI Committee for two quarters. The QAPI Committee will determine if any further action is required. **Element 5 Responsibility:** Director of Maintenance, Housekeeping Director, and the Administrator.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderate cognitive impairment and extensive ADL needs was found with urine-soiled bedding, an unmade bed, and a mattress that was torn and heavily stained, with staff stating the damage had been present for a while. On the secured unit, all observed residents were served meals on plastic trays holding their plates, utensils, and drinks instead of having items placed directly on the table, and staff and the DON confirmed this was the routine practice.
A facility failed to maintain a safe, homelike environment when a resident room had broken and missing floor tile exposing the wood underneath, and two bathrooms had sinks coming away from the wall and loose enough to move when pressure was applied. One resident said the floor had been bad for some time and had been reported without being addressed, and an LPN later confirmed the damaged flooring and loose sinks.
Furniture Not Kept in Good Repair: Armchairs in multiple resident rooms and chairs in the front sitting area were observed with torn or cracked upholstery exposing cloth material. The Maintenance Director stated the furniture was not in good repair and had not been notified of the damage, while the Administrator stated staff were to remove furniture with tears.
A facility failed to maintain a clean, homelike environment when a refrigerator used for resident supplement drinks had significant ice buildup with an unknown item in it, and staff were unsure who was responsible for cleaning or reporting it. In addition, meals were repeatedly served on trays and left in front of residents during dining, which an RN and the VPS confirmed had been occurring for some time and was not homelike.
Failure to Maintain Comfortable Room Temperatures: Several residents were found in hot, stuffy rooms with weak or nonworking AC units, and room temps were measured above 81 F, including one room at 89.5 F. Residents reported feeling hot and uncomfortable, and some were not offered a room change while the issue persisted. The facility did not follow its Hot Weather policy for relocating residents to cooler areas and monitoring room temps.
Excessive ambient temperatures were observed at the 100/200 and 300/400 nurses' stations when the wall thermostat and facility temperature monitoring device both showed readings in the low 80s. The surveyor verified the readings with the Facility Maintenance Director while residents were seated in nearby common areas.
Soiled Mattress and Tray-Based Meal Service
Penalty
Summary
The facility failed to replace a torn, stained mattress and did not ensure urine-soiled bedding was changed timely for a resident who had moderate cognitive impairment and required extensive assistance with dressing, grooming, toileting hygiene, transfers, and wheelchair mobility. The resident’s diagnoses included COPD, anxiety, and schizophrenia. The resident was observed stating that his bedsheet was wet with urine and that he was looking for staff to change it. Later, his bed was observed unmade with a rumpled soiled top sheet on the mattress and a strong urine odor in the room. When a nursing assistant later changed the resident’s linens, the mattress was found to have a 6-cm tear, a large 12 x 12-inch deep brown dry stain in the center, and scattered discoloration across the remaining surface. Staff stated the mattress had been stained and ripped for a while, and maintenance said they had only received a work order that day to replace it. The facility also failed to remove residents’ meal plates, beverages, and utensils from institutional serving trays before meal service for all 27 residents on the secured unit. During multiple meal observations, residents were served and ate from plastic trays that held their plates of food, silverware, and drinks. Staff continued this practice at breakfast, lunch, and dinner observations, and one nursing assistant stated that although it looked more homelike when plates and utensils were placed directly on the table, that was not how it was done at the facility. An RN stated the facility served meals on trays and was not sure why, and the DON stated the facility had previously used a steam cart to dish up food correctly but had switched to serving meals on trays after the cart broke.
Unsafe Room Flooring and Loose Bathroom Sinks
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in one resident room and two resident bathrooms. Facility policy dated 3/23/26 stated the objective was to keep the resident environment as free of accidents and safety hazards as possible and that monthly safety walkthroughs would be completed for each resident unit. During observation of one room on 7/6/26 at 12:05 p.m., four joined flooring tiles were missing pieces measuring approximately 6 inches by 12 inches, exposing the wood underneath, and numerous other tiles throughout the room were cracked with pieces missing from the corners. Resident R16 stated the floor had been bad for some time and that although it had been reported, no one had addressed it. R16 also reported concern about the bathroom sink being loose and feared it could fall off the wall if someone leaned on it. Observation of that room's bathroom showed the sink was coming away from the wall, loose, and able to move up and down when pressure was applied. A second room's bathroom was also observed on 7/6/26 at 12:22 p.m. with the same condition: the sink was coming away from the wall, loose, and able to move up and down when pressure was applied. Resident R44 said he/she was unsure how long the sink had been that way. On 7/8/26 at 11:34 a.m., an LPN confirmed the broken and missing tile in the room and confirmed that the sinks in both bathrooms were coming away from the wall, loose, and movable when pressure was applied.
Furniture Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure furniture was in good repair for 1 of 1 facility reviewed for physical environment. During an observation with the Maintenance Director, armchairs in rooms 10, 16, 18, 42, and 44 were observed with torn fabric on the armrests and exposed cloth material, with the torn areas measuring at least one inch in diameter. In the general sitting area by the front entrance, two chairs had multiple cracks in the synthetic leather on the seat covering exposing cloth material, and one armchair had missing synthetic leather exposing cloth material. The Maintenance Director stated the furniture was not in good repair, Staff 18 stated staff were to notify maintenance when furniture was ripped, and the Maintenance Director stated he had not been notified of the torn furniture. The Administrator stated that if there were tears in the furniture, staff were to remove the furniture.
Unclean refrigerator and tray service during dining
Penalty
Summary
The facility failed to maintain a clean, homelike environment when a refrigerator used to store resident supplement drinks was observed with a large amount of ice buildup on the top freezer section and an unknown item embedded in the ice. During the kitchen tour, the cook verified the condition of the refrigerator and stated they were unsure who was responsible for cleaning, monitoring, or reporting it. Maintenance later explained that staff are supposed to place a ticket in TELS when something needs attention, and the administrator later verified the ice buildup in the dining room refrigerator. The facility also failed to eliminate the use of meal trays during dining service. During multiple observations, noon and supper meals were served to residents on trays and left in front of them in the dining room. An RN verified that the noon meal was served and left on trays and stated this had been occurring for at least two years. The VPS also verified that meals were served on trays and left in front of residents and confirmed that this was not homelike. The facility policy stated that the environment should be homelike and that meal trays should be eliminated during dining service unless otherwise requested by the resident.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to ensure resident rooms remained at comfortable temperatures and failed to offer room changes to residents whose rooms exceeded 81 F when air cooling units were not working properly. On 7/1/2026 at about 10:30 AM, R6 was in a hot, uncomfortable room and stated the floor air conditioning wall unit was not working because no air came from the vent. R8’s unit was on but only weak air came through, and R8 appeared uncomfortable and said he was hot. R9 and R10 were in a dark, warm, and stuffy room with the windows closed and curtains pulled shut, and R7 was in a very hot room with weak air blowing from the floor unit and said the room was hot. When the surveyor returned with the Maintenance Director at 10:42 AM, the room temperatures were measured at 84.5 F for R6, 89.5 F for R7, 85.2 F for R8, and 82.9 F for R9 and R10. At 4:00 PM, R7 and R8’s rooms were still hot, with temperatures of 85.6 F and 83.1 F, respectively, and both residents remained in their rooms. R6 stated a room change had been offered only a few minutes earlier, while R7 and R8 stated they had not been offered a room change during the hot room temperatures. The facility did not follow its Hot Weather policy, which stated residents would be relocated to the cooler part of the facility and temperatures and humidity would be measured in several rooms on each floor identified as the warmest area.
Excessive Ambient Temperatures at Nurses' Stations
Penalty
Summary
The facility failed to consistently maintain ambient temperatures within the required range in the 100/200 Nurses' Station and the 300/400 Nurses' Station. During direct observation, the wall-mounted thermostat at the 100/200 Nurses' Station displayed 83 F. The surveyor then requested that the Facility Maintenance Director obtain ambient temperature readings using the facility's temperature monitoring device, and the readings were verified by the surveyor as they were obtained. At that time, the Facility Maintenance Director measured 82.2 F at the 100/200 Nurses' Station and 83.0 F at the 300/400 Nurses' Station. The surveyor also observed residents seated in common areas close to both nurses' stations while the temperatures were above the recommended comfort range. The facility census was 118.
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