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:
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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