Facility Fails to Maintain Sanitary and Functional Environment
Summary
The facility failed to maintain a clean, orderly, functional, and sanitary environment for its residents, as observed during a recertification survey. In one instance, a room had no hot water supply for approximately three weeks after a sink replacement. Residents in this room had to use a bathing room across the hallway to access hot water, which was inconvenient, especially during winter. Despite the maintenance department's records indicating the sink was reinstalled and in working condition, there was no documentation of the hot water issue in the maintenance book. Interviews with staff revealed a lack of communication and follow-up regarding the hot water problem, with several staff members assuming others had reported the issue. Additionally, several rooms and common areas were found in disrepair, with issues such as deep scratches on walls, broken tiles, and dust accumulation. The shared shower room on Unit 3 had broken tiles, a missing shower head clamp, and a brownish to black substance in the corners. The maintenance logs did not reflect these issues, and staff interviews indicated a lack of awareness and reporting of these environmental problems. The Director of Housekeeping and Maintenance stated that rounds are conducted weekly, but the issues observed during the survey were not documented or addressed. The 2nd Floor Unit also had multiple deficiencies, including cracked window screens, debris in air conditioning/heater units, and peeling baseboards. Flies were observed in the dining room and hallway, and there were white granules and black stains in the dining room pantry. Maintenance staff indicated that repairs are only made when work orders are submitted, and there was a lack of proactive identification and resolution of environmental issues. The Director of Plant Operations and Maintenance mentioned that rounds are conducted weekly, but the observed deficiencies were not addressed in a timely manner.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F584 483.10 Safe/Clean/Comfortable/Homelike Environment SS=E I. The following actions were accomplished for the resident(s) identified in the sample: 1. The facility engaged a certified plumber to permanently repair the hot water to the sink in room [ROOM NUMBER]. Completed 1/9/25. 2. The maintenance staff repaired and painted the wall scratches in the wall behind the bed and behind the door in room [ROOM NUMBER]. Completed 1/23/25. The maintenance staff replaced the headboard on the bed in room [ROOM NUMBER]. Completed 1/26/25. The maintenance staff will repair the identified panel molding in room [ROOM NUMBER]. Completed on 1/30/25. In Unit 3 Shared Shower Room, the maintenance staff permanently repaired the broken yellow tiles. Completed 1/8/25. The maintenance staff will replace the shower hose holder assembly and replace the changed stained ceiling tiles. Completed 1/27/25. The housekeeping staff completed a deep cleaning of the shower walls, floors, and the identified screen. Completed 1/8/25. 3. A. The maintenance staff will replace the identified window screen in the 2nd floor Dining Room. Completed on 1/30/25. B. The housekeeping staff cleaned the items from within the HVAC unit in room [ROOM NUMBER]. Completed 1/8/25. The maintenance staff will repair or replace the identified cove base in room [ROOM NUMBER]. Completed on 1/30/25. C. The housekeeping staff cleaned the items from within the HVAC unit in room [ROOM NUMBER]. Completed 1/8/25. The maintenance staff will repair or replace the identified cove base and repair and paint the damaged wall in room [ROOM NUMBER]. Completed on 1/30/25. D. The maintenance staff replaced the footboard on the bed in room [ROOM NUMBER]. Completed 1/26/25. Maintenance repaired the bathroom pipe faucet dripping and left faucet not closing to stop water from dripping. Completed 1/24/25. E. The maintenance staff will repair or replace the identified cove base, repair and paint the damaged wall (Completed on 1/30/25), and repaired the leaking sink faucet in room [ROOM NUMBER]. Completed 1/8/25. F. The maintenance staff will replace the window screen in room [ROOM NUMBER]. Completed on 1/30/25. The housekeeping staff removed the two round items from the top of the HVAC unit. Completed 1/8/25. G. The maintenance staff will replace damaged window screens on the 2nd floor. Completed on 1/30/25. The Director of Plant Operations contacted the facility's pest control vendor to provide a mitigation plan for flies. Mitigation plan and implementation was completed on 1/30/25. H. The housekeeping staff cleaned the 2nd floor Dining Room Pantry shelves and cabinets. Completed 1/24/25. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance will inspect all areas throughout the facility for the same deficiencies. Any deficiencies found will be scheduled for correction. III. The following system changes will be implemented to ensure continuing compliance with regulations: All maintenance staff, housekeeping, and nursing will receive additional education, and all participants will understand the requirements of providing a Safe, Clean, Comfortable, and Homelike Environment for residents in compliance with 483.10. The Director of Plant Operations and Staff Development has been assigned responsibility for the education of staff, and the Director of Plant Operations will report the findings to the QAPI Committee for the period of six (6) months. The Policy & Procedures will be reviewed and updated to include that all staff must report issues promptly in the maintenance log. Resident safety issues must be immediately reported to a supervisor in addition to the maintenance log. The Director of Plant Operations/Housekeeping will conduct weekly rounds to identify maintenance and housekeeping issues. The Director of Plant Operations/Housekeeping will each complete documentation of the weekly rounds in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Director of Plant Operations or Designee will review monthly audits for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as the correction plan if warranted. Responsibility: The Director of Plant Operations/Designee will be responsible for compliance.
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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