Deficiencies in Housekeeping and Maintenance
Summary
The facility failed to ensure timely housekeeping and maintenance in two resident hallways, affecting multiple residents. Observations revealed several environmental and housekeeping concerns, including a broken window air conditioner in a resident's room that had not been addressed since admission, stained and odorous privacy curtains, and visibly dirty floors with debris and darkened stains. Additionally, a resident's over-the-bed table had rust, and the recliner's headrest was worn off, making it difficult to clean. Another resident's room had a large area of unpainted plaster on the wall, which had been left unaddressed since a repair in late 2024. Interviews with the Housekeeping and Maintenance Directors revealed a lack of effective communication and follow-up on maintenance and housekeeping issues, with the Maintenance Director being the sole person responsible for repairs and life safety, leading to delays in addressing reported issues. Further observations in the common area and hallways showed that many ceiling vents were dirty or had a rust-like substance, and there were areas of bubbling and peeling paint on the walls. The Maintenance Director acknowledged these findings during an interview. The report highlights a systemic issue in the facility's housekeeping and maintenance processes, with inadequate documentation and follow-up on identified problems, contributing to an environment that does not meet the residents' right to a safe, clean, and comfortable living space.
Plan Of Correction
F-584 Safe/Clean/Homelike Environment 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Ceiling vents have been corrected. Ceiling vents on 100, 200, 300 and 400 Halls, and in the central common area have been removed, sanded & repainted to an acceptable condition, and then replaced in their proper slots. This was completed on All areas of bubbling and peeling paint were repaired and repainted in Hall 300 and Hall 400, as of Resident # 42 privacy curtains were replaced with new clean curtains on 3/, and privacy curtains will be examined daily and changed daily, or as needed. Resident # 42 baseboard behind bed was replaced with new, as of Resident # 42 A new bed was provided to this resident as of Resident # 42 Floor was sanitized and cleaned on , and this room is inspected daily and will be cleaned daily or as needed. Resident # 23 A new overbed table was provided for this resident, as of Resident # 23 The recliner was removed from this resident's room, as of Resident # 66 The wall behind the bed was repaired to an acceptable condition as of Resident # 244 A new Air Conditioner has been installed in this room, on Resident #42: room where this resident resides has been added to the 'target list' of rooms that are inspected every day. (2) How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Maintenance & Housekeeping Department Heads will incorporate a weekly resident room inspection at the beginning of the week. These inspections will be documented and discussed upon completion to identify areas of concern. Findings will be addressed and corrected depending on the severity & impact on the residents. Inspections for the room inhabited by resident #42 will be daily. The resident uses the privacy curtains to wipe himself when using the bathroom. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur? Maintenance & Housekeeping staff have been made aware of the additional weekly inspections. All other staff members have been re-educated regarding reporting maintenance & housekeeping issues in the maintenance logbooks posted at the nurse's stations. All staff members have also been instructed to verbalize their requests, when possible, in addition to noting them in the maintenance logs. All staff members have been educated on the escalation process should they feel an environmental issue has not been addressed. Daily inspections of the 'target rooms' list will continue ongoing. Facility staff were educated by the Executive Director/Designee on ensuring a safe, clean, homelike environment, and how to report concerns for maintenance and environmental services. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The Maintenance & Housekeeping Departments will conduct a weekly efficiency & quality review of the additional maintenance and housekeeping inspections & reporting process x 4 weeks, and then every 2 weeks x 2 months then PRN as indicated. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months, or until the committee determines substantial compliance. The Administrator/Designee will conduct a quality review of resident rooms, kitchen, to ensure the facility is providing a safe, clean and comfortable homelike environment 3 times weekly x 4, then weekly x 4 weeks, then monthly x 1 month and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months or until substantial compliance is maintained.
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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