Deficient Practice in Resident Relocation Following Plumbing Failure
Summary
The facility failed to ensure a safe, sanitary, and homelike environment for residents after an emergency plumbing issue rendered one of the locked units uninhabitable. As a result, residents from the affected unit were relocated to various areas throughout the facility, including the dining/activity room, day care room, and medical record room. These rooms, not originally intended for resident accommodation, were repurposed to house multiple residents in close proximity, with beds, call bells, and privacy curtains set up as temporary measures. Staff interviews confirmed that the relocation was due to ongoing plumbing repairs, and that the dining room, typically used for meals and activities, was now occupied by ten residents, while the day care and medical record rooms housed additional residents. Observations and interviews revealed that residents were eating meals at their bedside tables, and some residents' personal belongings, such as clothing, were stored in a maintenance area that also contained housekeeping equipment and tools. The maintenance and housekeeping staff confirmed that this area was being used for temporary storage of residents' clothes. The rooms used for resident accommodation were measured, and it was noted that the dining room, day care room, and medical record room varied in size, with the dining room being the largest. Despite the presence of call bells and privacy curtains, the environment was not consistent with a typical resident room, and the arrangement impacted the residents' privacy and comfort. Multiple residents interviewed reported being relocated for at least a week, with some indicating they had been in the dining room for up to three weeks. Residents described eating at their bedsides, using shared bathrooms, and receiving care such as showers outside of the temporary rooms. Staff also reported challenges related to staffing and the use of these non-traditional spaces for resident care. Facility policies reviewed indicated procedures for sheltering in place and partial evacuation, but the actual implementation resulted in residents being housed in areas not designed for long-term accommodation, affecting the overall safety, sanitation, and homelike environment for the residents involved.
Penalty
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The facility did not maintain a safe, orderly, and homelike environment in several resident rooms. One resident’s bathroom door had a hole, confirmed by a housekeeper. Another resident’s room had a urinal and a pair of scissors left on the floor, verified by an LPN. A third resident’s room had a long, deep gash in the lower part of the bathroom door and a trash bin with a large missing chunk on its rim, as confirmed by the DOM. These observations showed that housekeeping and maintenance services were not consistently ensuring a sanitary, comfortable environment as required by facility policy.
A resident with Parkinson’s disease, altered mental status, and severe cognitive impairment was housed in a room that was not maintained in good repair, where surveyors observed a chair rail with approximately four feet of splintered wood along the wall next to the resident’s low-position bed. The resident’s care plan did not indicate any refusal of housekeeping or maintenance services, and the Director of Plant Maintenance acknowledged that the chair rail was in disrepair and required replacement, contrary to facility policy stating that safety of residents, visitors, and employees is a top priority.
Surveyors found that air temperatures in multiple resident rooms and common areas on two pods were below the facility’s stated acceptable range, despite temperature logs uniformly recording 75°F with no variation and no work orders reflecting low-temperature concerns. The Director of Maintenance confirmed the low readings and the facility’s policy requiring temperatures between 71°F and 81°F in common areas. In addition, a resident was observed in a wheelchair near the nurses’ station that was visibly dirty and covered with debris, even though the wheelchair was listed on a twice-weekly cleaning schedule. The Therapy Program Director and a Unit Manager/LPN confirmed the wheelchair should have been cleaned as scheduled and acknowledged there was no specific facility policy for wheelchair cleaning, although nurses and unit managers were expected to oversee CNA completion of the cleaning schedule.
Surveyors identified widespread environmental deficiencies, including a mattress stored against a dining room wall with wheelchairs bracing it, damaged and unpainted walls, a loose handrail, separated wall corners, littered and dirty hallways, overflowing trash at nursing stations, cigarette butts in a corridor, and an elevator floor with multiple brown spots. On an upper floor, there were paint streaks on the floor and similar dirt and paper debris. Maintenance staff confirmed these conditions and acknowledged the non-homelike appearance, while housekeeping staff reported significantly limited hours, elimination of the floor-stripping/waxing role, and a practice of cleaning only select “important” areas and a limited number of rooms, with CNAs assisting when spills occurred. These practices and conditions did not align with facility policies requiring floors and building areas to be maintained in a clean, safe, and sanitary manner and kept in good repair and free from hazards.
Surveyors found that the facility did not maintain a safe, clean, and well-maintained environment for multiple residents. One shared room had a large, visibly substandard ceiling repair from a prior water leak directly over a bed, along with additional wall damage, while the resident who used that bed typically remained there most of the day. A shared bathroom for four residents had water-stained doors, a broken light switch plate, a baseboard heater pulling away from the wall, and an unknown hardened material around the heater. In the same room and at two nurse stations, baseboard heaters and ceiling vents had heavy dust buildup, including dust drooping from a ceiling vent. The administrator and CNAs confirmed these conditions, which did not align with the facility’s policy for a safe, clean, and homelike environment.
Surveyors identified widespread environmental deficiencies, including a persistent musty/mildew odor in a main hallway, dust and debris along hallway edges, and trash and disposable items on floors in some resident rooms. Multiple hallways and units had chipped and peeled paint where tape had been used to hang items, with some areas poorly repainted in mismatched colors, and numerous doors and door jambs were scuffed and scraped. One resident’s shared bathroom was found with an overfilled trash can containing an incontinent brief, floor debris, a towel placed under a raised toilet seat, dried residue on the floor, and feces splatter on the raised seat and inside the commode. Housekeeping was limited to two day-shift staff with no evening or night coverage; while a housekeeper felt staffing was adequate, a CNA, an RN, and the Maintenance Director reported that housekeeping struggled to keep up, with some residents stating their rooms had not been cleaned for weeks. The Maintenance Director also acknowledged a roof leak near the hallway with the musty odor and recognized the need for cleaning and repair of walls, doors, and FRP surfaces.
Failure to Maintain Safe and Homelike Resident Room Environments
Penalty
Summary
The facility failed to ensure a safe and homelike environment as required by its policy that housekeeping and maintenance services will be provided to maintain a sanitary, orderly, and comfortable environment. For one resident, observation of the resident’s room showed a hole in the bathroom door, which was confirmed by a housekeeper. For another resident, observation of the room revealed a urinal and a pair of scissors lying on the floor, which was verified by an LPN. For a third resident, observation of the room showed a long, deep gash in the lower part of the bathroom door and a large missing chunk on the rim of the trash bin, which was confirmed by the Director of Maintenance. These conditions were identified during observations and staff interviews and affected three residents out of six reviewed for the physical environment, in a facility with a census of 48 residents.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to maintain a resident room in good repair when one resident’s room was observed to be in general disrepair, specifically with a chair rail that had splintered wood approximately four feet long along the wall next to the resident’s bed. The resident, admitted with diagnoses including Parkinson’s disease without dyskinesia and altered mental status, had a quarterly MDS showing a BIMS score of three out of 15, indicating severe cognitive impairment. Review of the resident’s care plan showed no indication that the resident refused housekeeping or maintenance services. During observations on consecutive days, surveyors noted the splintered chair rail adjacent to the bed, which was in a low position and horizontal to the wall with the damaged rail, and the Director of Plant Maintenance confirmed that the chair rail was in disrepair and needed replacement, contrary to the facility’s Resident Rights policy stating that safety of residents, visitors, and employees is a top priority of care. This deficiency was cited under the requirement to ensure the nursing home area is safe, easy to use, clean, and comfortable for residents, staff, and the public, and was investigated under Complaint Number 2655564.
Failure to Maintain Required Temperatures and Sanitary Wheelchairs
Penalty
Summary
The deficiency involves the facility’s failure to maintain required ambient air temperatures and to ensure accurate monitoring and reporting of those temperatures. During an observation period, multiple resident rooms and common areas on D and E pods were found to have temperatures below the facility’s stated acceptable range of 71°F to 81°F, with readings between 67.6°F and 70.3°F obtained using the facility’s laser thermometer. The Director of Maintenance confirmed these readings and acknowledged that the facility’s policy called for temperatures in common resident areas to be kept between 71°F and 81°F, with any resident preference outside that range requiring an assessment. Review of temperature logs for several days showed all sampled temperatures documented uniformly as 75°F with no variation, and there were no open work orders or prior reports for the rooms where low temperatures were observed. The Maintenance Assistant reported he had been recording temperatures with the same thermometer for two months and denied recent concerns about temperatures being out of range. The deficiency also includes failure to maintain wheelchairs in a clean and sanitary condition. During observation on D pod, a resident was seen seated in a wheelchair near the nurses’ station that was covered in debris of different colors and was noticeably dirty. The Therapy Program Director confirmed the condition of the wheelchair and stated it had been scheduled to be cleaned on a specific night shift but it did not appear that this had been completed. The Unit Manager/LPN reported that nurses and unit managers were responsible for overseeing the wheelchair cleaning schedule carried out by CNAs and that staff were to be disciplined if cleaning was not done, but also verified that the facility did not have a policy specific to wheelchair cleaning. A wheelchair cleaning schedule for D pod showed that this resident’s wheelchair was to be cleaned twice weekly, on Mondays and Fridays.
Failure to Maintain Clean, Safe, and Well-Maintained Environment Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and sanitary environment in resident care and common areas, affecting all 62 residents in the building. Surveyor observations on the first floor showed a mattress propped against a dining room wall with two wheelchairs holding it up, holes and torn wallpaper behind it, and a broken chair part under the mattress edge. There was also a large streak-like hole in the wall near the dining room entrance. Hallways on the first floor had dirt and brown smears, were littered with small white paper pieces, and two nursing station trash cans were overflowing. Additional structural issues included a handrail pulled away from the wall, unpainted re-plastered wall sections, and multiple areas where walls and corners had separated, including near the soiled utility room, between a resident room and the resident/family lounge, and near the courtyard door. Seven cigarette butts were observed in the hallway between the courtyard and ambulance doors, and the elevator floor had multiple brown spots. On the second floor, surveyors observed white streaks on the floor from the elevator to a resident room that appeared to be paint streaks, as well as dirty hallways with brown spots and scattered small white paper pieces similar to those on the first floor. A CNA stated she did not know what the white streaks were but thought they looked like paint. The maintenance staff member confirmed the presence of the mattress, damaged walls, litter, overflowing trash, loose handrail, unpainted plaster, separated walls, cigarette butts, and dirty elevator floor, and explained that the white streaks on the second floor were paint streaks resulting from moving a heavy door. The maintenance staff member also verified that the overall appearance of the facility was not in a homelike manner. Housekeeping staff reported that the person who previously stripped and waxed floors was no longer employed because the position was considered unnecessary, and that housekeeping hours were limited to a budgeted 30 hours per week, resulting in housekeepers typically working only about four hours per day. According to housekeeping, cleaning efforts were focused on “important areas” such as bathrooms, nurses’ stations, main hallways, and a limited number of resident rooms, with staff doing only what they could within their limited hours and CNAs assisting with spills when housekeeping was not present. Subsequent observation confirmed missing handrail corners on two halls, which the Administrator verified at the time. Review of facility policies showed that floors were required to be maintained in a clean, safe, and sanitary manner with daily cleaning, and that maintenance services were required to keep the building, grounds, and equipment in good repair and free from hazards, which was not achieved as evidenced by the observed conditions.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, and adequately maintained environment for multiple residents. In one shared room, the ceiling above a resident’s bed had an approximately four-by-three-foot area of visibly substandard plaster repair from an apparent prior water leak, with unsanded spackling and partially painted areas, and additional water damage repairs on the outside wall. The administrator confirmed the poor-quality ceiling repair, and a CNA reported that one of the residents preferred to remain in bed under this area most of the day except for meals. In another shared bathroom used by four residents, surveyors observed water stains six to eight inches from the bottom of the door, a broken light switch plate, a baseboard heater detaching from the wall, and an unknown hardened sand-like material around and under the heater. A CNA confirmed that this bathroom was in disrepair. Further observations showed that the facility did not ensure a clean environment in resident rooms and common areas. In the same room with the ceiling repair, the baseboard heating vent had visible buildup of what appeared to be dust. At two nurse stations, ceiling vents had a thick layer of dust, with dust at one station drooping off the vent, and the baseboard heating vent at that station was coated inside and out with a thick layer of dust. The administrator verified these environmental and cleanliness issues. Review of the facility’s “Homelike Environment” policy, dated February 2021, showed that residents were to be provided a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting; however, the observed conditions did not meet these policy expectations.
Environmental Sanitation and Maintenance Deficiencies Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, clean, and homelike environment throughout the building, affecting all resident care areas. During an environmental tour of all four units, surveyors noted a distinct musty/mildew odor in the hallway connecting the independent living section to Home B Short hall, despite no visible mold, mildew, or recent water damage. The building appeared older and outdated, with vinyl wood-look flooring and FRP boarding on the lower half of the walls. Dust and debris were observed along the edge of the wall on Home B Long near a resident room, and debris such as wrappers, paper, and disposable gloves were seen on floors in some resident rooms, indicating inadequate routine cleaning. Surveyors observed multiple areas of chipped and peeled paint throughout the facility. On Home B Long, chipped paint was noted outside several resident rooms where adhesive tape had been applied and removed, leaving white areas that did not match the rest of the wall. Some of these areas had been painted over without patching and with a different color paint, resulting in a mismatched appearance. Similar peeled or chipped paint was observed outside rooms on Unit 1, Unit 2, and the secured memory care unit, including areas where tape removal had stripped paint and around a wall-mounted computer near the dining/lounge area. Multiple door jambs and doors were scuffed and scraped and in need of repainting, and the FRP boarding on Home B halls was noted to have scuff marks that required cleaning. In a resident-specific observation, a shared bathroom used by one resident was found to be unclean. The trash can was overfilled, with an incontinent brief protruding over the top, and a toilet paper roll wrapper was on the floor next to the trash can. A folded towel was on the floor under the front leg of a raised toilet seat, with unclear purpose, and dried white sediment was visible on the floor in front of and to the right of the toilet. The raised toilet seat and inside of the commode had feces splatter all around them. The resident reported that housekeeping staff swept and mopped her room about once a week and felt that was enough to keep things tidy. Staff interviews revealed differing views on housekeeping adequacy: a housekeeper stated there were typically two housekeepers on day shift only and felt staffing was adequate, while the Maintenance Director, a CNA, and an RN all indicated that housekeeping struggled to keep up, that there were not enough housekeepers, and that residents sometimes reported their rooms had not been cleaned for a couple of weeks. The Maintenance Director also acknowledged ongoing roof leak issues near the area with the musty odor and recognized the need for wall and door repairs and cleaning, but these environmental issues remained uncorrected at the time of the follow-up observation.
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