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F0584
D

Failure to Maintain Cleanliness and Equipment Integrity During Construction

Burlington, Vermont Survey Completed on 12-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment on one of its units, specifically the Second Floor, due to the presence of construction dust and debris on essential medical equipment and carts. White and grey powder-like substances, identified as construction dust, were found on the code cart, wound care/treatment cart, precaution supply carts, and Hoyer lifts. Multiple staff, including an LPN, the DON, the Infection Preventionist, and the Regional Nurse Consultant, confirmed the presence of dust and debris on these items. Additionally, the kitchenette hood was found to have a buildup of debris and had not been cleaned. The dust was attributed to ongoing construction activities, such as sanding and wall preparation for wallpaper installation. Further deficiencies were identified in the maintenance and readiness of resident room equipment. After a resident was discharged, a mattress with brown discoloration, a worn and chipped protective lining, and two pillows with holes in their protective coverings were found in a room that had been terminally cleaned and prepared for a new resident. Staff interviews confirmed that the mattress and pillows were compromised and not suitable for resident use, as they could not be properly cleaned or disinfected. Facility policy requires that equipment in disrepair be reported and removed from use, but this was not followed in this instance, as the compromised items remained in the room ready for the next resident.

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