Failure to Maintain Repairs and Housekeeping in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms, as required by its own “Homelike Environment” policy. Surveyors observed that in one resident room, the baseboard below the sink was coming off the wall on two separate dates. The resident in that room reported that housekeeping was aware of the issue. During a joint observation, the housekeeper who cleaned the room stated they had not noticed the loose baseboard and indicated that if they had seen it, they would have notified maintenance. The Maintenance Director later confirmed they were not aware of the baseboard problem and would have expected staff to submit a work order if they observed it. In another room, surveyors identified a hole in the bathroom ceiling above the toilet with black piping exposed, following a previously documented work order for water dripping from the ceiling that had a completion date several months earlier. One resident in that room stated the ceiling had been leaking since the prior year, and the roommate reported that water had dripped on them a couple of times and that maintenance was aware. A CNA stated they would report environmental disrepair or resident complaints to nursing and maintenance but said they had not seen the hole. A RN confirmed that the hole in the bathroom ceiling had been reported to maintenance and that maintenance was aware of it, while also stating they were not aware of the loose baseboard in the other room. The Maintenance Director acknowledged knowing about the ceiling hole and a slow drip and stated the hole had been present since October of the previous year. Surveyors also found housekeeping deficiencies in the same resident room where the baseboard was loose. The resident reported feces in the closet and said they had notified housekeeping and the Administrator in Training. Observations showed a smear of brown matter on the inside of the closet door and on the edge of the shelf, as well as cobwebs on the fire sprinkler above the resident’s bed, on the ceiling above the television, and by the closets. The resident stated their wound supplies were stored in that closet and expressed concern about infections. The housekeeper assigned to the room stated they cleaned closets and deep-cleaned rooms at discharge, claimed not to be aware of the brown matter, and acknowledged they were supposed to clean cobwebs. During a joint observation, the Housekeeping Supervisor confirmed expectations that closets be disinfected daily, rooms cleaned daily, cobwebs cleaned, and dusting done at least weekly, but also stated they were not aware of any complaints about feces in the closet until the surveyor’s observation.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.