Widespread Environmental Uncleanliness and Disrepair Across Multiple Units
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on multiple resident units, contrary to its own maintenance and environmental cleaning policies. Surveyors repeatedly observed strong urine odors, stained and soiled surfaces, and disrepair across Units 2, 3, and 4. On the 2nd floor, there was a noticeable urine odor upon exiting the elevator, and a resident room had a tarnished door frame with brown staining, brown substance on the wall, brown stains on the toilet, dirty brown tiles behind the toilet, foul‑smelling hand towels, and a dripping sink faucet. The 2nd floor shower room and dirty linen cart room contained brown substances on walls and floors, a dirty linen bag on the floor, a hairbrush and comb on the shower floor, and underwear left on a wheelchair. Additional 2nd floor observations included dusty oxygen equipment with white residue, undated tubing in use on a resident’s tracheostomy, a GT pole with brown residue and buildup at the base, blackened flooring at room entrances and around furniture, white splash marks on walls, dirty baseboards, and blackened tiles. The 2nd floor nurses’ station had black floor tiles, dirty and rusted oxygen tank holders, and a buildup of dirt and dust under the desk around wires. On the 3rd floor, surveyors observed environmental uncleanliness and disrepair in common areas and resident spaces. The nurses’ station had a black chair covered with paper as a barrier from dirt or residue, another black chair missing an armrest, old food and dark‑stained floor tiles under the desk, a stained wall behind the station, a cabinet door missing handles and appearing broken, and a resident refrigerator with brown rusted stains on the exterior. The 3rd floor resident shower room had a musty, stale odor, black‑stained floor tiles at the entrance, brown stains on ceiling tiles and flooring, and white and brown substances on the floor of one shower stall. In a resident room, the sink edges had brown substance and the floor was sticky with areas of dirt; another room contained a ripped chair and dirty bedside table tray, and peeling wallpaper was noted near a room. Both radiators in the 3rd floor shower room were rusted, and floor tiles leading to the shower stall had brown‑colored substance around the edges. Hallways and the dining room on this unit had dark brown stains, dark greasy stains in corners and on baseboards, and multiple cracked tiles. During a tour of two shower stalls with maintenance staff, the hot water in both stalls remained cool to the touch despite running for several minutes, with thermometer readings in the high 70s to low 80s °F, and one shower head was leaking. On the 4th floor, surveyors noted brown stains on floors, yellow stains in dining room and hallway floors, and dark, greasy, dirt‑filled stains in the corners of hallways and the day room, as well as brown stains at the entrance to the garbage holding station. Across the 2nd floor vent unit, there were tiles with visible brown stains, brown and white discoloration and white splatter on hallway wallpaper between guardrails, peeling wallpaper, and a fire extinguisher case with brown discoloration and a peeling directional sign. Interviews with housekeeping and maintenance staff revealed inconsistent cleaning responsibilities, lack of clear schedules for cleaning specific items such as oxygen concentrators and GT poles, and acknowledgment that floors, tiles, and walls were dirty and in need of replacement. Staff reported decreased housekeeping staffing, uncertainty about who was responsible for certain areas (such as hallways and dining areas), and that some areas were only cleaned when specifically instructed. The Director of Housekeeping/Maintenance stated they rely on staff to report needed repairs and that they try to address items as they are identified, while the Administrator acknowledged the poor condition of the facility without providing an explanation, confirming that the environment did not meet regulatory requirements for cleanliness and maintenance. The facility’s written policies required that maintenance services keep the building in good repair and free from hazards, and that environmental surfaces be cleaned and disinfected regularly and when visibly soiled, in accordance with CDC and OSHA standards. However, the observations documented by surveyors showed widespread failure to follow these policies, including persistent urine odors, visible dirt and staining on floors, walls, and equipment, cracked and peeling surfaces, rusted fixtures, and inadequate hot water in resident shower areas. Staff interviews further demonstrated gaps in implementation of these policies, with staff describing ad hoc cleaning based on supervisory direction rather than a structured schedule, and multiple staff acknowledging that the building and flooring needed repairs. These combined observations and statements formed the basis of the deficiency under 10 NYCRR 415.5(h)(2) and 10 NYCRR 415.5(h)(4) for not honoring residents’ rights to a safe, clean, comfortable, and homelike environment.
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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