F0584

E

Widespread Environmental Uncleanliness and Disrepair Across Multiple Units

Brooklyn, New York Survey Completed on 03-13-2026

Penalty

No penalty information released

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.