F0921

F

Failure to Maintain Clean, Safe, and Well-Maintained Environment Throughout Facility

Westerville, Ohio Survey Completed on 03-24-2026

Penalty

No penalty information released

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.