Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Summary
Three deficiencies were identified regarding the facility's failure to provide a safe, clean, and homelike environment for three residents. One resident's personal wheelchair went missing two to three weeks prior and was not reported to the Social Services Director as required. The resident, who had moderate cognitive impairment and relied on the wheelchair for mobility, reported the loss to a CNA, but no theft and loss report was initiated. The absence of the wheelchair limited the resident's ability to move freely and participate in activities such as going outside to smoke. Another resident, who had severe cognitive impairment and required assistance for toileting, was found to have a broken toilet seat in their bathroom. The seat was loose and missing a screw, leaving it detached from the toilet rim. The issue was reported by the resident's responsible party to staff, but the seat remained unrepaired at the time of observation. The resident's care plan indicated a risk for injury due to falls, and the broken seat presented a potential hazard during transfers. A third resident, who was dependent for all activities of daily living and had severe cognitive impairment, was found in a room where the patio sliding door could not be fully closed. Cold air was entering the room, and the maintenance supervisor was unable to close the door due to dirt in the track. The door had no screen, and it was noted that it was going to rain that day. The DON confirmed that such conditions were not homelike and could lead to discomfort or illness for the resident. Facility policies required prompt investigation of missing property, maintenance of equipment in good repair, and provision of a homelike environment, but these were not followed in the cited instances.
Plan Of Correction
F 584: Safe/Clean/Comfortable/Homelike Environment CORRECTIVE ACTION Resident 11's personal wheelchair was reported missing to the Social Services Director (SSD), and on 3/7/2025, a replacement wheelchair was provided for Resident 11. On 3/7/2025, Maintenance Director secured and fully attached the toilet seat in Resident 63's bathroom. On 3/10/2025, Maintenance Director repaired Resident 68's patio door to ensure it could be fully closed. OTHER RESIDENT AFFECTED IDENTIFICATION On 3/7/2025, the administrator and maintenance supervisor conducted environmental rounds to ensure all residents had a clean and safe environment. They confirmed that all patio doors could be fully closed and toilet seats were securely attached. No other residents were found to be impacted by the alleged deficiencies. On 3/7/2025, the SSD performed an inventory of residents with personal wheelchairs. No other residents were found to be affected by the alleged deficiency. MEASURES AND SYSTEMIC CHANGES Department heads will perform daily room rounds from Monday to Friday, ensuring that equipment in residents' rooms is in good working condition. Findings will be communicated to the leadership team during the daily standup. Maintenance staff will conduct monthly room rounds for all residents' rooms to verify that doors and toilet seats are in proper working condition. Upon a resident's new admission or issuance of a personal wheelchair, licensed staff must inventory the wheelchair and ensure it is marked for the resident's use only. Any missing or lost personal wheelchairs must be documented in the theft and loss log by the SSD/SSA for resolution. MONITORING PERFORMANCE The Maintenance Supervisor will present the findings from maintenance logs, specifically regarding the environmental inspections of patio doors and toilet seats, to the monthly Safety Committee for three months or until compliance is achieved for further review and recommendations. The Administrator is responsible for ensuring the continuity and sustainability of this process. The SSD will report any instances of lost or missing personal wheelchairs to the monthly QAA Committee for monitoring. 3/28/2025
Penalty
Resources
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Surveyors found that the facility did not maintain a homelike environment when a hole with exposed wiring remained in the dining room ceiling over several days while residents ate beneath it, and meal service was disorganized, with trays left intact, tables not served together, and one resident taking food from another’s uncovered tray before staff intervened. In addition, a resident with a pressure mattress and multiple medical conditions repeatedly had an ill-fitting bed sheet that did not fully cover the mattress, causing discomfort, a problem acknowledged by the resident’s representative and the Maintenance Director.
A resident with dementia, anxiety disorder, and chronic respiratory failure, but with mild or no cognitive impairment per MDS, and the resident’s daughter reported multiple missing or damaged personal items, including cameras, an SD card, a phone, a music device cord, and gifted socks. The daughter emailed the DON, ADON, state health department, and ombudsman about stolen or missing items and broken equipment, while the resident reported missing cameras and a removed cord. The ombudsman confirmed being notified of a missing SD card and that staff denied knowledge of it. The Administrator stated a camera was removed from the room without an SD card present and that staff had not been informed of missing items. The Regional Nurse confirmed there was no inventory list for the resident’s possessions, no recent informal documentation of the family’s concerns, and the concern log for a full year contained no entries for this resident, despite multiple complaints, resulting in a deficiency for failure to protect personal property and uphold resident rights.
The facility failed to maintain adequately warm water temperatures in the East Hall shower room, resulting in multiple residents with conditions such as CHF, Parkinson’s disease, COPD, anxiety, and diabetes reporting that the shower water was too cold, leading some to refuse showers and instead receive bed baths or wash at the sink. CNAs and an LPN confirmed ongoing resident complaints and described one shower stall as cold and the other as only barely warm. Direct measurements with the Maintenance Director showed shower and sink water temperatures well below the minimum required level, and review of water temperature logs revealed that weekly monitoring was not consistently performed, with several weeks lacking any recorded temperatures.
A resident with multiple chronic conditions and intact cognition was found living in a room that was not maintained in a clean, sanitary, or homelike condition, despite facility policies and expectations for daily thorough cleaning. Surveyors observed stained walls, a pile resembling drywall dust behind the bed, trash and items such as a plastic pitcher, pill cup, and used plastic wrap on the floor, and dried food-like debris on the bed frame and oxygen concentrator. An LPN confirmed these conditions, and the resident reported not knowing when the room was last cleaned and expressed dissatisfaction with living in that environment. The Administrator stated housekeeping was expected to clean resident rooms daily, and this issue represented continued noncompliance from a prior survey.
Surveyors found that multiple resident rooms had blue carpeting that was visibly stained, torn, snagged, and dirty, with damage and discoloration apparent from the hallway. A CNA reported that several carpeted rooms were not well kept and that prior attempts to clean the carpets with bleach had caused some of the staining, particularly in rooms that still had blue carpet rather than wood flooring. The Regional Maintenance Director confirmed that the carpets in these rooms needed replacement and noted that one apparent stain might actually be feces requiring prompt cleaning. Review of the facility’s room cleaning policy showed it addressed general room cleaning and disinfection but did not include any process for cleaning or maintaining resident room carpeting.
Surveyors found that residents using air mattresses were often placed directly on the mattress with only chux pads and no flat or bottom sheet, despite manufacturer instructions that the surfaces be used with appropriate linens. Several cognitively impaired residents with significant care needs were observed in this condition, and interviews with CNAs, an LPN, clinical support staff, the ADON, and the DON showed inconsistent and incorrect practices, including a belief that cognitively impaired or hospice residents might not need a sheet. In addition, the facility did not maintain an adequate supply of clean towels and washcloths; staff reported frequently running out and resorting to using towels as washcloths or pieces of blankets cut into rag-like washcloths with frayed edges and stains, which were stored alongside regular washcloths for resident care.
Failure to Maintain Homelike Environment, Dining Experience, and Proper Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Homelike Environment policy. Surveyors observed a missing tile in the dining room drop ceiling on multiple occasions, creating a rectangular hole with visible wiring exposed. This condition persisted over several days, including during meal service when residents were seated and eating directly beneath the opening. One resident with dementia, congestive heart failure, and type 2 diabetes, who had moderate cognitive impairment, noticed the hole and reported feeling worried about the ceiling falling and people getting hurt. A staff member confirmed the presence of the hole and stated that maintenance had been doing work above the ceiling but could not say how long the hole had been there. The facility also failed to ensure a homelike dining experience for residents who routinely ate meals in the dining room. During a lunch observation, staff delivered meal trays in a random order and left the food on the trays rather than placing plates and drinks on the tables. Residents at the same table did not receive their meals at the same time, with one resident receiving a tray significantly earlier than tablemates. While trays sat uncovered in front of residents waiting for assistance, another resident turned her wheelchair away from her own table and reached over to grab a hamburger from another resident’s tray. Staff intervened, removed the touched plate, and replaced it, but the initial service pattern and handling of trays were confirmed by the Business Office Manager, who stated that plates, drinks, and silverware were not normally removed from trays and that tables were not served together, and by the Dietary Director, who stated that staff should have removed items from trays and served tables together. Additionally, the facility did not provide comfortable and well-fitting bed linens for a resident with a history of cerebral infarction due to occlusion or stenosis of a small artery, type II diabetes, and a cognitive communication deficit, who had moderate cognitive impairment. On two separate observations, the resident’s pressure mattress was not fully covered by the bed sheet, leaving portions of the mattress exposed near the resident’s head. The resident’s representative reported that the sheets tended to slide off the mattress, and the resident stated that the sheets were bothersome, did not fit correctly, and that this issue had been reported to staff without resolution. The Maintenance Director confirmed that the sheet was not covering the mattress and identified this as a problem related to the pressure mattress in use. These conditions were inconsistent with the facility’s policy requiring clean bed linens in good condition as part of a comfortable, homelike environment.
Failure to Protect Resident Personal Property and Document Reported Losses
Penalty
Summary
The facility failed to protect a resident’s right to maintain personal property and to receive care in a manner that upholds dignity and autonomy. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and mild or no cognitive impairment per a recent MDS, had no documentation in her medical record of missing items or damaged property, including an SD card, socks, cord, phone, or cameras. Emails from the resident’s daughter to the DON, ADON, and the state health department reported that a set of cabin socks given as a Christmas present was stolen, and that two cameras and a phone had been broken by staff without reimbursement. Another email from the daughter to the ombudsman reported a missing camera and SD card. The facility’s Regional Nurse confirmed there was no inventory list for the resident’s possessions, and state records showed no alleged misappropriation events reported by the facility in the prior six months. During interviews, the resident reported that cameras were missing and that staff had taken the cord from her music device, rendering it unusable, though she was unsure if she had notified staff and believed her daughter likely had. The ombudsman confirmed being notified of a missing SD card and stated that when they followed up, facility staff denied knowledge of the missing item. The Administrator reported removing a camera from the resident’s room and stated there was no SD card present at that time, and that staff had not been informed of missing items such as the cord, socks, or SD card. The resident’s daughter stated that staff removed a camera from the bedside and returned it without the SD card she had purchased, and that staff had broken two cameras and the resident’s phone by dropping it. The Regional Nurse later confirmed there was no recent “soft file” documenting the facility’s response to the family’s concerns, and review of the resident concern log over a one-year period showed no entries related to this resident, despite multiple complaints, resulting in a deficiency related to resident rights and personal property.
Failure to Maintain Adequately Warm Shower Water Temperatures in East Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequately warm shower water temperatures in the East Hall shower room, resulting in residents not receiving safe, comfortable, and homelike bathing conditions. Multiple residents who required staff assistance for showers reported that the shower water was too cold, leading some to avoid showers and instead receive bed baths or wash at the sink. One resident with congestive heart failure, weakness, and parkinsonism stated he rarely used the shower because the water was too cold and instead received bed baths. Another resident with Parkinson’s disease, asthma, and depression reported that the shower water was chilly but bearable and acknowledged refusing showers in the past due to cold water. A resident with congestive heart failure, anxiety, and atrial fibrillation described the East Hall shower room as so cold she felt like she had icicles coming off her body and avoided showers, receiving bed baths instead. A closed record review for a resident with COPD, anxiety, Type II diabetes mellitus, and restless legs showed documentation that the shower water was too cold, leading the resident to wash up at the sink rather than shower. Staff interviews with CNAs and an LPN confirmed that residents complained about cold water in the East Hall shower room and that one shower stall was cold while the other was only barely warm. Direct observation with the Maintenance Director showed shower stall temperatures of 83°F and 88°F after several minutes of running, and the sink reaching only 90°F, all below the stated minimum requirement of 105°F and the facility’s intended range of approximately 109°F to 115°F. Review of water temperature logs revealed that required weekly monitoring for the East Hall shower room was not consistently performed, with no temperatures logged for several weeks and only two recorded readings showing compliant temperatures shortly before the survey. The Maintenance Director verified the low temperatures, acknowledged the lack of recorded monitoring during the specified periods, and confirmed that the water temperatures did not meet the minimum requirement.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide a safe, clean, comfortable, and homelike environment for a resident. The resident had multiple medical conditions including COPD, type II diabetes, morbid obesity, major depressive disorder, cirrhosis, anxiety disorder, ADHD, chronic pain syndrome, muscle wasting, venous insufficiency, an acquired absence of the left foot, and alcohol abuse. The resident’s MDS showed intact cognition with a BIMS score of 15, required set-up and clean-up assistance for eating and oral hygiene, moderate assistance with bed mobility, and often refused showers and shower transfers, preferring to remain in bed. Despite the facility’s policies requiring routine cleaning and disinfection of visibly soiled surfaces and high-touch areas, and maintaining a sanitary, orderly, and comfortable environment, the resident’s room was not maintained accordingly. During observation of the resident’s room, surveyors noted multiple dark-colored stains on the wall under the television, yellow streaks on the wall next to the bed, and a large pile resembling drywall dust on the floor behind the head of the bed. Additional items found on the floor included a clear plastic pitcher under the bed, an empty pill cup near the head of the bed, and a balled-up, used piece of clear plastic wrap under the bed. There were also multiple spots resembling dried food debris on the bed frame and oxygen concentrator. An LPN confirmed these findings during interview. The resident reported not knowing when the room was last cleaned and stated he should not have to live in that condition. The Administrator stated that housekeeping was expected to thoroughly clean each resident’s room daily. This deficiency was cited as continued noncompliance from a prior annual survey.
Failure to Maintain Clean and Well-Kept Carpeting in Resident Rooms
Penalty
Summary
Surveyors identified a failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment for multiple residents. Observations of several resident rooms showed blue carpeting with multiple white stains, a brownish-red stain, and tears/snags at the entryway and throughout the rooms, with these conditions visible from the hallway. In one room shared by two residents, the carpet was described as stained and torn/snagged, and a CNA reported that several rooms with blue carpet were stained, torn, and dirty, and that attempts to clean them with bleach had caused some of the visible staining. The CNA also noted that these issues were primarily in rooms that still had blue carpeting, as most other rooms had wooden floors. Further observations of additional resident rooms confirmed that the blue carpeting was stained, torn/snagged, and not well kept, and these conditions were again visible from the hallway. The Regional Maintenance Director confirmed during the observations that the carpeting in these rooms needed to be replaced and acknowledged that one apparent stain might actually be feces on the carpet that required cleaning as soon as possible. Review of the facility’s “5 Step Resident Room Cleaning Procedure” policy, dated 10/2019, showed it addressed cleaning and disinfecting resident rooms but did not include any process for cleaning and maintaining carpeting in resident rooms. This combination of observed conditions, staff interviews, and policy review supported the finding that the facility failed to maintain a safe, clean, comfortable, and homelike environment for the affected residents.
Improper Air Mattress Linen Use and Inadequate Supply of Clean Towels/Washcloths
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents using air mattresses had appropriate bed linens between them and the mattress surface. Multiple residents with cognitive impairment and limited mobility were observed lying directly on air mattresses with only disposable incontinence pads (chux) in place and no flat or bottom sheet. For example, one resident with Alzheimer’s disease and type 2 diabetes, who required assistance to roll in bed and had a provider order for a Drive air mattress, was observed during care with no flat sheet on the bed, and the CNA confirmed only chux pads were used under residents with air mattresses. The Drive air mattress owner’s manual specified that the support surface was designed to be used with appropriate linens, recommending deep-pocketed fitted or flat sheets. Another resident with severe cognitive impairment, muscle weakness, and age-related physical debility, who required substantial assistance with rolling in bed, was observed without a flat sheet between her and the air mattress; staff confirmed that no flat sheets were used for residents with air mattresses, only chux pads. A third resident with a history of cerebral infarction and moderately impaired cognition, who required substantial assistance with personal care, was also observed in bed with no sheet between him and the air mattress, only a chux pad. Multiple staff interviews, including CNAs, an LPN, clinical support staff, the ADON, and the DON, revealed inconsistent and incorrect practices and understandings: some staff stated they only used chux pads with air mattresses, others said some CNAs used flat sheets, and leadership gave varying explanations such as not using sheets for hospice residents or for cognitively impaired residents, without a clear method for CNAs to know which residents should have a bottom sheet. The facility also failed to maintain an adequate supply of clean towels and washcloths for resident care. Observation of the only linen room showed far fewer towels and washcloths than the number identified by the Director of Maintenance as the expected stock, and numerous pieces of blankets had been cut into washcloth-sized rags with frayed edges, strings, and stains, stored on the shelf with regular washcloths for use. Staff interviews confirmed that due to a shortage of linens, night shift staff sometimes cut up blankets to use as washcloths, and CNAs reported frequently running out of towels and washcloths over several months, sometimes using towels as washcloths or the cut-up blanket pieces when no other linens were available. The facility’s own admission agreement stated it would provide washcloths and towels, and its laundering policy required linens to be processed to result in a clean and visually acceptable end product, which was not met in these observations.
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