NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews conducted during the recertification and abbreviated (Case #'s NY 251, NY 834, NY 849, NY 717) survey, the facility did not provide effective housekeeping and maintenance services on six (6) of six (6) resident units. Specifically, floors and resident units were not clean and maintained. This is evidenced by: During observations on 6/08/2025 between 1:30 PM and 5:30 PM: ?? The floors were sticky in the corridors on resident units One (1), Three (3), and Six (6). ?? The floors were sticky in resident Room #s 305, 605, and 606. ?? Trash was found in the corridor on Unit One (1). ?? The bathroom toilet and floor were soiled in resident room [ROOM NUMBER]. ?? The bathroom floor was littered wads of used toilet paper, and the wallpaper was improperly patched in resident room [ROOM NUMBER]. ?? The baseboard below sink was warped in resident room [ROOM NUMBER]. ?? The privacy curtain was stained in resident room [ROOM NUMBER]. During observations on 6/08/2025 at 3:03 PM, the soap dispenser in the resident room [ROOM NUMBER] bathroom was ripped off the wall and laying on the floor. During observations of Resident #23's room on 6/09/2025 at 3:29 PM: ?? The bed A top bed sheet had several dried blood stains. ?? The bottom sheet was visibly soiled with a large stain; the stain was partially covered with folded sheets and a protective cloth. ?? A soiled brief was draped over the side of the resident waste receptacle; the waste receptacle was placed close to the bedside. ?? The bed table and nightstand were cluttered with empty and unopened beverage bottles. ?? The resident room floor was sticky. During an interview on 6/13/2025 at 12:49 PM, Resident #23 stated that staff changed their top bed sheet but did not change the bottom sheet. The same bottom sheet was on their bed all week. The sheet was not useable and disgusting. Resident #23 stated staff covered the dirty stained sheet with a folded blanket. During observations on 6/16/2025 at 11:41 AM through 2:00 PM: ?? The floors soiled where door frame meets floor on resident units Two (2), Four (4), Five (5), and Six (6). ?? A moldy odor was detected on Unit Two (2). During an interview on 6/16/2025 at 11:51 AM, Director of Housekeeping #1 stated that they would clean where the door frame meets the floors and that they were not able to detect a moldy odor on Unit Two (2). During observations on 6/17/2025 at 11:38 AM, the surface of the wall around the west stairwell was crumbling and was soiled with a black mold-like substance. During an interview on 6/17/2025 at 11:40 AM, Director of Maintenance #1 that that they would repair the west stairwell wall. Director of Housekeeping #1 stated that they would clean the wall. 10 New York Codes, Rules, and Regulations 415.5(h)(4) | Plan of Correction: ApprovedJuly 27, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Tag: F584 ?Çô Resident Environment Corrective Action for Residents Affected: ?Çó Resident #23, specifically identified in the survey, had their room assessed and cleaned. Interventions included: o Floor cleaned and spray buffed. o Privacy curtain was replaced. o All linen changed and inspected for stains. o Bathroom sanitized. o Room re-evaluated by Environmental Services and Nursing for cleanliness and repair needs. Corrective Action for Other Residents with Potential to Be Affected: ?Çó Environmental issues identified facility-wide were addressed as follows: o Sticky floors in corridors of Units 1, 3, 6, and Rooms #305, 605, 606 were recleaned and spray buffed. o Soiled floors where door frames meet the floor on Units 2, 4, 5, and 6 were cleaned and buffed. o Bathrooms cleaned in rooms [ROOM NUMBERS]. o Privacy curtain replaced in room [ROOM NUMBER]. o Stained linens facility-wide were replaced after a full audit. o Baseboard replaced in room [ROOM NUMBER]. o Wallpaper removed and wall skim-coated in room [ROOM NUMBER]. o West stairwell wall cleaned and repaired. o Soap dispenser replaced in room [ROOM NUMBER]. ?Çó All resident rooms were visually inspected. Any additional environmental concerns were added to the maintenance log and resolved. Systemic Measures to Prevent Reoccurrence: ?Çó Revised Housekeeping Checklist includes: oFloor mopping with edge detail. o Daily bathroom sanitation. o Trash and soil removal every shift. o Prompt replacement of stained linens and privacy curtains. ?Çó Linen Care Protocol: o Linens are changed daily and as needed. o Stained or soiled linens replaced immediately. o Joint daily rounds by Housekeeping and Nursing to ensure linen integrity. ?Çó Unit Room Checks: o Conducted daily by Unit Managers and Housekeeping staff. o Checks include cleanliness, odor control, trash removal, prompt repair reporting, and utility room order. ?Çó Maintenance Environmental Rounds: o Weekly inspections of walls, floors, fixtures, and equipment. o All findings are logged in the work order system and resolved promptly. ?Çó Staff Education: o All Housekeeping and Nursing staff re-educated on: - Daily cleaning protocols. - Environmental damage identification and reporting. - Maintaining a safe, clean, and comfortable environment. o Post-tests administered to validate training comprehension. Quality Assurance Monitoring: ?Çó Audit Details: o Weekly Environmental Audits of 10 randomly selected rooms and bathrooms. o Each audit includes: - Floor and wall condition. - Curtain and linen condition. - Bathroom cleanliness. - Presence of odors and trash. - Functional fixture checks. ?Çó Audit Duration & Oversight: o Audits will be conducted weekly for 6 weeks, then monthly for 3 months. The Environmental Services Director/Designee will review audit results and present findings at monthly Quality Assurance and Performance Improvement meetings. o Any deficiencies identified will result in immediate corrective action and retraining as needed. Responsible Party: Director of Housekeeping/Designee Date of completion: 08/16/2025 |