Failure of Exit Door Alarm Leads to Resident Elopement
Summary
The facility failed to provide a safe and functional environment when one of the four exit door alarms tested did not function properly. This deficiency was identified during an observation and interview with the Director of Maintenance (DOM), who discovered that the exit door alarm next to a specific room did not sound when the door was opened. The DOM attempted to fix the alarm, but it was initially non-functional, which was confirmed by multiple staff members who had not heard the alarm sound for some time. The deficiency was further highlighted by an incident involving a resident with severe cognitive impairment and a history of exit-seeking behavior. This resident had eloped from the facility without staff knowledge or supervision, as the Wander guard or exit door alarms failed to alert the staff. The resident was later found by a nurse in a church parking lot across the highway, indicating that the exit door alarm's failure contributed to the resident's undetected departure. Interviews with staff, including the Director of Nursing (DON) and the Administrator (ADM), revealed uncertainty about which exit door the resident used to elope and whether the door alarm had been checked for functionality after the incident. Additionally, the facility lacked a policy and procedure regarding the use and testing of exit door alarms and Wander guard door alarms, further contributing to the deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsanitary bathroom conditions were observed in 7 rooms, with black and dark filmy growth on ceilings, walls, doors, and door frames, along with warm, musty, foul-smelling conditions. Follow-up checks showed the growth and odors remained, and prior work orders documented mold, ventilation, and A/C concerns without completion dates recorded.
Peeling Wallpaper Left Unrepaired in Resident Room: A resident with severe cognitive impairment and diagnoses including Alzheimer's dementia, CKD, HTN, and depression was observed in a room where wallpaper next to the bed was loose and peeling away from the wall. A NA said the damage had been present for months and the resident had been pulling at it, while an LPN said they were not aware of the issue. The maintenance director said the wallpaper needed repair, but no maintenance requests were found for the room.
A facility failed to keep 4 hallways clean and comfortable, with stained carpets, food debris, urine odor, and cluttered resident rooms observed. Residents reported rooms were not cleaned routinely, one said a spill was left sticky after being wiped but not mopped, and a grievance showed food spills remained for days before cleaning. Staff said housekeeping could not always complete daily room cleaning and that staffing was limited.
Failure to maintain the sewer line and sanitary environment resulted in raw sewage backing up through toilets and shower drains into resident rooms and hallways, with wastewater also leaking into an office area. Residents reported repeated clogs, the building water supply was shut off for hours, and staff confirmed corroded piping, flushed wipes, and that no medical or clinical assessments were completed after residents were exposed to sewage and fumes.
Pest activity and unsanitary conditions were observed in resident areas and near the garbage area. A resident reported a spider on her curtain and a fly in her room, another resident reported flies during meals, and a family member reported roaches, moldy walls, and chipped paint in a resident room. Staff also observed dead insects near the kitchen exit, leaking waste at the garbage compactor, uncovered dumpsters, and unused equipment stored outdoors on muddy ground.
Failure to maintain comfortable temperatures in common areas: surveyors found the dining rooms, hallway, lobby, and kitchen at or above 81 F, with the kitchen reaching 86 F while outdoor heat index conditions were very high. Staff reported the chiller had failed the prior year, the roof unit serving the kitchen and dining room had gone out the prior week, and portable AC units were being used in hallways and dining areas; a resident said bingo was too hot and humid and hard to breathe.
Unsanitary bathroom conditions with unresolved maintenance issues
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in 7 of 60 rooms, specifically Rooms 341 through 347. During observation of the 300 Hall, the resident bathrooms for these rooms were seen with black and dark-colored filmy growth on multiple surfaces, including the ceilings, walls, doors, and door frames. The bathrooms were warm and had a musty, foul odor. Follow-up observations on multiple subsequent dates showed the black or dark growth remained present on the bathroom surfaces, and the bathrooms continued to be warm and musty with foul odors noted. Review of the Maintenance Repair/Housekeeping Logs and Work Orders/Repair Requests showed prior environmental concerns related to moisture, ventilation, water intrusion, and mold before the survey observations. One work order for a room noted mold in the bathroom after a resident complaint, another noted air filters needing replacement, windows needing cleaning, and mold on ceilings, and a maintenance log entry documented that the A/C and heat were not working in one of the affected rooms. The reviewed records did not contain documentation showing completion of the identified work, and the Maintenance Director acknowledged that the entries did not include a date of completion.
Peeling Wallpaper Left Unrepaired in Resident Room
Penalty
Summary
The facility failed to keep a resident room in good working condition for a resident who was severely cognitively impaired and diagnosed with Alzheimer's dementia, chronic kidney disease, hypertension, and depression. During observation, the resident was lying in bed with the bed positioned with its long side against the wall. Next to the bed, the wallpaper seam by the wall light was loose, and approximately 2 feet of wallpaper was peeling away from the wall, exposing a beige wall and some loose white matter where the wallpaper had been attached. During interviews, the maintenance director observed the room and stated the wallpaper needed to be repaired, and noted loose wallpaper may be a safety issue due to the possibility of lead paint in buildings, although they did not believe the facility had lead paint. A nursing assistant stated the wallpaper had been damaged for a few months and that the resident had been pulling at it and removing pieces. The assistant said staff normally notify the nurse when repairs are needed so a maintenance request can be entered. An LPN stated they had not been told about the damage and were not aware the resident was pulling on the wallpaper, and the interim DON and regional nursing consultant stated resident rooms should not have peeling wallpaper. Review of maintenance work orders from 1/1/26 through 8/5/26 showed no maintenance requests were placed for wallpaper repair in the resident's room.
Unclean hallways and inconsistent room cleaning
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in 4 of 4 hallways reviewed for physical environment, including hallways 100, 200, 300, and 400. Observation showed a large brown stain on the carpet near the nurses station on 100 hall, multiple large dark stains on the carpet on 200 hall, dark brown spots on the floor in rooms on 200 hall, dark stains with hardened substance on the carpet on the back side of 200 hall, dark stains in front of the nurses station between 200 and 300 halls, a large dark grayish spot in a doorway, a strong odor of urine at the end of 300 hall, and food particles under a table and in the sink of the dining area on 400 hall. The observation also noted multiple items on the floor in a resident room, including pillows, socks, bags, shoes, towels, books, cups, wheelchair legs, and the call light, as well as breakfast trays left on bedside tables in two rooms. Resident interviews and record review showed concerns about routine cleaning. One resident reported orange juice had been spilled on the floor and wiped with a paper towel but not mopped, leaving a sticky residue. Other residents said their rooms were not cleaned routinely, with one stating the room had been cleaned only once in two weeks and another saying the room was not cleaned on a routine basis. A resident council minute noted a request for more frequent sweeping, and a grievance documented food spills remaining on the floor for several days before the room was cleaned. Staff interviews confirmed housekeeping could not always complete daily room cleaning, that each housekeeper had about 19 to 20 rooms per shift, that only two housekeepers were working at the time, and that dining rooms should be swept and mopped after meals.
Failure to Maintain Sewer Line and Sanitary Conditions
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary for a safe, functional, sanitary, and comfortable environment when the main sewer plumbing line backed up and raw sewage containing urine and feces entered resident rooms and corridors. Surveyors observed that the flooding extended through the second-floor hallway, with wet bath towels and bedsheets used to soak up wastewater, and that the sewage also leaked through the first-floor ceiling into an administrative office. Stained ceiling tiles were later observed in a resident room, and a resident reported that a prior clogged toilet had caused the damage about six months earlier. Residents 2, 6, and 7 reported that sewage water backed up through toilets and shower drains, flooding the hallway and their rooms, and that the building water supply was shut off for several hours after the incident. Resident 6 also reported another clog the following week. Maintenance staff stated the main sewer drain backed up because of corroded cast-iron piping and flushed wipes, and confirmed that sewage entered resident rooms and that residents in wheelchairs traveled through the contaminated water. The Administrator confirmed the sewer line backed up due to pipe separation and flushed wipes, that staff tried to divert traffic and kept unaffected residents in their rooms, and that no medical or clinical assessments were conducted on residents after exposure to the sewage and fumes.
Pest activity and unsanitary conditions observed in resident areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment when bugs, flies, and spiders were observed in and near resident rooms. Resident 4, who was admitted with cellulitis of the lower limb and had a BIMS score of 15, stated she saw a spider on her curtain and a fly in her room. Housekeeping staff reported occasionally seeing dead fruit flies on the windowsill and sometimes finding spiders in resident rooms. Resident 5, who had a BIMS score of 14, stated she occasionally saw flies inside the room during lunch and dinner. Family Member 1 reported that upon arrival at the facility there were roaches in the hallway, moldy walls, and chipped paint inside the resident room. During observation, a deceased roach-like insect was seen near the exit door by the kitchen leading to the garbage area, with two similar dead insects outside the door. The garbage compactor area had liquid waste leaking toward the drain, and old manual lifts and other unused equipment were stored nearby on wet, muddy ground. Two dumpsters containing empty boxes were present without covers. Resident 6, who had a BIMS score of 14, stated flies were seen in the room during mealtimes and that she kept a fly swatter because she did not like seeing flies while eating; Resident 7 stated roaches ran around their room at night, and a fly and a spider were observed during the interview.
Failure to Maintain Safe Common-Area Temperatures
Penalty
Summary
The facility failed to ensure an air conditioning system maintained comfortable temperatures below 81 degrees F in common areas, including the dining rooms, hallways, lobby, and kitchen. Facility temperature logs showed the dining room at 86 F on one date and 81 F on another. During surveyor observations, portable air conditioning units were seen venting into hallways, the dining room, the entrance lobby, and other areas, while staff reported that the built-in heating/air conditioning units were used for heat only and that window air conditioning units had been installed in resident rooms after the chiller went out last year. Surveyors measured common-area temperatures of 80 F to 87 F in the west dining room, front hallway, main dining room, and kitchen, with the kitchen reaching 86 F while outside temperatures were 87 F with a feels-like temperature of 107 F. The Administrator reported that the roof unit that cooled the kitchen and helped cool the dining room had gone out the prior week, that the chiller had gone out last year, and that quotes were being sought for mini split air conditioning units for common areas and hallways. A resident reported leaving bingo in the main dining room because it was too hot and humid and hard to breathe.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.