Failure to Maintain Safe, Sanitary, and Comfortable Environment
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as required by regulation. Multiple residents experienced prolonged periods without functioning air conditioning in their rooms, despite documented work orders and repeated resident complaints. Residents dependent on oxygen and with significant medical conditions, such as heart failure and chronic respiratory issues, were observed in uncomfortably warm rooms, relying on fans for cooling. Maintenance staff confirmed that repairs were not completed due to unavailable parts and lack of assistance, and residents reported not seeing maintenance staff after initial contact. Environmental cleanliness and maintenance were also lacking throughout the facility. Several resident rooms were observed with dirty, sticky floors, rusted sinks, stained toilets, and built-up grime in corners and on fixtures. In some cases, furniture and call lights were damaged or inadequately repaired, and residents expressed dissatisfaction with the cleanliness and condition of their living spaces. The facility's A unit had widespread blackened buildup at room entryways and corners, and there was no written plan for floor replacement or deep cleaning. Resident council meeting minutes corroborated ongoing concerns about inadequate room cleaning. Common areas and shared facilities were similarly affected. The A unit shower room was repeatedly reported as uncomfortably cold by residents, with a measured temperature below the recommended range, a non-functioning wall heater, and significant dust and debris buildup on ceiling fans and louvers. Dining room chairs were found to be broken or worn, with exposed, unsealed wood surfaces, and at least one chair remained in use despite being identified as unsafe. Maintenance staff confirmed these issues and stated that some problems were not reported to them, resulting in delays or lack of repairs.
Plan Of Correction
F921 The facility failed to maintain a homelike environment for residents #3, #7, #8, #14, #29, #37, #38, #39, #198 directly and all 26 residents on A Wing when: A) 2 PTAC room units (HVAC) stopped working appropriately in residents #198 and #38 rooms. B) Resident #29 toilet dirty, sink rusted, and floors dirty/sticky. C) Resident #39 bed remote needing replaced, the floor was sticky, the light above the sink needed replaced, and the light cover was yellowed. Toilet caulking around toilet stained. D) Resident #8 sink rusted, light over sink yellowed, bathroom floor tiles stained, metal hinges on toilet seat dirty, gouges in bathroom doorway paint. E) Resident #3 floors with buildup in corners, gouges in drywall, tape on call light, bathroom floor with stains, toilet with yellowish stains, furniture in disrepair, unable to use over-the-bed light due to length of string, dust on lights/bulbs. F) Resident #37 toilet with yellowish stains and sticky floor. G) A Wing Shower Room 69 degree ambient temperature with non-functioning heater and fan louvers with build-up. H) All resident rooms on A Wing with buildup of blackened material at threshold to hallway. I) Resident #14 missing/damaged wallpaper near bed. J) One chair in main Dining Room with damaged armrest, remaining chairs with protective finish removed due to wear and in overall disrepair. Step 1: The facility immediately A) replaced the PTAC units in the rooms of both resident #198 and #38, in addition to placing order with contracted maintenance company BIS to assess, secure parts, and/or order additional units. Completed 6/5/25. B) The Maintenance Director audited resident rooms/bathrooms to identify a priority schedule for installation of new flooring, replacement of lighting units, toilets, and sinks. Completed on 7/10/25. C) The toilets in question were immediately cleaned. Completed on 6/10/25. D) DOM will create a schedule for installation of new flooring into non-priority rooms/areas as well as replacement of lighting units, sinks, and toilets. Completed on 7/10/25. The Maintenance Director has initiated repairs to identified areas noted above including the following measures: B) Resident #29 toilet cleaned 6/10/25, sink plan to replace, floors cleaned 6/10/25. C) Resident #39 bed remote needing replaced completed 6/10/25, the floor was sticky and cleaned 6/10/25, the light above the sink needed replaced and the light cover was yellowed both replaced 6/10/25, toilet caulking around toilet stained plan to replace. D) Resident #8 sink rusted plan to replace, light over sink yellowed replaced 6/10/25, bathroom floor tiles stained plan for new flooring, metal hinges on toilet seat dirty cleaned 6/10/25, gouges in bathroom doorway paint, plan to repaint. E) Resident #3 floors with buildup in corners cleaned 6/10/25, gouges in drywall repaired 6/4/25, tape on call light removed 7/10/25, bathroom floor with stains plan to replace, toilet with yellowish stains plan to replace, furniture in disrepair plan to replace, unable to use over-the-bed light due to length of string replaced 7/10/25, dust on lights/bulbs cleaned/dusted 7/10/25. F) Resident #37 toilet with yellowish stains plan to replace and sticky floor cleaned 6/10/25. G) A Wing Shower Room 69 degree ambient temperature with non-functioning heater and fan louvers with build-up corrected 6/4/25. H) All resident rooms on A Wing with buildup of blackened material at threshold to hallway, adhesive from new/replaced hallway flooring removed 7/10/25. I) Resident #14 missing/damaged wallpaper near bed, plan to remove paper and paint room. J) One chair in main Dining Room with damaged armrest removed from use, remaining chairs with protective finish removed due to wear and in overall disrepair, plan to replace all Dining Room chairs. Step 2: This has the potential to affect all residents. The DOM or designee will create a Master Deep Cleaning schedule for all resident rooms/bathrooms/shower rooms. The LNHA will place a request for capital funds to replace sinks, toilets, and furniture identified as in disrepair. Will be completed on 7/10/25. Step 3: To prevent this from recurring, the LNHA, DOM, or designee will educate staff on the work order process. The DOM will educate the environmental services staff on the Master deep cleaning schedule. The DON will educate STNA's on the need for cleaning toilets and floors throughout the day and night when soiled. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the LNHA or designee will audit 5 rooms for repair/maintenance needs 5 times per week and complete work order notifications. The DON will audit 8 toilets weekly for 4 weeks then monthly for 2 months. The DOM will audit 6 HVAC vents weekly for 4 weeks then monthly for 2 months. Audits to begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An open floor drain near the dish machine was observed without a grate, and the FSM confirmed it had no grate and was unsure how long it had been open. In the Hair Salon, the sink drain filter had a glob of hair, and 3 brushes plus a box of hair curlers had hair on them; the AD and HS both confirmed the unsanitary conditions, and the HS stated she might have forgotten to clean the salon after the beautician visit.
A resident room was observed in disrepair with unpainted wall areas, black marks, discoloration, ceiling staining, and scuffed, missing paint on the door frame, and the same conditions remained on follow-up. The memory care dining room floor also had food crumbs and debris under multiple tables; an LPN said it appeared not to have been cleaned after the prior night's meal, and the administrator confirmed the food was still present.
Leaking and Loose Faucets in Facility Sinks: During a facility tour, a beauty shop style sink was observed leaking where the faucet connected to the sink, and maintenance staff stated they were not aware it needed repair. A sink in the soiled linens room on D/F Hall was also observed with a loose swivel faucet that leaked when turned on, and maintenance staff confirmed the observation.
Sharps containers on a locked dementia unit were observed full to the point that they could not be opened, including one in a shower room with three uncapped used disposable razors sitting on top of it and another on a medication cart. The DON and an LPN confirmed the containers were unusable, and the LPN noted two residents on the unit required routine blood glucose monitoring with lancets that would need disposal in a sharps container.
Resident room walls were observed with moisture, black/gray staining resembling mildew or mold-like substance, bubbling paint, cracks, gouges, and dirty vents in multiple rooms, including B-2, B-4, B-6, B-8, B-10, and B-12. The Tel's record review showed no reports about the wall conditions for the past 6 months, and the ADM stated the moisture had been present for a while and had not previously been brought to the ADM and Maintenance Director's attention.
A resident with moderate cognitive impairment and anticoagulant use had a bedside table within reach that was observed to be broken, with an unfinished edge, exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed the table was in poor repair and accessible to the resident.
Unsanitary Hair Salon and Open Kitchen Drain
Penalty
Summary
The kitchen floor drain near the dish machine was observed on 6/09/2026 at 8:08 AM without a grate. The FSM confirmed the drain was open and stated she was not sure how long it had been without a grate. She also stated the facility had no pests and that they were waiting for the Maintenance Supervisor to start working at the facility so she could let him know about it. Later that day, the FSM stated she had told the prior Maintenance Supervisor about it a week or 2 weeks earlier, and that the new Maintenance Supervisor had started on 6/8/2026 after the former supervisor left on 6/5/2026. In the Hair Salon on 6/11/2026 at 11:07 AM, the sink drain filter contained a glob of hair, and 3 brushes in a cabinet had hair on them, along with a box of hair curlers with hair on them. The Activity Director confirmed these observations and stated Housekeeping was responsible for cleaning the Hair Salon sink. The Activity Director also stated the beautician had visited on 6/9/2026. The Housekeeping Supervisor confirmed the hair in the sink drain filter and stated she might have forgotten to clean the Hair Salon after the beautician visited that week.
Dirty resident room and unclean memory care dining room
Penalty
Summary
The facility failed to maintain a resident room in a clean, sanitary, and orderly condition for one resident, R5. During observations, R5 was lying in bed while the room showed multiple areas of disrepair: a section of wall below the mounted TV was not painted the same color as the rest of the wall, the wall across from the bed had multiple black marks and light brown discoloration, the ceiling above the window had a yellowish discolored area about the size of a basketball extending along the ceiling/wall, and the door frame had multiple scuff marks and missing paint. These same conditions were still present on follow-up observation, and R5's family member stated they had concerns about the environment, describing the facility as not clean, smelling bad, and reporting concerns about the room's smell, missing paint, and ceiling to staff. The facility also failed to keep the memory care dining room floor in a clean and sanitary condition. During observation, the floor under multiple dining tables had light-colored crumbs, brown crumbs, pieces of a white meat-like substance, and spaghetti noodles. An LPN stated it looked like the floors had not been cleaned after the prior night's meal and said housekeeping was supposed to clean the floors after meals were served. The administrator confirmed the food under the tables and stated any staff member who observed it should help clean it up, not just housekeeping. The maintenance policy stated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Leaking and Loose Faucets in Facility Sinks
Penalty
Summary
The facility failed to maintain plumbing in the building, as observed during a facility tour with maintenance employee C. On 05/27/2026 at 9:45 AM, the beauty shop style sink with a head rest and hair rinse hose was observed leaking where the faucet connects to the sink, and maintenance employee C also observed the faucet leaking and stated they were not aware it needed repair. Later, on 05/27/2026 at 10:16 AM, the sink in the soiled linens room in the D/F Hall was observed with a swivel faucet that was loose and leaking when the sink was turned on, and maintenance employee C confirmed this observation during interview at the time.
Sharps Containers Left Full and Unusable
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for residents by not maintaining sharps containers in a safe manner in two of four observed sharps containers. Record review of the facility’s Sharps Container Policy showed that the facility would use sharps containers for disposal of sharp items, including lancets, and that containers were to be sealed with tape and dated when disposed of, but the policy did not address when or how often the containers should be emptied. During observation, the sharps container in the shower room on the locked dementia unit was full to the point that it could not be opened, and three uncapped used aqua-blue disposable razors were sitting on top of the container. The DON confirmed the container should have been properly disposed of and replaced with a new one and stated the razors on top of the container could pose a potential safety hazard to residents. A second observation showed the sharps container on the medication cart for the locked dementia unit was also full to the point that it could not be opened. An LPN stated the unit had two residents who required routine blood glucose monitoring and that lancets used for blood glucose checks would need to be disposed of in a sharps container, but the container on the medication cart was not usable because it could no longer be opened. The Administrator stated she expected staff to provide for resident safety in the shower room and anywhere sharps containers were located, and confirmed that leaving uncapped or unsheathed disposable razors on top of the sharps container in the shower room could pose a safety hazard for residents.
Resident Room Walls Found Moist, Stained, and Damaged
Penalty
Summary
Resident room walls were not kept free from moisture, black/gray staining, gouges, bubbling paint, and dirt in multiple rooms. On 5/27/26 at 11:00 AM, an observation found room B-2 with dirty vents and a small gouge in the drywall; room B-4 with an outside wall that was moist and had a grayish stain about 1 foot by 1 foot resembling mildew or a mold-like substance; room B-6 with a moist outside wall, a black/gray substance resembling mildew, and several bubbles and cracks in the paint; room B-8 with an outside wall that felt moist to touch and had a blackish/gray substance about 2 feet by 2 feet resembling mildew or a mold-like substance; room B-10 with streaks and stains going down the outside wall; and room B-12 with cracks in the drywall, streaks down the wall, and bubbling paint. A record review of the Tel's program showed no report regarding the resident walls for the past 6 months. During an environmental tour on 5/28/2026 at 1:00 PM with the Administrator and Maintenance Director, the same wall conditions were confirmed in rooms B-2, B-4, B-6, B-8, B-10, and B-12. In an interview at that time, the Administrator stated the moisture on the walls in the resident rooms had been there for a while and should have been reported by staff who see the wall daily, and also stated this was the first time the walls had been brought to the Administrator and Maintenance Director's attention.
Broken Bedside Table Within Resident Reach
Penalty
Summary
The facility failed to ensure that a bedside table was in good repair for Resident #59, who was admitted with diagnoses including cerebral infarction, schizophrenia, and acute embolism. The resident’s MDS assessment showed moderate cognitive impairment, no upper body impairment, and anticoagulant use, and the care plan identified risk for bleeding related to anticoagulant medications. During observation, the resident’s bedside table was within reach and was found to have an unfinished, broken edge with approximately three inches of exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed that the bedside table was broken with rough, exposed particle board and wood chips and was within reach of the resident.
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