Environmental Deficiencies Impacting Resident Safety and Comfort
Summary
Multiple deficiencies were identified regarding the facility's failure to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Several residents reported malfunctioning overhead lights in their rooms, with one resident stating the light flickered and another indicating their light did not work at all. Staff confirmed these issues during observations. Additionally, a resident who received a replacement bed reported that the new bed's head would not go up or down, and another resident's overhead bed light required aggressive pulling to operate, which the resident was unable to do independently. Environmental concerns were also observed in common areas and food storage locations. The activities room had a ceiling tile with visible gray/black and brown discoloration, loose baseboards, and green and black bio growth near the sliding glass door and adjacent wall. Water was found collected in a garbage can under the affected area. In the east hallway pantry, the refrigerator and freezer were found to be operating at temperatures above safe ranges, with milk being lukewarm and frozen items thawed. The area under the pantry sink contained dark brown/black bio growth, and a ceiling tile above the door was partially hanging down. A wall fan had an opening to the outside environment, with leaves and debris present. Additional deficiencies included loose flooring in the east hallway and room 215, which could be lifted easily and posed a tripping hazard, as noted by a resident using a walker. In a three-resident room, one resident's air conditioning unit was not functioning, resulting in a room temperature of 80 degrees Fahrenheit, and the AC filter was covered in heavy black bio growth. The bathroom for these residents had a missing ceiling tile with exposed pipes. Facility staff and administration confirmed these findings during a tour and acknowledged the areas of concern.
Plan Of Correction
F921: What corrective actions (s) will be accomplished for those residents found to have been affected by the deficient practice: 1. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews and room audits completed. 2. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 3. By 7/12/2025, Resident #7 bed replaced with head of bed working property. 4. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 5. By 7/12/2025, the loose baseboard along the perimeter of the activities room was replaced. 6. By 7/12/2025, the bio-growth substance outside of the sliding glass door to the left of the activities room exiting to the courtyard was cleaned. 7. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling tile was repaired and repainted. 8. By 7/12/2025, the refrigerator in the nourishment room on the east hallway was removed, discarded and replaced. The cupboard under the sink of the east pantry was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall was cleaned. 9. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room. The missing ceiling tile in the bathroom was replaced. The flooring in Resident #12 room was replaced. 10. By 7/12/2025, the loose flooring was replaced/repaired in the east 200 hallway. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident room and common area audits will be conducted to ensure equipment is safe, sanitary, comfortable, and operational. The audit will include resident room HVAC, refrigerator and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired and/or replaced as appropriate. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on reporting safe, sanitary, comfortable, and operational equipment via TELS. 2. Newly hired staff will be educated on reporting safe equipment, maintenance, and environmental concerns via TELS. How the corrective actions will be monitored to ensure the practice will not recur, e.g., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational weekly for 4 weeks then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met and sustained.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 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.