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F0921
F

Deficient Sanitation, Ventilation, and Safety in Resident Shower Rooms

Boston, Massachusetts Survey Completed on 09-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified multiple deficiencies in three resident shower rooms, including nonfunctional door locks, unclean and unsanitary conditions, and malfunctioning ventilation systems. Observations revealed that door locks were either difficult to operate or missing, with some doors left unlocked, allowing unrestricted access. The shower rooms were found to have musty odors, visible mold on ceilings, tiles, and shower curtains, and significant dust buildup on ventilation grills. In all three shower rooms, the ventilation systems were nonfunctional, as evidenced by the lack of airflow when tested with toilet paper. The Maintenance Director confirmed that the facility's HVAC system was not working throughout the building and that no professional remediation had been conducted for the mold, with only partial cleaning attempted by maintenance staff. Further inspection showed that personal hygiene items, towels, and residents' belongings were left in the shower rooms after use, contrary to facility expectations. Items such as damp towels, opened bottles of bathing products, and soiled linens were found on benches and floors, some with visible black or brown discoloration. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the frequency of shower room cleaning and the status of the ventilation system. Despite the unclean conditions, documentation indicated that residents continued to use the showers, with several residents scheduled and reported to have received showers in the affected rooms. Additionally, water temperature issues were noted in at least one shower room, where the temperature remained cold and the gauge was not functioning properly. The Maintenance Director acknowledged that the water temperature gauge and pressure switch needed replacement and that shower water temperatures had not been included in daily audits since hot water was restored. The DON was aware of the water temperature issue but was not informed about the HVAC system's status or any plans for repair or replacement. These findings collectively demonstrate a failure to maintain a safe, functional, and sanitary environment in the resident shower rooms.

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