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F0921
E

Failure to Maintain Clean and Safe Environment in Resident Shower Areas

Delaware, Ohio Survey Completed on 11-26-2025

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 that the facility failed to maintain a clean, safe, and comfortable environment for residents, staff, and the public. During an initial tour, observations revealed the presence of a black substance on the ceiling in the shower room on one hall, loose plaster in the corner of the shower room over the tub, a loose ceiling grate with cracked plaster, and a black/brown substance on the ceiling near a sprinkler head by the door, which appeared to have been painted over but was now visible again. Similar conditions were observed in the Memory Care Unit shower room, where a blackish brown substance, suspected to be mold, was present on the ceiling and a musty smell was noted. Staff interviews confirmed the presence of these substances and the musty odor, with one CNA stating the musty smell was noticeable at the start of her shift. Record review indicated that the facility's policy requires maintaining a safe, clean, comfortable, and homelike environment, including providing necessary housekeeping and maintenance services. Despite this policy, the observed conditions affected a significant number of residents on both the 300 hall and the Memory Care Unit. The deficiency was identified through record review, observation, resident and staff interviews, and policy review, and was investigated under multiple complaint numbers.

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