Failure to Maintain Safe Resident Room Environment
Summary
A deficiency was identified when observations and staff interviews revealed that a resident's room on the Rehabilitation Unit had a window with broken glass pieces that were taped with duct tape, and additional broken glass pieces were found between the glass panel and the screen. Further inspection of the same room showed a dresser with two broken drawer fronts, with the broken pieces placed inside the drawers. These conditions were confirmed by the DON during the observation. The facility failed to provide a safe environment for the resident as required by regulations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Privacy Curtains in Resident Room: A resident with schizophrenia, hyperglyceridemia, and nicotine dependence had no room curtains observed in place during an observation. HK stated curtains removed for cleaning should be replaced immediately with extra curtains to maintain privacy, and the ED stated the facility did not have extra curtains available when the curtains were being washed. The facility policy stated curtains are to be washed as needed and replaced immediately if spare curtains are available.
Surveyors found that multiple residents’ rooms and the 3rd floor lounge were not maintained in a clean, sanitary condition. Numerous room curtains were visibly soiled or stained, one room had peeling and missing wallpaper behind the beds, and a shower used by a resident contained a brown substance on the floor. That resident reported that staff rinse a roommate’s bedpan in the shower and leave brown residue without cleaning or disinfecting, preventing the resident from using the shower. The lounge carpet also had dark stains and paper debris. These conditions were confirmed by the DON, and the NHA stated that one resident’s constant presence in the room made wall repair difficult.
Privacy curtains did not fully enclose the bed spaces for several residents, and staff confirmed the curtains did not reach around the beds. Residents reported being exposed when using the bathroom in bed or receiving bed baths, and said staff and visitors passed by their beds to reach roommates. The DON stated the curtains should reach around the bed for privacy, while housekeeping reported limited curtain supply and no maintenance requests were found.
Resident rooms did not provide enough space for comfort and privacy for two residents. One resident was dependent for transfers, severely cognitively impaired, and required a Hoyer lift, while another resident was alert and oriented. Staff had to move the second resident’s bed to position the lift and then shift the first resident’s bed to make room for the wheelchair and lift, disrupting the other resident.
Three resident rooms lacked privacy curtains, and eighteen rooms had soiled or stained privacy curtains on the 1st floor dementia care unit. This failure to provide adequate privacy and maintain clean equipment was confirmed by facility leadership.
A resident using an alternating pressure mattress experienced discomfort and had to relocate to the lobby due to a malfunctioning mattress. The facility lacked a policy for maintaining patient care electrical equipment and did not have documentation of inspection or maintenance for the mattress. The Maintenance Director was unaware of the requirement for electrical testing, leading to the deficiency.
Missing Privacy Curtains in Resident Room
Penalty
Summary
Privacy curtains were not in place in Resident 15’s room. Resident 15 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, hyperglyceridemia, and nicotine dependence. The MDS dated 4/18/2026 indicated the resident was cognitively intact and independent for eating, toileting, and bathing. During an observation on 5/4/2026 at 10:10 a.m., no room curtains were observed hanging in Resident 15’s room. During a concurrent observation and interview on 5/4/2026 at 2:36 p.m., Housekeeping stated that when room curtains are removed for cleaning, the Janitor should replace them with extra curtains to ensure resident privacy, and that staff should have replaced the curtains immediately after taking them down. The Environmental Director later stated that extra curtains were not available on 5/4/2026 when Resident 15’s curtains were being washed, and that the facility should have had extra curtains available to replace them while they were being washed. The facility policy dated 12/2025 stated curtains are to be washed semi-annually or when soiled or requested, and replaced immediately if spare curtains are available or if damaged or torn.
Unclean Resident Rooms and Lounge Environment on 3rd Floor Unit
Penalty
Summary
Surveyors identified that multiple resident rooms and common areas on the 3rd floor care unit were not maintained in a clean and sanitary condition. During observations conducted between 10:00 a.m. and 12:00 p.m. on April 22, 2026, window curtains in the rooms of fifteen residents were noted to be soiled or stained with brown discoloration. In one resident room, wallpaper was observed peeling off the wall behind one bed, and wallpaper was missing on portions of the wall behind both beds. In another resident’s shower, a brown substance was observed on the shower floor. That resident reported that staff flush the roommate’s bedpan in the toilet and sometimes rinse the bedpan in the shower, leaving brown substances in the shower without cleaning or disinfecting it, and stated that he/she had been unable to use the shower because it had not been sanitized. Additional observations on the same unit showed that the 3rd floor lounge area carpet had dark stains and paper debris present. These environmental concerns, including the soiled curtains, deteriorating wallpaper, unclean shower, and stained, debris-littered lounge carpet, were observed in the presence of the DON on the afternoon of April 22, 2026. In a subsequent interview, the NHA acknowledged that the resident in one of the affected rooms rarely leaves the room, which the NHA stated made it difficult for maintenance to repair the wall. The DON confirmed the observations and noted that residents sometimes eat lunch in the lounge area.
Privacy Curtains Did Not Enclose Multiple Resident Bed Spaces
Penalty
Summary
The facility failed to ensure resident rights for privacy and a dignified existence were respected for seven residents when their privacy curtains did not enclose their bed spaces. During multiple observations from 3/16/26 through 3/19/26, Residents 31, 39, 66, 76, 130, 141, and 143 were observed with curtains that did not surround their beds for privacy. CNA 3 verified that the curtains did not reach around the beds of Residents 66 and 130 and stated they should be longer, and CNA 4 verified that the curtains did not reach around the beds of Residents 76 and 141. The DON stated the curtains should reach around the bed for privacy. Residents also described the lack of privacy during personal care and when staff or visitors passed by their beds. Resident 39 stated there was no privacy when using the bathroom in bed or taking a bed bath because staff could come in and pass by. Resident 31 stated staff and visitors passed by her bed to get to her roommate’s bed and that she was exposed without a privacy curtain, and she said she would like a privacy curtain to maintain her dignity. Resident 143 stated staff and visitors frequently passed by her to get to her roommate’s bed and said she would like the curtain to extend all the way around her bed. CNA 6 confirmed that Residents 31 and 143 had no privacy when staff or visitors passed through to adjacent beds. Housekeeping stated curtains are replaced between residents and as needed, but supplies had been very limited recently, and the maintenance log from 1/14/26 through 3/18/26 showed no request for curtain replacement or lengthening. The facility policy stated bedrooms are designed to provide full visual privacy with ceiling-suspended curtains that extend around the bed.
Resident Room Space and Privacy
Penalty
Summary
Resident rooms did not provide enough space for comfort and privacy for 2 of 3 residents reviewed, including one resident who was dependent for transfers and severely cognitively impaired and another resident who was alert and oriented. The dependent resident’s care plan directed staff to use a Hoyer lift for transfers, and the room contained three beds with the dependent resident in the bed next to the window, the second resident in the middle bed, and another resident closest to the door. During observation, staff had to move the second resident’s bed to position the Hoyer lift near the dependent resident’s bed, and after the resident was lifted, staff pushed the dependent resident’s bed toward the window to create more room for the wheelchair and lift. The second resident stated that nursing assistants had to move his bed to get the Hoyer lift under the other resident’s bed and that this disrupted him. The administrator acknowledged that the expectation was not to create an environment where residents feel they do not have their own space for comfort.
Deficiency in Resident Room Privacy and Cleanliness
Penalty
Summary
Surveyors observed that three out of thirty-two resident rooms on the 1st floor dementia care unit did not have privacy curtains, and eighteen rooms had privacy curtains that were soiled or had brown stains. These observations were made over a three-day period. The lack of privacy curtains and the presence of soiled curtains were confirmed during interviews with the Nursing Home Administrator and the Director of Nursing. The deficiency was identified as a failure to provide adequate privacy and maintain clean equipment in resident rooms, as required by regulations.
Plan Of Correction
Soiled curtains were immediately replaced with clean privacy curtains and privacy curtains were hung in rooms that were missing privacy curtains. Facility-wide audit conducted by NHA/Designee to ensure resident rooms have privacy curtains and are free from soilage. NHA/Designee provided education to housekeeping and maintenance staff on assuring that resident rooms have privacy curtains in place and free from soilage. NHA/Designee will audit random rooms to ensure privacy curtains are present and free from soilage. Audits will be done weekly x4 then monthly x2 or until compliance is achieved. Results will be discussed at monthly QAPI.
Failure to Maintain and Document Safe Operation of Patient Care Electrical Equipment
Penalty
Summary
The facility failed to maintain patient care electrical equipment in safe operating condition for a resident using an alternating pressure mattress. The facility did not have a policy regarding the maintenance of patient care electrical equipment, and there was no documentation available for the inspection or maintenance of the mattress. On observation, the resident was found lying in bed with the mattress, and reported having to sit in the lobby the previous day due to the mattress malfunctioning and feeling uncomfortable. The Corporate Executive confirmed that the Maintenance Director was unaware of the electrical testing requirement for the mattress, resulting in the absence of maintenance records.
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