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F0584
D

Failure to Maintain Safe and Homelike Resident Environment During Prolonged Construction

New Braunfels, Texas Survey Completed on 11-24-2025

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

The facility failed to provide necessary maintenance services to ensure a safe, clean, and comfortable environment for a resident whose room and restroom were under prolonged construction. The resident's shower was sealed off with plastic, with drywall and tile removed, leaving the area in a state of disrepair for over two months. The floor in the resident's room had a large, uneven, sunken area with a lip, and there were brown stains on the linoleum under the vanity. The room and restroom also had a noticeable mildew odor. These conditions were directly observed by surveyors and confirmed by interviews with both the maintenance staff and the resident. The resident involved had a history of dementia, lack of coordination, right hip pain, and difficulty walking, but was alert, oriented, and independent in most activities of daily living. She had no history of falls and used a rolling walker. Despite the environmental hazards, she reported no issues walking over the uneven floor and had not experienced any falls. The resident expressed dissatisfaction with the ongoing construction and lack of access to her own shower, though she was able to use a main shower room nearby. Interviews with facility staff revealed that the shower remodeling project was halted when the original contractor withdrew, citing additional plumbing issues and seeking to renegotiate the contract. The project remained at a standstill for about two months, coinciding with a change in facility ownership. The maintenance staff acknowledged the uneven floor as a trip hazard and noted that the building required significant repairs. Facility policies reviewed by surveyors required maintenance to keep the building in good repair and free from hazards, which was not met in this instance.

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