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F0584
D

Failure to Maintain Clean Shower Rooms and Wheelchair in Good Repair

Huntersville, North Carolina Survey Completed on 12-11-2025

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 maintain a clean and sanitary environment in two of three shower rooms observed. During inspections, a black/gray substance was found covering the tile floor, cracks, and walls of the 100-hall and 300-hall shower rooms. The Environmental Service Manager acknowledged that daily cleaning and monitoring of the shower rooms was required but admitted to not having checked the 100-hall shower room on the day of observation. Housekeeping staff assigned to the 300-hall shower room reported being aware of the substance but believed the standard cleaner would not remove it, although it was later demonstrated that the substance could be removed with the available cleaning product. Additionally, the facility failed to maintain a resident's wheelchair in good repair. The resident, who had intact cognition and used a wheelchair as a primary mobility device, was observed with both arms in contact with torn and ripped vinyl armrests, which he reported had been in disrepair since admission and caused him itchiness and irritation. Nursing staff were aware of the damaged armrests but did not report the need for repair to maintenance. The Assistant Maintenance Manager stated that repair needs were typically identified through work orders or verbal notification, and he did not routinely check residents' wheelchairs unless notified by staff. Interviews with facility leadership, including the DON and Administrator, confirmed that all staff were expected to report repair needs for mobility devices and maintain a clean environment. However, the lack of timely reporting and follow-through resulted in the deficiencies observed in both the shower room cleanliness and the condition of the resident's wheelchair.

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