F0584

E

Environmental Disrepair and Unsanitary Shower Areas Compromise Homelike Conditions

Orlando, Florida Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in multiple resident care areas and rooms. Surveyors observed that two shower rooms on the East Wing were in deteriorated and unsanitary condition. In one shower room, walls and grout were discolored and stained, grout at the base of the walls was cracked, deteriorated, and separated, and the 2x2 inch floor tiles were worn, uneven, damaged, and included missing and mismatched tiles. In the second shower room, the toilet bowl contained dark brown standing liquid with heavy staining consistent with prolonged buildup, poor drainage, or inadequate cleaning and maintenance, and this condition remained unchanged when rechecked the following day. The Housekeeping Director and Environmental Services District Manager, after reviewing photographs, acknowledged degraded or missing grout and apparent growth on the walls, and the Housekeeping Director stated that housekeepers entered the shower rooms daily but had not reported the clogged toilet.

Additional environmental deficiencies were identified in resident rooms on the [NAME] Wing and in the West Wing back hallway. In one resident room, the lower portion of the entrance door was warped and broken with sharp edges, and the bottom panel was lifted approximately eight inches; the closet door was chipped, uneven, and did not close properly. Another room had missing closet doors, a cracked baseboard near the bathroom door measuring approximately three to five inches, scratches on the bathroom door, and unfinished drywall patchwork near the bathroom entrance and window. A third room had deteriorated wall surfaces along the lower portion near the floor, unfinished drywall patchwork with visible spackling, and a cracked baseboard near the bathroom door measuring approximately two to four inches. In another room, the baseboard near the bathroom door was cracked two to four inches wide, the bathroom door had multiple scuff marks, and four to six penny-sized holes were present on the wall above the B-side dresser, with black speckles on the ceiling above bed B and in the bathroom.

Surveyors also found that the back hallway floor on the [NAME] Wing around a drain was in poor repair, with multiple missing tiles, mismatched and patchworked tiles, visible cracked and broken tile edges, exposed subfloor material, erosion, and uneven flooring. Interviews revealed that a resident reported the entrance door damage occurred when a roommate’s wheelchair got caught in it a few days earlier and that the closet door had been broken for a long time. A family member reported holes in the wall and stains on the bedroom and bathroom ceilings and stated that while the East Wing had been renovated, nothing had been done on the [NAME] Wing. The Maintenance Director, who had been working alone for several weeks and relied on CNAs to enter work orders, confirmed the damaged doors, patchwork flooring, and deteriorated room conditions and stated he had been unaware of the missing tiles in the shower floor. Review of maintenance logs from November 2025 through the survey date showed no documented work orders or repairs for the deteriorated shower rooms, unsanitary toilet, damaged resident room doors and walls, or hallway flooring, despite facility policies requiring ongoing inspections, preventive maintenance, and housekeeping to promote a sanitary, safe, and comfortable environment.