F0921

E

Failure to Maintain Adequate Hot Water and Environmental Cleanliness

Cleveland, Ohio Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain required hot water temperatures and to keep resident rooms and common areas clean and in good repair. On an environmental tour of the third floor, the Maintenance Director measured water temperatures in several occupied rooms using the facility thermometer. In one resident’s bathroom, the sink water reached only 100°F after running for five minutes and then quickly dropped to 62°F. In another room, the bathroom water did not rise above 54°F after running for over three minutes, and in a third room the bathroom water reached only 99°F after six minutes. The Maintenance Director stated that water temperatures should be between 105°F and 120°F and acknowledged ongoing concerns with the mixing valve. He reported that he ordered a rebuild kit on 12/23/25 after being made aware of hot water concerns, then went on vacation, and that the company he used was also on vacation when he returned. He confirmed that the facility did not contact an alternate company to obtain the part or service sooner.

Residents and staff reported persistent problems with inadequate hot water on the third floor. One resident stated that staff had to run the water for a long time to get it slightly warm and that sometimes the water used for cleaning felt slightly warm and sometimes cold, adding that the problem had been going on a long time and that she had informed the Administrator. Another resident reported receiving bed baths with cold water. CNAs reported that residents had expressed concerns about water not getting hot enough and that staff had to let the water run for a while before it would get warm, but sometimes it could run for hours and still not get warm on the third floor. The Maintenance Director confirmed that the first and second floors had sufficient hot water if it ran long enough, but the third floor was not always reaching the appropriate temperature. The Administrator stated that the hot water issue was due to a broken mixing valve first identified on 12/23/25 and confirmed that no interventions were put in place so third-floor residents could wash or be washed with warm water.

The deficiency also includes failures to maintain resident rooms and facility areas in a clean and orderly condition and in good repair. One resident, who was cognitively intact with end stage renal disease, muscle weakness, gait and mobility abnormalities, and total dependence for personal hygiene, bed mobility, and transfers, reported that his toilet had not flushed for a week, that a light above his bed had not worked correctly for several weeks, and that a socket by his bed had no cover since his admission. Observation confirmed the toilet would not flush, one of two bed lights had no bulb, and the phone jack socket was broken. The Maintenance Director stated he had removed the bulb two or three weeks earlier and had not replaced it because he was ordering new lights, and he was unaware of the broken socket.

Additional observations showed significant uncleanliness and disrepair in other resident rooms and hallways. In one room, five visible floor tiles under the bed were broken with missing pieces, the floor and floor mat next to the bed were very dirty with ground-in dirt, dried spills, and apparent food particles, and there were large areas of thick black/brown substance resembling removed floor strips and remnants of a mat stuck to the floor. The dresser drawer had a broken handle, and the dresser surface had dust and dried spills. The resident stated that the facility needed to clean better and that he would like that. In another room, the floor was very dirty with ground-in dirt and mud throughout, and there were multiple trash items under and protruding from under the bed into the walkway, including used tissues, dirty clothing, crumpled papers, and wrappers, with embedded dirt and grime under and beside the trash. The resident was resting on a mattress without sheets, reported preferring to lie on sheets, and stated that the sheets provided did not fit and would not stay in place. He confirmed his room was very dirty and stated that staff only wiped the middle of the floor and did not perform deep cleaning, saying it had been that way forever.

Staff interviews corroborated the poor environmental conditions. A CNA who viewed the two residents’ rooms described them as disgusting and stated that housekeeping did not do a good job. The CNA also confirmed that the third-floor halls, including around the entire nurses’ station, were scuffed with multiple large scrapes that were discolored gray, with the edges showing the tiles were originally light tan. The Administrator, observing the same rooms and hallways, confirmed the dirty floors, trash under the bed, lack of sheets on the mattress, and heavily scuffed, discolored hallway floors. The Housekeeping Manager stated that the conditions were not right and confirmed that none of the facility floors had received a deep cleaning in over a year, explaining that there was no equipment or person to perform it despite repeated requests. An LPN stated that the building was filthy and that everybody knew it. These conditions were inconsistent with the facility’s written policy on providing a safe, clean, comfortable, and homelike environment with clean, sanitary, and orderly surroundings and clean bed and bath linens in good condition.