Failure to Maintain Resident Bathroom Access and Homelike Environment During Prolonged Shower Renovation
Summary
The deficiency involves the facility’s failure to provide a safe, comfortable, and homelike environment by not ensuring that resident bathrooms and showers were maintained in usable condition for an extended period. Four bathrooms in the women’s secured unit had their doors screwed shut after a contractor began but did not complete shower renovations around July or August 2025. The Maintenance Supervisor reported that the contractor discovered more damage than expected, requested additional funds, and when that request was denied, the renovation work stopped. To address the unfinished and potentially unsafe showers, the facility screwed the bathroom doors shut, leaving multiple residents without access to the toilets and showers in their own rooms for about six months. Resident #1, who had Alzheimer’s disease, a psychotic disorder with delusions due to a known physiological condition, anxiety disorder, and major depressive disorder, had moderate cognitive impairment with a BIMS score of 12/15 and was frequently incontinent of bowel and bladder. She required supervision and setup or clean-up assistance with toileting. Her bathroom door was observed to be screwed shut, and she stated she could not use her own toilet because it was locked and that she did not like having to use a different bathroom. Her family member reported that Resident #1 could not remember where the designated bathrooms were and had to be led there by CNAs, and that Resident #1 disliked using another resident’s bathroom. The family member described feeling awkward entering other residents’ rooms, noted that other residents stared at them, and stated this had been an ongoing issue since at least October 2025. Resident #2, who had unspecified intellectual disabilities, unspecified dementia of unspecified severity without behavioral, psychotic, mood, or anxiety disturbance, and bipolar disorder, had a BIMS score of 9/15 indicating moderate cognitive impairment and was occasionally incontinent of bowel and bladder. She required supervision to extensive assistance with toileting, and her care plan called for routine and PRN toileting assistance. She stated she hated not having her own bathroom and having to go to another resident’s room to use the toilet, and reported that the residents whose bathrooms she used did not like it either. Resident #3, with age-related cognitive decline, lack of coordination, and unsteadiness on her feet, had a BIMS score of 8/15 indicating severe cognitive impairment, was continent of bowel and bladder, and required supervision or setup assistance with toileting. She stated it was an inconvenience to use another resident’s bathroom and to walk down a cold hallway to the shower carrying her toiletries, and that it had been a long time since her bathroom had been locked and she wished they would fix her shower. CNA A, who had worked at the facility for about one year, confirmed that four bathrooms in the women’s secured unit had been inaccessible since July or August 2025 because their doors were screwed shut after the incomplete shower remodeling. She stated that affected residents, including Resident #1, Resident #2, and Resident #3, were instructed to use toilets in specific other resident rooms (rooms 36 and 38), the main shower room, and the room across from the shower room, which were at a distance and not liked by residents, especially at night when it was cold. She reported that residents in the designated rooms questioned why others were using their bathrooms and that affected residents and some family members complained frequently about when the bathrooms would be fixed. CNA A described the situation as inconvenient for the affected residents and a privacy issue for the residents sharing their bathrooms. The ADON and Maintenance Supervisor acknowledged that the four bathrooms were locked down and that residents were directed to other bathrooms, and the ADON stated he understood all residents should have their own bathroom and that it was an inconvenience, but said he could not do anything because approval for renovations rested with upper management. The Administrator and DON reported that corporate had requested bids for the shower renovations, that bids were obtained and sent to corporate, and that the matter was stalled with the main owner, while acknowledging that the situation had been ongoing for months, that affected residents should have their own bathrooms, and that it created inconvenience and privacy issues. The facility’s Homelike Environment policy stated that staff should provide person-centered care emphasizing residents’ comfort, independence, and personal needs and preferences, and that management should maximize characteristics reflecting a personalized, homelike setting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unclean Bed Linens: A resident with hypothyroidism and chronic diastolic heart failure had a pillowcase with several dry dark brown/red areas and sheets that appeared gray and unclean. The resident could not remember the last time the linens were changed, and the DON confirmed the linens should have been changed.
Dirty Resident Room and Respiratory Equipment: A resident with dysphagia, a feeding tube, and a tracheostomy had a room observed with a dirty fan, debris on the mattress, dust and dried debris on the O2 concentrator and trach machine, and a dirty towel on the bed. A family member reported the area by the bed was often dirty from tube feeding, and an LPN Resident Care Manager agreed the room was dirty and needed daily cleaning.
A resident’s room and the second-floor hallway had missing baseboards, including under the window in the room and periodically along both sides of the hall. During interview, an Mnt. employee stated the machine must be hitting them and that they had been taken off.
A resident room wall near the window was observed damaged and in disrepair, with a crack large enough for an ink pen to be inserted through it. The Maintenance Director said he knew about the damage after the resident reported it about 2 weeks earlier and believed it was caused by an AC leak. The damaged area covered about 6 square feet, while the Administrator said she was not aware of it and that the facility did not have a specific audit for wall or structural integrity checks.
Unsafe and Deteriorated Resident Room Conditions: Surveyors observed multiple resident rooms with broken, rusted, unsecured, and deteriorated conditions, including a hanging drawer front, scuffed and chipped walls, missing wall trim/chair rails, rust on a bedframe and AC shelf, a broken bathroom tile, and a gallon of Clorox stored in a bathroom. The Maintenance Director acknowledged the environmental conditions during the walkthrough, and photographic evidence was obtained.
The facility failed to maintain a clean, safe, and homelike environment. Surveyors observed dirty hallway vents, ceiling areas with residue, damaged walls, protruding door panel edges, missing tile and cracked flooring in shower areas, and multiple unsanitary conditions in resident rooms, including cracked light covers with bugs, uncovered soiled items, and substances on floors, mattresses, bed sheets, and bedside tables. Two residents’ wheelchairs also had dried substances and hair buildup, and staff acknowledged some areas needed repair or cleaning.
Unclean Bed Linens
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain clean bed linens for one resident. Facility policy stated bed linens are to be changed at least weekly and whenever clinically indicated or requested by the resident. The resident was admitted with diagnoses including hypothyroidism and chronic diastolic heart failure, and the care plan included an intervention to keep bed linen clean due to impaired skin. During observations, the resident’s pillowcase had several dry areas of a dark brown/red substance and the bed sheets had a gray hue and appeared unclean. The resident stated he/she could not remember the last time the sheets were changed. The DON later confirmed that the pillowcase had dark brown/red areas, the sheets appeared unclean, and the bed linens should have been changed.
Dirty Resident Room and Respiratory Equipment
Penalty
Summary
The facility failed to provide a homelike environment for Resident 6, who was admitted in 2022 with diagnoses including dysphagia and whose annual MDS dated 10/25/25 showed a feeding tube for nutrition and a tracheostomy in place. During observation, the resident’s room contained a small black fan that was very dirty and dusty and appeared not to have been cleaned for a long time. The resident’s room was later observed with a mattress on the floor near the bed that appeared dirty with dried clear debris, an oxygen concentrator with dried clear debris and dust on it, a tracheostomy machine with dried white debris all over it, the black fan covered in dust, and a dirty towel on the resident’s bed. A family member stated the area next to the resident’s bed was dirty and often had liquid on it from the tube feeding and appeared gross. An LPN Resident Care Manager observed the room and agreed it was dirty and needed to be cleaned daily.
Missing Baseboards on Second-Floor Hallway and Resident Room
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the second floor. During a tour with Maintenance Employee E9, Resident R171’s room was observed to have a missing part of a baseboard under the window, and the left side of the hallway had baseboards missing periodically down the hall. The right side of the hallway also had baseboards missing periodically down the hall. During an interview, Maintenance Employee E15 stated that the machine must be hitting the baseboards and that they had been taken off.
Damaged Resident Room Wall Left in Disrepair
Penalty
Summary
The facility failed to provide maintenance services to keep a resident bedroom in good repair. In room [ROOM NUMBER], the wall near the window was observed to be damaged and in disrepair, with a crack large enough that the end of an ink pen could be inserted through the wall. The observation was made during a surveyor visit, and photographic evidence was obtained. When the wall was re-observed with the Maintenance Director, he stated he was aware of the damage and said the resident in the room had reported it about 2 weeks earlier. He stated he believed the damage was caused by the air conditioning leaking. The damaged area covered about 6 square feet and extended about 12 inches up the wall. The Administrator later stated she was not aware of the damage and said the facility had room rounds but did not have a specific audit to inspect walls and structural integrity. The facility policy stated that environmental repairs and upkeep would be addressed and corrected in a timely manner, with resident safety taking priority over cosmetic repairs.
Unsafe and Deteriorated Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple resident rooms and resident-use areas were observed in damaged, deteriorated, unsecured, or unsanitary condition in 8 of 64 rooms observed. During observations, surveyors found a broken and hanging drawer front on a built-in wall cabinet, scuffed walls with chipped and scraped paint, rusted air return vent grilles, unsecured trim adjacent to a grille, rust on a bedframe, a broken bathroom floor tile, missing wall trim/chair rail leaving unfinished wall areas, a gallon of Clorox in a bathroom, and a metal air conditioning shelf with visible rust. One room also had a dresser that was scratched and heavily exposed the wood underneath the paint. Additional observations showed more rooms with scuffed walls, chipped and scraped paint, missing wall trim/chair rail, exposed torn sheetrock, and chipped and scraped paint beneath a window. During an interview and walkthrough, the Maintenance Director acknowledged the identified environmental conditions requiring repair or correction. Photographic evidence was obtained of all the issues observed.
Cleanliness, Safety, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, and homelike environment. Surveyors observed multiple areas of disrepair and cleanliness concerns throughout the building, including shower room flooring with dark residue and chipped, open penetrations, hallway vents and ceiling areas with black, gray, and cobweb-like substances, wall gouges, and dining room ceiling vents and lights with dry splattering and rust-colored residue. The facility’s maintenance manager and maintenance director stated they were aware of some of the shower room and panel issues and knew repairs were needed. Surveyors also observed unsafe conditions in resident areas and common spaces. Plastic door panels outside two rooms had protruding edges, the south hall shower room had two large holes where tile was missing and a smaller crack, and staff acknowledged the flooring needed correction. In resident rooms, surveyors observed cracked light covers containing bugs, gouges in walls and railings, a missing bathroom door, a thick black substance at a room entrance threshold, and uncovered soiled items such as an isolation bin with soiled linen and a bedpan on the floor under the sink. Equipment cleanliness concerns were also identified. Two residents’ wheelchairs had dried substances on the cushions and wheels, with hair accumulated in the wheel mechanisms, and a CNA stated night shift should have cleaned the wheelchairs. In another room, surveyors observed mattresses with dried brown and white substances, a mattress leaning against the wall with dried white substance, dried substances on the floor and bed sheets, and a bedside table with dried brown substance. Facility logs reviewed did not document cleaning of hallway vents, mats, or mattresses at the bedside, and the Housekeeping Supervisor stated vents should have been cleaned and that nurse aides were responsible for cleaning body fluids from mattresses and mats before housekeeping cleaned them.
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