Failure to Maintain Safe Grab Bars and Sanitary Mattress Conditions
Summary
The deficiency involves the facility’s failure to provide a safe environment for one resident and a sanitary sleeping environment for another. One resident with a history of falls, heart failure, anxiety, limited physical mobility, and moderately impaired cognition was care planned as being at risk for falls and was allowed to use the bathroom and self-transfer independently. While attempting to transfer from a wheelchair to the toilet using a bathroom grab bar, the grab bar detached from the wall, causing the resident to come down with knees on the floor and head against the door. The resident later reported chest pain, and a chest x-ray identified fractures of the left 5th to 7th ribs. Staff documentation and interviews confirmed that the grab bar was found dislodged on the floor and that prior to this incident, the facility’s monthly environmental rounds did not include checking grab bars for stability. The deficiency also includes the facility’s failure to ensure a sanitary sleeping environment for another resident with diagnoses including congestive heart failure, history of UTIs, and history of pressure ulcers, who was severely cognitively impaired, dependent for all care, and required a mechanical lift with two-person assistance. The resident’s care plan identified a self-care deficit and risk for skin breakdown, with interventions including regular repositioning, incontinence care, and use of barrier cream. A visitor reported that the resident’s mattress sometimes smelled of urine. During an observation with nursing staff, the resident was found incontinent of urine; while the brief did not have an odor, lifting the mattress sheet revealed a strong urine odor from the mattress. Interviews showed confusion among staff about responsibility for mattress cleaning, and facility documentation, including the Cleaning Checklist and Monthly Environmental Round Logs, did not identify a mattress cleaning schedule or checks of grab bar stability.
Penalty
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Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
Inadequate Shower Function and Hot Water Temperatures: The facility failed to maintain a functioning shower in the Magnolia unit and failed to keep shower and room sink water temperatures within the expected range. A resident reported delayed showers and inconsistent warm water, while staff confirmed residents were using showers on another hall because the Magnolia shower was out of service and water pressure was poor. Observations and log review showed repeated low hot water readings in Magnolia rooms and showers, and the Wildflower shower also measured below the facility's temperature range.
Surveyors observed that the lab specimen refrigerator had brown stains on the door and bottom shelves and multiple small dead bugs on the door shelf, demonstrating that staff failed to maintain a clean environment in an area used for specimen storage. The Infection Prevention Nurse acknowledged the refrigerator was dirty.
The facility failed to maintain a clean, safe, and homelike environment in multiple resident rooms, shower rooms, and common areas. Surveyors observed shower rooms with broken and missing tiles, jagged holes, dark residue in grout, and hair and brown matter in drains. A resident’s dinner tray with food remained on the bed the next morning, and several rooms had wall damage, exposed metal bars near a commode, missing bathroom doors, and vents coated with thick gray buildup. The dining room and hall ceilings had cobwebs and dirty vents, and the kitchen ceiling, pipes, and vents were covered with thick, gray, fuzzy material. Staff, including the Maintenance Supervisor and Administrator, acknowledged that these areas should have been repaired or cleaned and that some surfaces were not included in the cleaning schedule.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Inadequate Shower Function and Hot Water Temperatures
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff, and the public by not maintaining functioning showers and adequate hot water temperatures in resident rooms and shower areas. The deficiency involved 2 of 3 showers, identified as Magnolia and Wildflower, and 2 of 12 rooms. The Magnolia shower had been out of order for approximately 4 months, with an undated sign on the shower door stating, "DO NOT USE." During observation, the Magnolia shower had inconsistent water pressure and the handheld shower head only trickled water. Staff interviews confirmed the shower had been out of service since at least February 2026 and that residents were being directed to use another unit's shower instead. Resident and staff interviews described ongoing problems with shower access and water temperature. A resident stated the Magnolia shower had not been working for a while, showers were sometimes delayed, and the water was not always warm because other residents had used the same shower. CNA and LVN interviews confirmed residents on Magnolia were using showers on another hall and that hot water had been an issue throughout the facility. The DON stated the importance of hot water and a functioning shower was for residents to be comfortable, clean, and to decrease infection risk. The ADM stated the hot water concerns had started the prior week and that the facility had approved repair of the tankless water heater. Record review showed repeated water temperature readings below the facility's stated range for resident rooms and shower areas. In Magnolia unit rooms, documented hot water temperatures included readings such as 93.6 F, 92.4 F, 86.2 F, 83.4 F, 89.6 F, 83.7 F, and 90.3 F. In the Magnolia shower, documented temperatures included 95.1 F, 99.6 F, 93.8 F, 95.4 F, and 93.7 F, and later observation showed 70.4 F. In the Wildflower shower, observation showed 95.3 F. A confidential resident council interview included 9 residents stating the water did not get hot enough during showers. Facility policy stated water heaters serving resident rooms, bathrooms, common areas, and tub/shower areas were to be set to no more than 110-115 F or the maximum allowable temperature per state regulation, and maintenance staff were responsible for checking and recording water temperatures.
Unclean Lab Specimen Refrigerator Compromises Environmental Cleanliness
Penalty
Summary
Surveyors identified a deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment when the lab specimen refrigerator was found to be unclean. During an observation of the refrigerator, brown stains were noted on the door shelf and bottom shelf, and multiple small dead bugs were present on the door shelf. In a subsequent interview, the Infection Prevention Nurse acknowledged that the lab specimen refrigerator was dirty. These conditions demonstrated that the facility failed to maintain a clean environment in the area where lab specimens are stored.
Failure to Maintain Clean, Safe, and Homelike Environment Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Safe, Homelike Environment policy dated October 2007. Surveyors observed multiple shower rooms with cleanliness and maintenance issues, including black hair and dark residue in shower drains, broken and missing tiles with jagged-edged holes, cracks in tiles, dark residue in grout, and small round holes in shower stall walls. In one resident room, a prior night’s dinner tray with dishes and a full bowl of vegetables was left sitting on the resident’s bed the following morning. Additional observations included missing floor tiles and dark black residue debris between shower floor tiles in another shower room, and a shower drain with brown formed matter and dark strands of hair in a different hall’s shower room. Surveyors also observed disrepair and unclean conditions in resident rooms and common areas. One bathroom had two metal bars sticking out of the wall near the commode, a bathroom door with a missing 3 x 2 inch piece of wood by the hinges, and a vent with a thick gray substance. Another room had a hole on the outside of the bathroom door, and a separate room had two large holes in the wall and no bathroom door; the resident in that room stated the holes and lack of bathroom door had been present since moving in. In the dining room, vents and ceiling areas had thick gray substances and long cobwebs, and vents on the east hall ceiling also had a gray substance. In the kitchen, the ceiling, pipes, and vents were observed with a thick, gray, fuzzy substance. The Maintenance Supervisor and Administrator acknowledged that tiles, vents, doors, and other areas should have been repaired or cleaned and that certain areas were not included in existing cleaning schedules.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
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