F0584

E

Failure to Maintain Clean, Safe, and Homelike Resident Rooms and Shower Areas

Lexington, Kentucky Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms and shower areas. Surveyors observed that 11 of 25 sampled rooms had significant maintenance and cleanliness issues, including damaged drywall and baseboards, cracked and dented flooring, unpainted drywall patches, wall stains, dirty floors and baseboards, and a PTAC unit with a heavily rusted, corroded grille containing black grime and debris on and within the vent slats. In one room, there was a large dried food stain on the wall, dried food on the bed rail and floor, and dirt and dried material consistent with food residue beneath a fall mat. Another room had extensive brown water staining and deterioration on the ceiling, black discoloration on a bathroom baseboard, a newly replaced raw wood baseboard, and holes and unsecured edges in the linoleum flooring, including by the commode and near a bed.

Surveyors also found that both working shower rooms had significant cleanliness problems. The East Unit shower room had multiple areas of fecal staining and several formed fecal deposits on the floor, red mold in the shower area, and a visibly soiled shower chair. The other shower room had mold around the base, faucet, and grab bars, and a dirty floor with dark-stained grout lines. These conditions were observed despite a facility policy titled “Homelike Environment” that required provision of a safe, clean, comfortable, and homelike environment and minimization of institutional characteristics. Maintenance documentation showed periodic entries for cleaning air filters and inspecting condenser coils on PTAC systems, but did not identify which specific units were serviced.

Interviews revealed that staff were aware of needed repairs but did not consistently initiate or track maintenance requests. One LPN stated she would enter maintenance requests into the computer portal but had not done so recently. The East Unit manager acknowledged knowing that several rooms needed repairs but had not personally submitted work orders for the damaged rooms on her unit. A resident in a room with water-stained ceilings, cracked areas, a large gash in the bathroom floor, and rotted wood on a baseboard reported having voiced concerns to staff and the Administrator and stated these conditions made her feel anxious and concerned for her safety, including fear of potential mold exposure and that the bathroom floor was a safety hazard. Another resident and family reported they had been told the room floor and bathroom would be refinished and remodeled, but after 14 months had not seen any repairs. The Corporate Director of Plant Operations stated that repairs to walls, ceilings, floors, and baseboards were done when rooms were vacant and that some tasks were tracked outside the electronic system, but the requested separate log of tasks was not provided to surveyors. The DON stated she expected staff to enter repair requests but did not have access to track them and did not believe the disrepair prevented a homelike environment, while the Administrator acknowledged that repairs had not been completed because the facility maintained full census instead of creating vacancies to complete room repairs.