F0584

F

Environmental Disrepair, Linen Shortages, and Excessive Hot Water Temperatures

Ellicott City, Maryland 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 bathrooms. Surveyors observed in one resident’s bathroom a loose plastic threshold on the shower floor, a shower chair with a jagged piece of plastic where a person would sit, a severely discolored and cracked sink, and multiple gouges in the drywall. In another shared room, two residents identified a large, rough, unsanded spackled area on the wall without paint, additional unsanded or unpainted spackling, gouges in the drywall, stained sinks and toilets, gouges in the toilet bowl, and a gap in the wall near the pipes under the sink. A further resident’s bathroom showed extensive drywall damage with gouges, rough spackling, and holes around piping under the sink, while another resident’s room had peeling paint and drywall, a dresser drawer handle hanging by one screw, multiple areas of chipped paint, and a cracked, discolored bathroom sink. Another resident’s sink was noted to be slow to drain, cracked, and stained.

The deficiency also includes the facility’s failure to ensure adequate linens and supplies for activities of daily living (ADLs). One resident reported that the facility was often out of soap, towels, and washcloths, which affected their ability to receive baths or showers. Two GNAs reported frequent or very often shortages of towels and washcloths, stating that these shortages caused delays in providing ADL care such as bed baths and showers, and that they had to plan ahead and improvise because the issue had been ongoing. The Nursing Home Administrator later acknowledged that a systemic change was needed after being informed that residents and staff reported linen shortages impacting timely care.

A further deficiency was identified in the facility’s management of hot water temperatures in resident rooms. Surveyors measured bathroom sink water temperatures in several rooms and found readings ranging from 123.7°F to 126.3°F, above the range that maintenance staff stated should be maintained. Maintenance documentation from that same morning showed unit temperatures between 120.9°F and 126.7°F, which had not been reported to supervisors or the Administrator. Subsequent random checks by surveyors found additional room temperatures between 124.3°F and 128.9°F, and the Maintenance Director’s own log showed room temperatures up to 137°F. A resident cautioned surveyors to be careful when checking water temperatures, implying the water became excessively hot. The Administrator and Maintenance Director reported they were unaware of the elevated temperatures recorded by maintenance staff prior to the surveyors’ findings.