F0921

F

Unsanitary, Leaking Toilets and Poor Bathroom Maintenance for Multiple Residents

Bethesda, Maryland Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a functional, sanitary, and comfortable bathroom environment for five residents whose rooms had toilets with rust, black mildew-like buildup, missing caulk/sealant, instability, and active water leakage. Facility policies on Resident/Patient Room Cleaning and Safe and Homelike Environment required regular cleaning and disinfection of restrooms, including toilets and surrounding areas, and provision of housekeeping and maintenance services as necessary to maintain a sanitary, orderly, and comfortable environment. Despite these policies, surveyors observed that the toilets in the rooms of five residents had a rust stain approximately five inches wide and seven inches long, black discoloration around the toilet seal resembling mildew, missing caulk/sealant, and unsteady commodes that shifted side to side, with water leaking from the base.

The affected residents had multiple medical diagnoses and varying levels of cognitive function and dependence on staff for ADLs, including toileting. One resident had Type II diabetes, dysphagia, hyperlipidemia, depression, hypertension, GERD, and frequent bowel and bladder incontinence, and was cognitively intact and able to report that the toilet rust stain had been present for a while, that housekeeping cleaned daily but the stains remained, that the toilet moved and leaked where the caulking was missing, and that no one should live with a dirty bathroom. Another resident with dementia, hyperlipidemia, hypertension, GERD, major depressive disorder, dysphagia, and frequent incontinence, who used a walker and went to the bathroom independently, reported that the toilet leaked and expressed concern about slipping and falling, though they did not know how long the leakage had been occurring. Other residents involved had conditions such as dementia, chronic kidney disease, hemiplegia, aphasia, schizophrenia, bipolar disorder, COPD, and failure to thrive, and were dependent on staff for toileting and transfers, yet their toilets were also found with rust, mildew-like buildup, missing caulk, and leakage.

Staff interviews revealed inactions and incomplete follow-through that contributed to the ongoing unsanitary and nonfunctional bathroom conditions. A housekeeper with 16 years of experience stated they clean the bathroom, including the toilet bowl and the area behind the toilet, and are expected to report room problems to a supervisor so a work order can be placed, but acknowledged they did not see the rust stain behind the toilet, could not remove a stain, and simply left it, planning only to inform the supervisor if it happened again. The Environmental Services Manager stated that rooms are expected to be cleaned daily and that only about 10% of rooms receive a complete daily check, and reported having seen caulk/sealant issues but not rust stains. The Maintenance Supervisor, in the role for two months, stated they noticed the rust stain two to three weeks earlier, notified housekeeping to clean again, and asked a technician to complete caulking, but did not perform any follow-up to ensure the work was completed. These actions and omissions allowed the rust, mildew-like buildup, missing caulk, toilet instability, and water leakage to persist in resident bathrooms in violation of facility policies and regulatory expectations for a safe, clean, and comfortable environment.