F0921

E

Failure to Maintain Homelike Room Environment Due to Stained and Deteriorating Pipes

London, Ohio Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to the facility’s failure to maintain a homelike environment in multiple resident rooms after receiving vendor recommendations. Observations on 02/20/26 revealed that numerous rooms had uncovered soffits above the windows, concealed only by structured fabric window valances. When the valances were lifted, pipes of various shapes and sizes were visible, showing deep gray to black speckled staining and layers of white, flaking paint-like material. This condition was consistently observed in the rooms of Residents #24, #22, #23, #27, #28, #29, #30, #16, #71, #72, #14, #73, and #74.

Resident #24, admitted on 01/23/26 with multiple sclerosis, depression, muscle weakness, fatigue, orthostatic hypotension, and transient ischemic attack, had such stained and flaking pipes above the window in their room. Similar conditions were documented for Resident #22, admitted with hemiplegia, pain, dysphasia, chronic kidney disease, and major depressive disorder, and Resident #23, admitted with syncope and collapse, muscle weakness, dysphagia, cognitive communication deficit, and seizures. In each of these rooms, surveyors observed the same pattern of uncovered soffits, visible piping, gray to black speckled staining, and white flaking paint-like material behind the valances.

The same environmental condition was also present in the rooms of other residents with significant medical conditions. Resident #27, with COPD, vascular dementia, systolic heart failure, cognitive communication deficit, muscle weakness, emphysema, dysphagia, acute kidney failure, and altered mental status, and Resident #28, with cerebral infarction, encephalopathy, seizures, dysphagia, altered mental status, and cognitive communication deficit, had stained and flaking pipes above their windows. Residents #29, #30, #16, #71, #72, #14, #73, and #74, each with multiple serious diagnoses including adult failure to thrive, pulmonary hypertension, acute respiratory failure, Type 2 DM, glaucoma, heart failure, COPD, dementia, traumatic subdural hemorrhage, cerebral infarction, aphasia, and dysphagia, were also found to have the same visible staining and flaking material on pipes above their windows.

During interviews and joint observations, the Maintenance Director confirmed the presence of the staining and flaking material on the pipes above resident windows and acknowledged that the discoloration did not align with a homelike environment. He stated he was unable to remedy the discoloration with paint due to its recurrence. The Administrator reported that the facility had been aware of the issue since late summer or early fall and that the facility had obtained vendor evaluation and recommendations for aesthetic resolution. The resident handbook dated 07/14/11 stated that the facility promotes a homelike environment and will make every attempt to accommodate reasonable requests to individualize residents’ living spaces, which contrasted with the observed stained and deteriorating pipe surfaces in the resident rooms.