F0584

E

Failure to Maintain Clean, Intact Shower Room Environment

Cary, North Carolina Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike shower environment, specifically in the 100/200 shower room. A cognitively intact resident, as coded on a quarterly MDS, reported receiving showers in this room several times per week and stated she had observed what she described as black mold and filth on the walls and ceiling for at least three months, dating back to after her admission. She had not reported these concerns to facility staff. Surveyor observation of the 100/200 shower room confirmed broken and loose 1-inch floor tiles under the shower head, broken 6-inch wall tiles along the base of the wall, black-colored buildup on the tile walls and grout, and black-colored buildup on the tile floor and grout. A large tan ring with black spotting, approximately 2–3 feet in diameter, was also observed on the ceiling.

Staff interviews revealed awareness of the conditions but a lack of reporting and follow-through. A nurse aide acknowledged she was aware of the black-colored buildup on the shower floors and walls but had not reported it to anyone and did not provide a reason for not reporting. The maintenance log covering several months contained no entries regarding loose or broken tiles or buildup on the shower floor or walls. The Maintenance Director stated he had observed the loose tiles since starting work at the facility at least two months earlier and had heard about the loose and broken tiles by word of mouth, but he could not recall who informed him or when. He described the loose tiles as large sections with visible old mortar underneath and identified the ceiling ring as likely caused by a leak, while stating that black and pink areas on the tiles were mold or mildew and the responsibility of housekeeping rather than maintenance.

Housekeeping staff interviews further demonstrated gaps in cleaning and oversight of the shower room. The Housekeeping Assistant Supervisor initially thought the black and pink buildup on the tiles and grout was shower grime, then stated it looked like mold and grime upon closer inspection, and acknowledged the area did not look clean. She stated the shower room was supposed to be cleaned daily by a designated housekeeper and had last been cleaned the day before the survey observation, but also noted that housekeeping could not address the ceiling discoloration due to its height and that maintenance would need to handle it. The assigned housekeeper later reported she had not been cleaning the 100/200 shower room for about six months due to being physically unable to clean it and said the task had been shifted to other housekeepers and the Housekeeping Assistant Supervisor. She stated there had been mold all over the tile when she saw the shower the previous day and that the discolored ceiling spot had been present for her entire nearly two-year employment, and she claimed to have previously informed prior maintenance workers about the ceiling and loose tiles. The Housekeeping Supervisor stated he had not been aware of the ceiling spot, had not been notified, and did not look up when in the room, and although he reported deep cleaning the floors weekly and cleaning ceiling vents near the area, he had not noticed the discolored ring on the ceiling. The Administrator stated that housekeepers and maintenance workers should keep the shower room clean and in good repair.