Failure to Maintain Sanitary, Safe Environment and Proper Smoking Controls
Summary
The deficiency involves the facility’s failure to maintain a sanitary, clean, and safe environment for residents on the secured women’s behavioral unit and for residents using the main entrance. Multiple resident rooms and common areas were observed to be heavily soiled and in disrepair. One resident with schizophrenia, COPD, hypertension, hypothyroidism, schizoaffective disorder, and osteoarthritis, who had impaired cognition and required staff assistance with ADLs and medications, was found to have a bathroom with brown splatter on the walls behind and opposite the toilet, a heavily soiled toilet, and a floor blackened with dirt and debris. Her bedroom walls were soiled, scuffed, and had exposed drywall, with unknown splatter and dried substances around the receptacle and under the light. A CNA confirmed these conditions. Another resident with essential hypertension, antisocial personality disorder, inhalant abuse, DM, schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder, who had severely impaired cognition and required supervision or set-up for ADLs and was dependent on staff for medications, was observed without sheets on her bed. Her bed contained a wadded-up blanket heavily soiled with yellow and brown substances and swarmed with fruit flies. The floor in front of the bed was blackened with dirt and debris, and a soiled incontinent brief with apparent blood and stool was on the bedroom floor, surrounded by reddish-brown droplets and brown dried splatter on the wall near the toilet. The bathroom floor was missing tiles. The CNA stated the blanket was soiled with urine and verified the room conditions. A housekeeper confirmed the presence of stool and blood on the bathroom floor and stated she does not clean up blood. Later observation showed the bathroom sink filled with brown water and cigarette butts, with no running hot or cold water, and dried blood on the floor. The maintenance supervisor acknowledged awareness of the non-functioning sink and standing brown water and stated no pest treatment had been provided to the room. On the women’s secured unit, the shared shower room used by all twelve residents had a floor blackened with dirt and heavily soiled, with unknown brown spots and splatter in the shower corners and up the walls. The toilet in the shower room was heavily soiled, the shower drain was partially broken, and the ceiling fan was hanging down with the ceiling spotted by an unknown black substance that a CNA stated appeared to be mold. The large dining/activity room on the unit had a half-broken window opening into the nurse’s station, leaving a sharp edge, and a large hole in the wall with exposed drywall beneath it. Five large ceiling lights in this room had no light bulbs. The maintenance supervisor verified the non-functioning lights and the hole in the wall and stated he was not aware of the broken window. Another resident with DM, hypertension, asthma, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and GERD, who had impaired cognition and required supervision, moderate, or set-up assistance for ADLs and was dependent on staff for medications, reported that her room was very cold. She indicated her heating unit, covered with a blanket and with another blanket at the base of the window, was blowing cold air despite being told it had been fixed. Observation confirmed the unit was running but blowing cold air, and her bathroom was soiled, missing floor tiles, and had a heavily soiled toilet with a black ring. A CNA confirmed the room had been cold for some time and verified the bathroom conditions. The maintenance supervisor later confirmed the heater was blowing cold air and noted holes in the wall beside the bed and shredded privacy curtain pieces hanging from the ceiling. A further resident with impaired cognition and diagnoses including hypertension, DM, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and cystitis was observed to have a dish of water under her sink and a large pile of what appeared to be mouse droppings under the sink. The sink did not drain correctly when water was running. The resident stated the dish of water was for mice living in a large hole in the corner under the sink and referred to the mouse as her pet. The maintenance supervisor stated he was aware of the mouse droppings and the mouse issue in the room and that the facility had been treated for mice. However, review of pest control work orders showed no specific treatments for fruit flies in the room with the soiled blanket and flies, or for mice in this resident’s room. At the main entrance, residents and staff used a double set of doors with a small concrete pad and awning. One resident was observed smoking directly outside the front doors in a posted non-smoking area. Numerous discarded cigarette butts were scattered across the ground near the front door, in the landscaping rocks on both sides of the doors, and around a trash can with a plastic liner, with no container provided for cigarette disposal. A CNA confirmed the resident was smoking in the non-smoking area and identified a designated smoking area across the parking lot, also verifying the scattered cigarette butts. The resident stated he often smoked by the main entrance doors. On a subsequent observation, two other residents were seen smoking directly outside the main entrance in the same non-smoking area, with the area still littered with cigarette butts on the ground and in the landscaping. An LPN confirmed the residents were smoking in the non-smoking area and verified the large amount of discarded cigarette butts. Facility policy stated that the maintenance department was responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, including heating/cooling systems, plumbing fixtures, and ensuring lights were in good working condition, with the maintenance director responsible for inspection of the building.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderate cognitive impairment and extensive ADL needs was found with urine-soiled bedding, an unmade bed, and a mattress that was torn and heavily stained, with staff stating the damage had been present for a while. On the secured unit, all observed residents were served meals on plastic trays holding their plates, utensils, and drinks instead of having items placed directly on the table, and staff and the DON confirmed this was the routine practice.
A facility failed to maintain a safe, homelike environment when a resident room had broken and missing floor tile exposing the wood underneath, and two bathrooms had sinks coming away from the wall and loose enough to move when pressure was applied. One resident said the floor had been bad for some time and had been reported without being addressed, and an LPN later confirmed the damaged flooring and loose sinks.
Furniture Not Kept in Good Repair: Armchairs in multiple resident rooms and chairs in the front sitting area were observed with torn or cracked upholstery exposing cloth material. The Maintenance Director stated the furniture was not in good repair and had not been notified of the damage, while the Administrator stated staff were to remove furniture with tears.
A facility failed to maintain a clean, homelike environment when a refrigerator used for resident supplement drinks had significant ice buildup with an unknown item in it, and staff were unsure who was responsible for cleaning or reporting it. In addition, meals were repeatedly served on trays and left in front of residents during dining, which an RN and the VPS confirmed had been occurring for some time and was not homelike.
Failure to Maintain Comfortable Room Temperatures: Several residents were found in hot, stuffy rooms with weak or nonworking AC units, and room temps were measured above 81 F, including one room at 89.5 F. Residents reported feeling hot and uncomfortable, and some were not offered a room change while the issue persisted. The facility did not follow its Hot Weather policy for relocating residents to cooler areas and monitoring room temps.
Excessive ambient temperatures were observed at the 100/200 and 300/400 nurses' stations when the wall thermostat and facility temperature monitoring device both showed readings in the low 80s. The surveyor verified the readings with the Facility Maintenance Director while residents were seated in nearby common areas.
Soiled Mattress and Tray-Based Meal Service
Penalty
Summary
The facility failed to replace a torn, stained mattress and did not ensure urine-soiled bedding was changed timely for a resident who had moderate cognitive impairment and required extensive assistance with dressing, grooming, toileting hygiene, transfers, and wheelchair mobility. The resident’s diagnoses included COPD, anxiety, and schizophrenia. The resident was observed stating that his bedsheet was wet with urine and that he was looking for staff to change it. Later, his bed was observed unmade with a rumpled soiled top sheet on the mattress and a strong urine odor in the room. When a nursing assistant later changed the resident’s linens, the mattress was found to have a 6-cm tear, a large 12 x 12-inch deep brown dry stain in the center, and scattered discoloration across the remaining surface. Staff stated the mattress had been stained and ripped for a while, and maintenance said they had only received a work order that day to replace it. The facility also failed to remove residents’ meal plates, beverages, and utensils from institutional serving trays before meal service for all 27 residents on the secured unit. During multiple meal observations, residents were served and ate from plastic trays that held their plates of food, silverware, and drinks. Staff continued this practice at breakfast, lunch, and dinner observations, and one nursing assistant stated that although it looked more homelike when plates and utensils were placed directly on the table, that was not how it was done at the facility. An RN stated the facility served meals on trays and was not sure why, and the DON stated the facility had previously used a steam cart to dish up food correctly but had switched to serving meals on trays after the cart broke.
Unsafe Room Flooring and Loose Bathroom Sinks
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in one resident room and two resident bathrooms. Facility policy dated 3/23/26 stated the objective was to keep the resident environment as free of accidents and safety hazards as possible and that monthly safety walkthroughs would be completed for each resident unit. During observation of one room on 7/6/26 at 12:05 p.m., four joined flooring tiles were missing pieces measuring approximately 6 inches by 12 inches, exposing the wood underneath, and numerous other tiles throughout the room were cracked with pieces missing from the corners. Resident R16 stated the floor had been bad for some time and that although it had been reported, no one had addressed it. R16 also reported concern about the bathroom sink being loose and feared it could fall off the wall if someone leaned on it. Observation of that room's bathroom showed the sink was coming away from the wall, loose, and able to move up and down when pressure was applied. A second room's bathroom was also observed on 7/6/26 at 12:22 p.m. with the same condition: the sink was coming away from the wall, loose, and able to move up and down when pressure was applied. Resident R44 said he/she was unsure how long the sink had been that way. On 7/8/26 at 11:34 a.m., an LPN confirmed the broken and missing tile in the room and confirmed that the sinks in both bathrooms were coming away from the wall, loose, and movable when pressure was applied.
Furniture Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure furniture was in good repair for 1 of 1 facility reviewed for physical environment. During an observation with the Maintenance Director, armchairs in rooms 10, 16, 18, 42, and 44 were observed with torn fabric on the armrests and exposed cloth material, with the torn areas measuring at least one inch in diameter. In the general sitting area by the front entrance, two chairs had multiple cracks in the synthetic leather on the seat covering exposing cloth material, and one armchair had missing synthetic leather exposing cloth material. The Maintenance Director stated the furniture was not in good repair, Staff 18 stated staff were to notify maintenance when furniture was ripped, and the Maintenance Director stated he had not been notified of the torn furniture. The Administrator stated that if there were tears in the furniture, staff were to remove the furniture.
Unclean refrigerator and tray service during dining
Penalty
Summary
The facility failed to maintain a clean, homelike environment when a refrigerator used to store resident supplement drinks was observed with a large amount of ice buildup on the top freezer section and an unknown item embedded in the ice. During the kitchen tour, the cook verified the condition of the refrigerator and stated they were unsure who was responsible for cleaning, monitoring, or reporting it. Maintenance later explained that staff are supposed to place a ticket in TELS when something needs attention, and the administrator later verified the ice buildup in the dining room refrigerator. The facility also failed to eliminate the use of meal trays during dining service. During multiple observations, noon and supper meals were served to residents on trays and left in front of them in the dining room. An RN verified that the noon meal was served and left on trays and stated this had been occurring for at least two years. The VPS also verified that meals were served on trays and left in front of residents and confirmed that this was not homelike. The facility policy stated that the environment should be homelike and that meal trays should be eliminated during dining service unless otherwise requested by the resident.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to ensure resident rooms remained at comfortable temperatures and failed to offer room changes to residents whose rooms exceeded 81 F when air cooling units were not working properly. On 7/1/2026 at about 10:30 AM, R6 was in a hot, uncomfortable room and stated the floor air conditioning wall unit was not working because no air came from the vent. R8’s unit was on but only weak air came through, and R8 appeared uncomfortable and said he was hot. R9 and R10 were in a dark, warm, and stuffy room with the windows closed and curtains pulled shut, and R7 was in a very hot room with weak air blowing from the floor unit and said the room was hot. When the surveyor returned with the Maintenance Director at 10:42 AM, the room temperatures were measured at 84.5 F for R6, 89.5 F for R7, 85.2 F for R8, and 82.9 F for R9 and R10. At 4:00 PM, R7 and R8’s rooms were still hot, with temperatures of 85.6 F and 83.1 F, respectively, and both residents remained in their rooms. R6 stated a room change had been offered only a few minutes earlier, while R7 and R8 stated they had not been offered a room change during the hot room temperatures. The facility did not follow its Hot Weather policy, which stated residents would be relocated to the cooler part of the facility and temperatures and humidity would be measured in several rooms on each floor identified as the warmest area.
Excessive Ambient Temperatures at Nurses' Stations
Penalty
Summary
The facility failed to consistently maintain ambient temperatures within the required range in the 100/200 Nurses' Station and the 300/400 Nurses' Station. During direct observation, the wall-mounted thermostat at the 100/200 Nurses' Station displayed 83 F. The surveyor then requested that the Facility Maintenance Director obtain ambient temperature readings using the facility's temperature monitoring device, and the readings were verified by the surveyor as they were obtained. At that time, the Facility Maintenance Director measured 82.2 F at the 100/200 Nurses' Station and 83.0 F at the 300/400 Nurses' Station. The surveyor also observed residents seated in common areas close to both nurses' stations while the temperatures were above the recommended comfort range. The facility census was 118.
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