Failure to Maintain Adequate Hot Water Temperatures on Two Units
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining acceptable hot water temperatures on two of three units (North and South). Facility policies titled “Resident Environment” and “Water Temperature” required a safe, comfortable environment and potable hot and cold water at outlets at all times. The grievance log documented two concerns related to hot water: one from a resident reporting issues with hot water temperatures and another from a resident’s daughter reporting no hot water. Staff interviews confirmed that one boiler had been having issues and that two units experienced only lukewarm water, while the subacute unit retained hot water. Multiple staff members, including RNs, LPNs, NAs, and housekeeping, reported that there had been a period when hot water was not adequate on one side of the building, describing the water as lukewarm and stating that residents on the affected units had to use the subacute side for showers or to obtain hot water for basins. The Nursing Home Administrator acknowledged that the boiler had issues and that water was not warm enough, although it was not completely shut off. Maintenance staff stated that for several days, from a Friday afternoon until a Tuesday morning, the North and South units did not have readily available hot water in the rooms and that no water temperatures were taken during that time; the water was described as feeling cool. During the survey tour, direct measurements of hot water temperatures at resident room sinks and shower rooms on the North and South units showed readings in the mid‑90s to just under 100°F, below the facility’s stated goal of 107–108°F for hot water. Residents reported that for about a week the water temperatures had been low, that they had only recently resumed showers that felt warmer, and that the water had to run quite a bit and still only became lukewarm. One resident reported taking a cold shower that morning, stating it was not enjoyable and that they could not wash their hair, while another resident in the same room described the water as “barely” warm. These observations and interviews demonstrate that residents on two units did not have consistent access to adequately hot water for bathing and daily care.
Plan Of Correction
1. The hot-water boiler system was replaced on 4/14/26. 2. The water temperatures were checked throughout the facility and are within range. 3. The NHA or designee educated the maintenance director on maintaining comfortable water temperatures. 4. The NHA or designee with audit the water temperatures in the facility 5x a week for 4 weeks. The findings will be forwarded to QAPI.
Penalty
Resources
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Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
Surveyors found that two residents’ bathrooms had damaged and deteriorated walls and baseboards, with peeling paint, staining, gaps, and missing baseboards, despite prior entries in the maintenance log noting needed repairs. In the memory care common area, a recliner actively used by a resident had torn and cracked upholstery with exposed underlying material, and a built-in cabinet had a drawer missing its front panel, leaving unfinished wood exposed. The Administrator reported relying on verbal communication rather than consistent use of the maintenance log, and the Director of Environmental Services acknowledged awareness of these unrepaired environmental issues and described delays in completing the work.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one room, the wall behind a bed had multiple strips of missing paint and numerous holes, and the ceiling near the curtain track had exposed sheetrock. Another room had a damaged windowsill with exposed rebar. In common areas, a dining room vent was covered with a black substance, and a large light fixture above the nurse’s station lacked a cover and had long, thick cobwebs. The Maintenance Supervisor reported difficulty repairing concrete walls, noted that a resident had recently moved into one of the damaged rooms, and stated that housekeeping should have cleaned the cobwebs and vent.
Surveyors found that the facility failed to maintain a clean, safe, and homelike environment for several residents and in common areas. A resident was observed sitting in a wheelchair with the seat and cushion covered in dried food, sticky residue, and grime, confirmed by a respiratory therapist. In one room, a pipe cover was on the floor under the sink, and in another room, window blinds were damaged with slats missing and one slat on the floor, while thick cobwebs covered the window area behind the blinds, as confirmed by an LPN and the Administrator. Two elevators near the dietary entrance had lower-wall plastic bumpers with sharp shards of broken plastic exposed, which maintenance staff attributed to repeated impact from carts.
Surveyors found that several resident rooms were not maintained in a safe, clean, and homelike condition, including missing baseboards, peeling and missing paint, exposed walls, holes near baseboards, loose door handles, missing toilet paper holder mounts, stained floor tiles, cracked and gapped sink walls, and dirty bathroom vents. The Maintenance Director confirmed these conditions, acknowledged awareness of at least one problematic room for about a month, and reported relying on calls and texts for repair requests while awaiting access to the electronic maintenance log. Review of the maintenance work history showed no entries for these needed repairs, despite the DON and Administrator describing processes in which staff should enter issues into the maintenance log or verbally report them, resulting in the identified room deficiencies remaining uncorrected.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Failure to Maintain Clean, Homelike Resident Rooms and Memory Care Common Area
Penalty
Summary
Surveyors identified a failure to maintain a safe, clean, comfortable, and homelike environment on one of three units, including resident rooms and a memory care common area. In one resident’s bathroom, the lower wall and baseboard area were in poor repair, with visible discoloration or staining, peeling or damaged wall finish, and cracked or deteriorated caulking or paint along the baseboard line, as well as separated or poorly sealed baseboard sections creating gaps. In another resident’s bathroom, the wall showed visible damage with peeling loose paint, gaps or holes, staining, and broken or missing sections, and there was no baseboard present. The facility maintenance log contained prior entries referencing needed repairs in both of these bathrooms. In the memory care common living area, surveyors observed a beige upholstered recliner in use by a resident, with both armrests torn and underlying material exposed; on a later observation, the same recliner’s seat cushion and armrests showed extensive cracking, peeling, and splitting of the upholstery. A built-in cabinet unit in the same memory care common area had a drawer with the front panel missing, exposing unfinished wood. During interviews, the Administrator acknowledged having observed the recliner but not consistently using the maintenance log to track such issues, and the Director of Environmental Services and Plant Services acknowledged awareness of the damaged cabinet, the unrepaired bathroom drywall and baseboards, and the worn recliner, noting delays in repair and that a blanket was usually placed over the recliner to cover the damage.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, as required by the facility’s Homelike Environment policy revised in February 2021. Observations showed multiple areas of disrepair and uncleanliness in resident rooms and common areas. In one resident room, the wall behind the bed had four strips of missing paint with four holes in each strip, along with multiple additional small holes. The ceiling near the curtain railing in the same room had two areas of missing sheetrock paper measuring approximately 1 x 2 inches and 1 x 3 inches. In another resident room, part of the bottom right corner of the windowsill, approximately 1.5 x 2.5 inches, was missing, exposing the lower part of the rebar. Additional observations in common areas included a dining room vent covered with a black substance and a large light fixture above the nurse’s station that lacked a cover and had two long, thick cobwebs hanging from the light fixture frame. During an interview, the Maintenance Supervisor stated that the walls are concrete and difficult to repair around the window when beds break pieces off, and that the resident in one of the affected rooms had just moved in and he had not yet had time to fix the wall behind the bed. He also stated that housekeeping should have cleaned the cobwebs on the light at the nurse’s station and the vent in the dining room.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility did not maintain a clean, safe, comfortable, and homelike environment in multiple areas. One resident was observed in the main dining room seated in a wheelchair whose seat and cushion were completely covered in dried food, a sticky substance, and dark grime; this condition was confirmed by a respiratory therapist. In another resident’s room, a white pipe cover was observed lying on the floor under the room sink, and this was confirmed by an LPN. Additional environmental deficiencies were observed in a different resident’s room and in common areas. One resident’s window blinds had three leaves missing and one leaf lying on the floor under the air conditioning unit, as confirmed by an LPN. During a tour with the Administrator, the entire width of this resident’s window was noted to be draped with thick cobwebs behind the blind, which the Administrator confirmed. Two elevators located next to the dietary entrance had lower-wall plastic bumpers with sharp shards of broken plastic exposed, a condition confirmed by the maintenance employee, who stated that carts banging into the bumpers caused the damage. The Administrator confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment in these instances.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of three units, as required by 42 CFR 483.10(i). During observations of multiple resident rooms, surveyors noted missing baseboards, peeling paint, exposed wall surfaces, holes near baseboards, cracked and gapped walls, loose door handles, missing toilet paper holder mounts, stained floor tiles, and dirty bathroom vents. In one room, the bathroom doorway lacked baseboards, the wall was peeling with black stains, tiles around the toilet were lifting or missing, there was a brown substance on the tiles, and the bathroom vent was covered in gray matter. Other rooms had missing or peeling paint exposing the wall, holes near the baseboard, loose bathroom and room door handles, a missing toilet paper holder mount, and heavily stained floor tiles. The Maintenance Director accompanied surveyors on follow-up observations and confirmed the poor conditions in the identified rooms, describing one room as "horrible" and acknowledging that the vent looked filthy and that the sink appeared to be coming off the wall. The Maintenance Director stated that he had been informed about one problematic room about a month earlier and had been looking for a plumbing company to address it, but he had not been able to determine which room it was. He also acknowledged that the door handle needed adjustment and the toilet paper holder needed replacement in another room. The Maintenance Director reported that he had taken over the position in January and was focusing on large projects, delegating smaller details to his assistant. Record review and staff interviews revealed that the facility’s system for reporting and tracking maintenance issues was not effectively used for these deficiencies. Review of the electronic maintenance system work history from January through March showed no entries for the needed repairs in the affected rooms. The Maintenance Director stated he typically received calls or text messages about repairs and was waiting for a laptop to access the maintenance repair log, making it difficult to look back and verify reported issues. The DON reported that she typically entered items into the maintenance repair log and also communicated verbally or via messages to maintenance and unit managers when repairs were needed, and the Administrator stated that staff were expected to enter needed repairs into the maintenance log during rounds or communicate directly with maintenance. Despite these processes and the facility’s written policy on maintaining resident environment quality and preventive maintenance, the needed repairs in the identified rooms were not documented in the maintenance system and remained unaddressed at the time of survey.
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