Failure to Maintain a Safe and Sanitary Therapy Environment Due to Mold-Contaminated Vents
Summary
The deficiency involves the facility’s failure to provide a safe, functional, sanitary, and comfortable environment in the primary therapy room, where black, spotty substance consistent with mold was observed on four air vents and the surrounding ceiling. During an observation, surveyors noted this substance in the primary therapy room, which was actively being used for resident therapy. The facility’s own mold report documented that the physical therapy room had visible mold growth around the vents on the ceiling and that ductwork testing showed heavy mold spore populations. The report also stated that employees working in that room had reported irritation to skin and other symptoms that may be caused by mold exposure. Two residents who regularly used the primary therapy room were observed receiving services directly underneath vents and ceiling areas with the black, spotty substance. One resident, a male with a history of spinal stenosis of the cervical region, weakness, unsteadiness on feet, gait abnormalities, and hemiplegia/hemiparesis following a cerebral infarction, had a BIMS score of 15 indicating normal cognition and received therapy services at least 15 minutes a day on one or more days in the last 7 days. He was observed using a SciFit machine directly under the affected vent and ceiling area and reported using the primary therapy room at least once a day, though he had not noticed the substance because he did not often look up. Another resident, a male with diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia/hemiparesis affecting the right dominant side, muscle weakness, and unsteadiness on feet, had a BIMS score of 13 indicating normal cognition and also received therapy services at least 15 minutes a day on one or more days in the last 7 days. He was observed completing a puzzle at a table directly underneath a vent and ceiling area with the black substance and reported entering the primary therapy room daily, but stated he had never looked up to see it. Staff interviews and record review showed that facility leadership and therapy staff were aware of environmental issues in the primary therapy room but continued to allow resident use of the space. The Director of Rehab stated that someone had come to the facility months earlier, that they were instructed not to use the air conditioning or heat in that room, and that residents were to be brought to a separate therapy area when it was too hot or too cold. He reported that a wall unit was later installed to regulate temperature and believed it was safe because no air was going through the vents. The PT and PTA both reported being instructed around December not to use the main air system in the therapy room due to a water leak and inability to use the vented air system, and that a new window or wall unit had recently been installed; the PTA stated the vents had looked black, brown, and dusty since December and their appearance had not changed. The ADON was aware the air system was not working but unaware of further issues, while the DON acknowledged there had been talk of mold, that therapy had been moved to a separate area, and believed the vents were recently cleaned, though she was unsure if the substance was mold. The Administrator reported waiting on bids to repair the therapy area, planned to remove and replace the venting system, and knew the substance had been tested but could not provide who had deemed the room safe for resident use. The regional director of maintenance confirmed test results showing penicillin, aspergillus, and another fungus in the vents and ceiling and stated he would not want his family receiving therapy under those conditions. The facility’s own mold report recommended that the HVAC system not be operated until the ductwork was cleaned and remediated and described required containment and access restrictions for remediation, while the facility’s Homelike Environment policy required a clean, sanitary, and orderly environment. Despite this, the primary therapy room with visible mold growth on vents and ceiling remained in use for resident therapy. A review of facility records cross-referencing residents with pneumonia in the last six months and residents receiving therapy services showed no residents who had received therapy in the front therapy room had been diagnosed with pneumonia. Residents observed in the room did not have observable skin irritation or respiratory issues and denied experiencing such symptoms. However, the mold assessment report documented that the ductwork had heavy mold spore populations and that employees working in the room had reported irritation to skin and other symptoms that may be caused by mold exposure. The mold assessment consultant later stated that most typical mold spores in the area were low, with the air duct being the exception, and that the facility was obtaining quotes for remediation work. The facility’s continued use of the primary therapy room for resident services, despite visible mold growth on vents and ceilings, documented heavy mold spore populations in ductwork, and internal acknowledgment of suspected mold and the need for remediation, constituted the failure to maintain a safe, functional, sanitary, and comfortable environment as required by facility policy and regulatory standards.
Penalty
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An open floor drain near the dish machine was observed without a grate, and the FSM confirmed it had no grate and was unsure how long it had been open. In the Hair Salon, the sink drain filter had a glob of hair, and 3 brushes plus a box of hair curlers had hair on them; the AD and HS both confirmed the unsanitary conditions, and the HS stated she might have forgotten to clean the salon after the beautician visit.
A resident room was observed in disrepair with unpainted wall areas, black marks, discoloration, ceiling staining, and scuffed, missing paint on the door frame, and the same conditions remained on follow-up. The memory care dining room floor also had food crumbs and debris under multiple tables; an LPN said it appeared not to have been cleaned after the prior night's meal, and the administrator confirmed the food was still present.
Leaking and Loose Faucets in Facility Sinks: During a facility tour, a beauty shop style sink was observed leaking where the faucet connected to the sink, and maintenance staff stated they were not aware it needed repair. A sink in the soiled linens room on D/F Hall was also observed with a loose swivel faucet that leaked when turned on, and maintenance staff confirmed the observation.
Sharps containers on a locked dementia unit were observed full to the point that they could not be opened, including one in a shower room with three uncapped used disposable razors sitting on top of it and another on a medication cart. The DON and an LPN confirmed the containers were unusable, and the LPN noted two residents on the unit required routine blood glucose monitoring with lancets that would need disposal in a sharps container.
Resident room walls were observed with moisture, black/gray staining resembling mildew or mold-like substance, bubbling paint, cracks, gouges, and dirty vents in multiple rooms, including B-2, B-4, B-6, B-8, B-10, and B-12. The Tel's record review showed no reports about the wall conditions for the past 6 months, and the ADM stated the moisture had been present for a while and had not previously been brought to the ADM and Maintenance Director's attention.
A resident with moderate cognitive impairment and anticoagulant use had a bedside table within reach that was observed to be broken, with an unfinished edge, exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed the table was in poor repair and accessible to the resident.
Unsanitary Hair Salon and Open Kitchen Drain
Penalty
Summary
The kitchen floor drain near the dish machine was observed on 6/09/2026 at 8:08 AM without a grate. The FSM confirmed the drain was open and stated she was not sure how long it had been without a grate. She also stated the facility had no pests and that they were waiting for the Maintenance Supervisor to start working at the facility so she could let him know about it. Later that day, the FSM stated she had told the prior Maintenance Supervisor about it a week or 2 weeks earlier, and that the new Maintenance Supervisor had started on 6/8/2026 after the former supervisor left on 6/5/2026. In the Hair Salon on 6/11/2026 at 11:07 AM, the sink drain filter contained a glob of hair, and 3 brushes in a cabinet had hair on them, along with a box of hair curlers with hair on them. The Activity Director confirmed these observations and stated Housekeeping was responsible for cleaning the Hair Salon sink. The Activity Director also stated the beautician had visited on 6/9/2026. The Housekeeping Supervisor confirmed the hair in the sink drain filter and stated she might have forgotten to clean the Hair Salon after the beautician visited that week.
Dirty resident room and unclean memory care dining room
Penalty
Summary
The facility failed to maintain a resident room in a clean, sanitary, and orderly condition for one resident, R5. During observations, R5 was lying in bed while the room showed multiple areas of disrepair: a section of wall below the mounted TV was not painted the same color as the rest of the wall, the wall across from the bed had multiple black marks and light brown discoloration, the ceiling above the window had a yellowish discolored area about the size of a basketball extending along the ceiling/wall, and the door frame had multiple scuff marks and missing paint. These same conditions were still present on follow-up observation, and R5's family member stated they had concerns about the environment, describing the facility as not clean, smelling bad, and reporting concerns about the room's smell, missing paint, and ceiling to staff. The facility also failed to keep the memory care dining room floor in a clean and sanitary condition. During observation, the floor under multiple dining tables had light-colored crumbs, brown crumbs, pieces of a white meat-like substance, and spaghetti noodles. An LPN stated it looked like the floors had not been cleaned after the prior night's meal and said housekeeping was supposed to clean the floors after meals were served. The administrator confirmed the food under the tables and stated any staff member who observed it should help clean it up, not just housekeeping. The maintenance policy stated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Leaking and Loose Faucets in Facility Sinks
Penalty
Summary
The facility failed to maintain plumbing in the building, as observed during a facility tour with maintenance employee C. On 05/27/2026 at 9:45 AM, the beauty shop style sink with a head rest and hair rinse hose was observed leaking where the faucet connects to the sink, and maintenance employee C also observed the faucet leaking and stated they were not aware it needed repair. Later, on 05/27/2026 at 10:16 AM, the sink in the soiled linens room in the D/F Hall was observed with a swivel faucet that was loose and leaking when the sink was turned on, and maintenance employee C confirmed this observation during interview at the time.
Sharps Containers Left Full and Unusable
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for residents by not maintaining sharps containers in a safe manner in two of four observed sharps containers. Record review of the facility’s Sharps Container Policy showed that the facility would use sharps containers for disposal of sharp items, including lancets, and that containers were to be sealed with tape and dated when disposed of, but the policy did not address when or how often the containers should be emptied. During observation, the sharps container in the shower room on the locked dementia unit was full to the point that it could not be opened, and three uncapped used aqua-blue disposable razors were sitting on top of the container. The DON confirmed the container should have been properly disposed of and replaced with a new one and stated the razors on top of the container could pose a potential safety hazard to residents. A second observation showed the sharps container on the medication cart for the locked dementia unit was also full to the point that it could not be opened. An LPN stated the unit had two residents who required routine blood glucose monitoring and that lancets used for blood glucose checks would need to be disposed of in a sharps container, but the container on the medication cart was not usable because it could no longer be opened. The Administrator stated she expected staff to provide for resident safety in the shower room and anywhere sharps containers were located, and confirmed that leaving uncapped or unsheathed disposable razors on top of the sharps container in the shower room could pose a safety hazard for residents.
Resident Room Walls Found Moist, Stained, and Damaged
Penalty
Summary
Resident room walls were not kept free from moisture, black/gray staining, gouges, bubbling paint, and dirt in multiple rooms. On 5/27/26 at 11:00 AM, an observation found room B-2 with dirty vents and a small gouge in the drywall; room B-4 with an outside wall that was moist and had a grayish stain about 1 foot by 1 foot resembling mildew or a mold-like substance; room B-6 with a moist outside wall, a black/gray substance resembling mildew, and several bubbles and cracks in the paint; room B-8 with an outside wall that felt moist to touch and had a blackish/gray substance about 2 feet by 2 feet resembling mildew or a mold-like substance; room B-10 with streaks and stains going down the outside wall; and room B-12 with cracks in the drywall, streaks down the wall, and bubbling paint. A record review of the Tel's program showed no report regarding the resident walls for the past 6 months. During an environmental tour on 5/28/2026 at 1:00 PM with the Administrator and Maintenance Director, the same wall conditions were confirmed in rooms B-2, B-4, B-6, B-8, B-10, and B-12. In an interview at that time, the Administrator stated the moisture on the walls in the resident rooms had been there for a while and should have been reported by staff who see the wall daily, and also stated this was the first time the walls had been brought to the Administrator and Maintenance Director's attention.
Broken Bedside Table Within Resident Reach
Penalty
Summary
The facility failed to ensure that a bedside table was in good repair for Resident #59, who was admitted with diagnoses including cerebral infarction, schizophrenia, and acute embolism. The resident’s MDS assessment showed moderate cognitive impairment, no upper body impairment, and anticoagulant use, and the care plan identified risk for bleeding related to anticoagulant medications. During observation, the resident’s bedside table was within reach and was found to have an unfinished, broken edge with approximately three inches of exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed that the bedside table was broken with rough, exposed particle board and wood chips and was within reach of the resident.
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