Soiled Privacy Curtain Not Reported for Replacement: A resident’s bedside privacy curtain had a visible soiled area that was observed during one room check and was still present days later when a housekeeper was working in the room. The HSKP supervisor stated soiled curtains are to be removed and replaced when identified, but this resident’s room was not included on the list of curtains needing replacement.
Unsafe and Uncomfortable Facility Temperatures: An LPN and residents were observed in cold rooms and common areas, with temperatures measured as low as 53 F in the lobby, 57.6 F at the nurses' station, and low 60s in hallways and dining areas. A resident in bed said, "I'm freezing," while the facility acknowledged awareness of the heating issue and had only been closing resident doors to preserve heat. Residents later reported they had complained about being uncomfortable and needing heat for at least two weeks before the survey.
Two residents were affected when the facility failed to maintain a safe and sanitary environment. A resident with a history of falls and limited mobility, who was allowed to self-transfer, used a bathroom grab bar that detached from the wall during a wheelchair-to-toilet transfer, resulting in a fall and later-confirmed rib fractures; facility environmental rounds did not include checking grab bar stability. Another dependent, severely cognitively impaired resident with CHF, prior UTIs, and pressure-ulcer risk was found to have a mattress emitting a strong urine odor beneath clean linens, despite reports from a visitor about urine smells and the absence of any mattress-cleaning schedule in facility checklists.
Unclean and Poorly Maintained Shower Room: The second floor Ledgewood 2 shower room had chipped and cracked ceiling paint, a black/brown substance on the floors and walls, and a used wet washcloth on the shower floor. An LPN stated environmental rounds were done every other week and that the shower was not clean, and the Maintenance Director also confirmed the room was not clean. Environmental Rounds logs did not identify concerns for any of the 6 showers over the past 6 months.
Resident areas on the C/D and E/F units were found with rust-stained drop ceiling frames, damaged wallpaper, bowed or broken ceiling tiles, loose cove base molding with debris or black growth behind it, missing thresholds, and chipped flooring tiles. Facility interviews showed the QAPI plan addressed only Units A and B, and leadership reported no written plan or timeline for repairs on the other units; maintenance relied on requests and limited rounds rather than a building-wide audit.
Resident rooms were not maintained within the required 71 to 81 degree range. A resident with dementia, psychotic disturbance, mood disturbance, and anxiety reported the room was cold most days and needed extra layers and blankets to stay comfortable. Survey observations found room temperatures in the mid-to-high 60s at resident level, while a thermometer placed near the ceiling read 71 degrees, and the baseboard heater was cold. The DON/maintenance staff acknowledged temperature discrepancies, noted temperatures were only documented when below 70 degrees, and observed multiple rooms on the wing below range with residents using extra blankets and layered clothing.
A resident with dementia and a known elopement risk was found outside exterior fire doors after a fire alarm event in which a bathroom fan caught fire and activated the facility’s alarm system. Later observation showed that one of the exterior fire doors, controlled by a keypad and magnetic lock, did not latch shut on its own and had to be pulled closed, with interior weather stripping noted on the bottom of the door. The Maintenance Director reported that fire alarms disable door alarms and cause the doors to open automatically, acknowledged that the doors were old and known to require pulling to close, and stated that maintenance did not check the doors after the alarm to ensure they were secured. The DNS also confirmed that the exterior fire doors were not checked for secure closure following the fire event.
Missing Bureau Drawer Knobs: A resident with anxiety and depression, who was cognitively intact and needed set up or supervision for some ADLs, had two lower bureau drawers with missing knobs and exposed screws, making the drawers unusable. The maintenance log had no entry for the issue, environmental rounds did not identify the problem, and unit staff reported not noticing the missing knobs; the roommate’s bureau also had missing knobs.
Unsafe and Unclean Resident Areas: Survey observations found urine odor, sticky floors, rust-colored stains, peeling wallpaper, standing dirty water in a hallway fountain, and black substance with exposed insulation and wiring in multiple resident rooms and hallways. An LPN said the fountain had not worked since prior to COVID and was not cleaned regularly, while an RN said the sticky floor issue had been addressed with housekeeping. A resident lounge was also observed to be hot and humid because the AC was not working, and a resident reported the room had been unusable for more than two months.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure treatment and supports for daily living were delivered safely.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.