Deficiency in Resident Room Certification and Readiness
Summary
The facility failed to ensure that certain resident rooms were certified and equipped for adequate nursing care, comfort, and privacy. Specifically, rooms #45 and #46, which were certified for two Title 18 resident beds each, were not resident-ready as they had been converted into a large activities room by removing the shared wall. Similarly, rooms #47, #48, and #49 were combined into a theater room, and rooms #52 and #53 were turned into a therapy room, with their shared walls removed. These modifications rendered the rooms unsuitable for immediate transition back to resident-ready status. During an interview, the facility's administrator admitted to not having a reason for why the beds were not decertified and acknowledged a lack of policy regarding bed class/certification. The administrator, who had been in the position for over a year and a half, stated that the rooms had been set up in their current configurations since her tenure began and had not considered the need for decertification. The facility's Bed Classification Form and CMS-671 confirmed that these rooms were still certified for resident beds, despite their current use for non-residential purposes.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that multiple residents’ rooms and the 3rd floor lounge were not maintained in a clean, sanitary condition. Numerous room curtains were visibly soiled or stained, one room had peeling and missing wallpaper behind the beds, and a shower used by a resident contained a brown substance on the floor. That resident reported that staff rinse a roommate’s bedpan in the shower and leave brown residue without cleaning or disinfecting, preventing the resident from using the shower. The lounge carpet also had dark stains and paper debris. These conditions were confirmed by the DON, and the NHA stated that one resident’s constant presence in the room made wall repair difficult.
Three resident rooms lacked privacy curtains, and eighteen rooms had soiled or stained privacy curtains on the 1st floor dementia care unit. This failure to provide adequate privacy and maintain clean equipment was confirmed by facility leadership.
A resident's room was found to have a window with broken glass pieces taped with duct tape and additional broken glass between the glass panel and screen. The same room also contained a dresser with two broken drawer fronts, with the broken pieces left inside the drawers. These issues were confirmed by the DON during observation, indicating a failure to provide a safe environment.
A resident using an alternating pressure mattress experienced discomfort and had to relocate to the lobby due to a malfunctioning mattress. The facility lacked a policy for maintaining patient care electrical equipment and did not have documentation of inspection or maintenance for the mattress. The Maintenance Director was unaware of the requirement for electrical testing, leading to the deficiency.
Staff did not ensure privacy for residents in most semi-private rooms, as both closets were located on one side, requiring a resident to cross the privacy curtain and enter their roommate's space to access personal belongings. Interviews with two cognitively intact residents and staff confirmed this practice, and facility leadership acknowledged the issue.
Surveyors found that multiple resident bathrooms lacked blinds, curtains, or frosted windows, resulting in inadequate privacy. A family member raised concerns, and surveyors confirmed that bathrooms were visible from outside. The MD was unaware of any window coverings ever being used, and the DON acknowledged the issue.
Unclean Resident Rooms and Lounge Environment on 3rd Floor Unit
Penalty
Summary
Surveyors identified that multiple resident rooms and common areas on the 3rd floor care unit were not maintained in a clean and sanitary condition. During observations conducted between 10:00 a.m. and 12:00 p.m. on April 22, 2026, window curtains in the rooms of fifteen residents were noted to be soiled or stained with brown discoloration. In one resident room, wallpaper was observed peeling off the wall behind one bed, and wallpaper was missing on portions of the wall behind both beds. In another resident’s shower, a brown substance was observed on the shower floor. That resident reported that staff flush the roommate’s bedpan in the toilet and sometimes rinse the bedpan in the shower, leaving brown substances in the shower without cleaning or disinfecting it, and stated that he/she had been unable to use the shower because it had not been sanitized. Additional observations on the same unit showed that the 3rd floor lounge area carpet had dark stains and paper debris present. These environmental concerns, including the soiled curtains, deteriorating wallpaper, unclean shower, and stained, debris-littered lounge carpet, were observed in the presence of the DON on the afternoon of April 22, 2026. In a subsequent interview, the NHA acknowledged that the resident in one of the affected rooms rarely leaves the room, which the NHA stated made it difficult for maintenance to repair the wall. The DON confirmed the observations and noted that residents sometimes eat lunch in the lounge area.
Deficiency in Resident Room Privacy and Cleanliness
Penalty
Summary
Surveyors observed that three out of thirty-two resident rooms on the 1st floor dementia care unit did not have privacy curtains, and eighteen rooms had privacy curtains that were soiled or had brown stains. These observations were made over a three-day period. The lack of privacy curtains and the presence of soiled curtains were confirmed during interviews with the Nursing Home Administrator and the Director of Nursing. The deficiency was identified as a failure to provide adequate privacy and maintain clean equipment in resident rooms, as required by regulations.
Plan Of Correction
Soiled curtains were immediately replaced with clean privacy curtains and privacy curtains were hung in rooms that were missing privacy curtains. Facility-wide audit conducted by NHA/Designee to ensure resident rooms have privacy curtains and are free from soilage. NHA/Designee provided education to housekeeping and maintenance staff on assuring that resident rooms have privacy curtains in place and free from soilage. NHA/Designee will audit random rooms to ensure privacy curtains are present and free from soilage. Audits will be done weekly x4 then monthly x2 or until compliance is achieved. Results will be discussed at monthly QAPI.
Failure to Maintain Safe Resident Room Environment
Penalty
Summary
A deficiency was identified when observations and staff interviews revealed that a resident's room on the Rehabilitation Unit had a window with broken glass pieces that were taped with duct tape, and additional broken glass pieces were found between the glass panel and the screen. Further inspection of the same room showed a dresser with two broken drawer fronts, with the broken pieces placed inside the drawers. These conditions were confirmed by the DON during the observation. The facility failed to provide a safe environment for the resident as required by regulations.
Failure to Maintain and Document Safe Operation of Patient Care Electrical Equipment
Penalty
Summary
The facility failed to maintain patient care electrical equipment in safe operating condition for a resident using an alternating pressure mattress. The facility did not have a policy regarding the maintenance of patient care electrical equipment, and there was no documentation available for the inspection or maintenance of the mattress. On observation, the resident was found lying in bed with the mattress, and reported having to sit in the lobby the previous day due to the mattress malfunctioning and feeling uncomfortable. The Corporate Executive confirmed that the Maintenance Director was unaware of the electrical testing requirement for the mattress, resulting in the absence of maintenance records.
Failure to Provide Resident Privacy Due to Closet Placement in Semi-Private Rooms
Penalty
Summary
Facility staff failed to provide adequate privacy for residents in 71 out of 88 semi-private rooms by not ensuring that each resident had a closet located on their designated side of the room. In these rooms, both built-in closets were situated on one resident's side, requiring the other resident to cross the privacy curtain and enter their roommate's space to access their personal belongings. This arrangement was confirmed through direct observation during the survey, as well as through interviews with staff and residents. Interviews with cognitively intact residents revealed that they had to enter their roommate's side of the room to access their own closets. Staff interviews further confirmed that this was a common practice, and that some residents either could not or chose not to retrieve their belongings themselves, relying on staff assistance. The director of maintenance acknowledged the lack of closets on both sides of the semi-private rooms, and no policy regarding privacy in resident rooms was provided by facility administration.
Inadequate Privacy in Resident Bathrooms Due to Uncovered Windows
Penalty
Summary
Surveyors identified a deficiency related to inadequate privacy in resident bathrooms throughout the facility. During interviews and observations, it was noted that multiple resident bathrooms on the ground floor lacked blinds or curtains on the windows, and the windows were not frosted, allowing visibility from outside. Brackets for blinds or curtains were present but not in use. A family member of a resident expressed concerns about bathroom privacy, and during an exterior tour, surveyors confirmed that the interiors of these bathrooms were visible from outside. The Maintenance Director stated he was unaware of any blinds or curtains ever being used in these bathrooms, and the DON acknowledged the privacy concerns.
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