Failure to Inventory and Protect Resident's Durable Medical Equipment
Summary
Facility staff failed to protect a resident's property from loss by not properly inventorying a right hand resting splint (RHRS) on the resident's clothing and possession form when it was received. The RHRS, a piece of durable medical equipment prescribed to assist with the resident's contracture management, was not documented as received on the inventory form, and there was no record of its loss in the resident's progress notes. Despite physician orders for the resident to use the RHRS at night, staff did not update the inventory or document the device's whereabouts after it was last seen. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, reported that staff lost the RHRS shortly after it was received and did not respond to requests for its return or provide information about its location. Interviews with staff confirmed that the RHRS was last seen the day after it was received, and that staff were responsible for tracking and documenting the device in the resident's records. However, there was no evidence that staff reported the device missing or investigated its disappearance as required by facility policy. The facility's policy on personal property required that resident belongings be inventoried upon admission and updated as necessary, and that any complaints of missing property be promptly investigated. In this case, the lack of documentation and follow-up regarding the RHRS resulted in the resident being without the prescribed device, with no indication in the records that staff took steps to locate or account for the missing equipment.
Plan Of Correction
F584 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 2 was referred to the facility's rehabilitation department for a reassessment of their need for durable medical equipment (DME). If deemed necessary, an appointment with an external rehabilitation provider will be coordinated per resident preference. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18, 2025, the Director of Nursing (DON) or designee conducted a review of all residents with splints in the facility to ensure that the durable medical equipment (DME) was accurately accounted for and easily locatable. No additional findings were noted. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 17 to March 21, the Director of Nursing (DON) or designee conducted an in-service training for licensed nursing staff on the importance of accurately inventorying resident durable medical equipment (DME) and ensuring its proper placement. This training aims to meet resident needs effectively and eliminate barriers to care. Additionally, the Medical Records department or designee will audit admissions and readmissions to verify proper inventory logging of applicable DME. Any negative findings will be reported to the DON for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 21st, 2025 F 584
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
Inadequate Shower Function and Hot Water Temperatures: The facility failed to maintain a functioning shower in the Magnolia unit and failed to keep shower and room sink water temperatures within the expected range. A resident reported delayed showers and inconsistent warm water, while staff confirmed residents were using showers on another hall because the Magnolia shower was out of service and water pressure was poor. Observations and log review showed repeated low hot water readings in Magnolia rooms and showers, and the Wildflower shower also measured below the facility's temperature range.
Surveyors observed that the lab specimen refrigerator had brown stains on the door and bottom shelves and multiple small dead bugs on the door shelf, demonstrating that staff failed to maintain a clean environment in an area used for specimen storage. The Infection Prevention Nurse acknowledged the refrigerator was dirty.
The facility failed to maintain a clean, safe, and homelike environment in multiple resident rooms, shower rooms, and common areas. Surveyors observed shower rooms with broken and missing tiles, jagged holes, dark residue in grout, and hair and brown matter in drains. A resident’s dinner tray with food remained on the bed the next morning, and several rooms had wall damage, exposed metal bars near a commode, missing bathroom doors, and vents coated with thick gray buildup. The dining room and hall ceilings had cobwebs and dirty vents, and the kitchen ceiling, pipes, and vents were covered with thick, gray, fuzzy material. Staff, including the Maintenance Supervisor and Administrator, acknowledged that these areas should have been repaired or cleaned and that some surfaces were not included in the cleaning schedule.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
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.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Inadequate Shower Function and Hot Water Temperatures
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff, and the public by not maintaining functioning showers and adequate hot water temperatures in resident rooms and shower areas. The deficiency involved 2 of 3 showers, identified as Magnolia and Wildflower, and 2 of 12 rooms. The Magnolia shower had been out of order for approximately 4 months, with an undated sign on the shower door stating, "DO NOT USE." During observation, the Magnolia shower had inconsistent water pressure and the handheld shower head only trickled water. Staff interviews confirmed the shower had been out of service since at least February 2026 and that residents were being directed to use another unit's shower instead. Resident and staff interviews described ongoing problems with shower access and water temperature. A resident stated the Magnolia shower had not been working for a while, showers were sometimes delayed, and the water was not always warm because other residents had used the same shower. CNA and LVN interviews confirmed residents on Magnolia were using showers on another hall and that hot water had been an issue throughout the facility. The DON stated the importance of hot water and a functioning shower was for residents to be comfortable, clean, and to decrease infection risk. The ADM stated the hot water concerns had started the prior week and that the facility had approved repair of the tankless water heater. Record review showed repeated water temperature readings below the facility's stated range for resident rooms and shower areas. In Magnolia unit rooms, documented hot water temperatures included readings such as 93.6 F, 92.4 F, 86.2 F, 83.4 F, 89.6 F, 83.7 F, and 90.3 F. In the Magnolia shower, documented temperatures included 95.1 F, 99.6 F, 93.8 F, 95.4 F, and 93.7 F, and later observation showed 70.4 F. In the Wildflower shower, observation showed 95.3 F. A confidential resident council interview included 9 residents stating the water did not get hot enough during showers. Facility policy stated water heaters serving resident rooms, bathrooms, common areas, and tub/shower areas were to be set to no more than 110-115 F or the maximum allowable temperature per state regulation, and maintenance staff were responsible for checking and recording water temperatures.
Unclean Lab Specimen Refrigerator Compromises Environmental Cleanliness
Penalty
Summary
Surveyors identified a deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment when the lab specimen refrigerator was found to be unclean. During an observation of the refrigerator, brown stains were noted on the door shelf and bottom shelf, and multiple small dead bugs were present on the door shelf. In a subsequent interview, the Infection Prevention Nurse acknowledged that the lab specimen refrigerator was dirty. These conditions demonstrated that the facility failed to maintain a clean environment in the area where lab specimens are stored.
Failure to Maintain Clean, Safe, and Homelike Environment Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Safe, Homelike Environment policy dated October 2007. Surveyors observed multiple shower rooms with cleanliness and maintenance issues, including black hair and dark residue in shower drains, broken and missing tiles with jagged-edged holes, cracks in tiles, dark residue in grout, and small round holes in shower stall walls. In one resident room, a prior night’s dinner tray with dishes and a full bowl of vegetables was left sitting on the resident’s bed the following morning. Additional observations included missing floor tiles and dark black residue debris between shower floor tiles in another shower room, and a shower drain with brown formed matter and dark strands of hair in a different hall’s shower room. Surveyors also observed disrepair and unclean conditions in resident rooms and common areas. One bathroom had two metal bars sticking out of the wall near the commode, a bathroom door with a missing 3 x 2 inch piece of wood by the hinges, and a vent with a thick gray substance. Another room had a hole on the outside of the bathroom door, and a separate room had two large holes in the wall and no bathroom door; the resident in that room stated the holes and lack of bathroom door had been present since moving in. In the dining room, vents and ceiling areas had thick gray substances and long cobwebs, and vents on the east hall ceiling also had a gray substance. In the kitchen, the ceiling, pipes, and vents were observed with a thick, gray, fuzzy substance. The Maintenance Supervisor and Administrator acknowledged that tiles, vents, doors, and other areas should have been repaired or cleaned and that certain areas were not included in existing cleaning schedules.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 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.