Deficiencies in Physical Environment and Equipment Maintenance
Summary
Multiple deficiencies were identified in the facility's physical environment, impacting both resident rooms and common areas. Observations revealed that several residents had non-functional or malfunctioning overhead lights, with some lights flickering or not working at all. In one case, a resident received a replacement bed that was also not fully operational, as the head of the bed would not adjust. Additionally, air conditioning issues were noted, with one resident's AC unit not providing airflow and the filter covered in heavy black bio growth, resulting in a room temperature of 80 degrees Fahrenheit. Another room had a missing bathroom ceiling tile with exposed pipes. Common areas, including the activities room and pantry, exhibited significant maintenance and sanitation concerns. The activities room had a ceiling tile with visible water damage and bio growth, loose baseboards, and bio growth outside the sliding glass door. The pantry refrigerator and freezer were found to be operating at temperatures above safe ranges, with perishable items such as milk and ice cream thawed and not properly chilled. The pantry also had a large collection of dark bio growth under the sink, a partially hanging ceiling tile, and an exterior wall vent with an opening to the outside environment. Throughout the facility, loose flooring was observed in hallways and resident rooms, with some areas easily lifted by foot and posing a tripping hazard. Residents and staff confirmed these issues during interviews and walkthroughs. Facility leadership, including the NHA and DON, were made aware of these deficiencies during the survey and acknowledged the findings.
Plan Of Correction
What corrective actions (s) will be accomplished for those residents found to have been affected by the deficient practice: 1. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews and room audits completed. 2. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 3. By 7/12/2025, Resident #7 bed replaced with head of bed working properly. 4. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 5. By 7/12/2025, the loose baseboard along the perimeter of the activities room was replaced. 6. By 7/12/2025, the bio-growth substance outside of the sliding glass door to the left of the activities room exiting to the courtyard was cleaned. 7. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling tile was repaired and repainted. 8. By 7/12/2025, the refrigerator in the nourishment room on the east hallway was removed, discarded and replaced. The cupboard under the sink of the east pantry was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall was cleaned. 9. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room. The missing ceiling tile in the bathroom was replaced. The flooring in Resident #12 room was replaced. 10. By 7/12/2025, the loose flooring was replaced/repaired in the east 200 hallway. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident room and common area audits will be conducted to ensure equipment is safe, sanitary, comfortable, and operational. The audit will include resident room HVAC, refrigerator and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired and/or replaced as appropriate. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on reporting safe, sanitary, comfortable, and operational equipment via TELS. 2. Newly hired staff will be educated on reporting safe equipment, maintenance, and environmental concerns via TELS. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational weekly for 4 weeks then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met and sustained.
Penalty
Surveyors identified multiple failures to maintain a safe environment, including a razor left on a sink in a cognitively intact resident’s room, that resident’s personal razors stored in a nightstand despite facility rules prohibiting razors in rooms, an LPN discarding unused lancets into regular trash instead of a sharps container after a blood glucose check, and unattended housekeeping carts on an upper floor with germicidal wipes left on top and easily accessible, contrary to facility policy requiring chemicals to be locked in cart compartments.
Surveyors found that three rooms had over-the-toilet seats with visible rust, indicating a failure to maintain a safe and clean environment. The Director of Maintenance confirmed that preventative room checks were not being performed, despite existing policies and inspection forms outlining such procedures.
A resident, who was cognitively intact but required partial assistance to walk and was on multiple medications, left the facility undetected and was found several blocks away by police. Staff did not observe the resident for approximately 20-30 minutes before the elopement was discovered. The incident revealed a failure to provide adequate supervision and to implement appropriate elopement prevention measures as required by facility policy.
The facility failed to maintain a clean and sanitary environment in the kitchen and nourishment rooms. Observations included a milky liquid on the kitchen floor, debris under storage shelves, a green film in the refrigerator, and leaking pipes. In the nourishment rooms, debris and residue were found on counters and under sinks. Staff interviews revealed a lack of awareness and action regarding these issues, with gaps in cleaning procedures noted.
The facility's laundry room was found to be unsanitary, with chemicals improperly stored on the floor, rusted washer bases, and washers draining into a dirty sink. The Director of Environmental Services acknowledged these issues, which were contrary to the facility's cleaning policy.
The facility did not provide a homelike dining experience for residents during breakfast and dinner in the unit day/dining rooms. Meals were served on trays, creating an institutional appearance, with no centerpieces or table linens. Staff interviews revealed a lack of guidance on creating a homelike environment, and the facility's policy did not address this need.
Failure to Control Razors, Sharps, and Chemical Access in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and hazard‑free environment on one of two floors, including improper handling of razors, sharps, and chemical products. During an observation, a shaving razor was found on the sink in a resident’s room. The resident, who was cognitively intact with a Brief Interview of Mental Status score of 15/15 and had diagnoses including malignant neoplasm of overlapping sites of the bladder with self‑care deficits related to activity intolerance and generalized muscle weakness, stated the razor on the sink was not his and that he kept his own razors in the nightstand. The LPN initially removed only the razor from the sink and, when questioned by the surveyor about whether residents were allowed to keep razors in their rooms unattended, acknowledged they were not and then returned to remove the razors from the nightstand as well. Facility leadership, including the ADON, Administrator/Risk Manager, and DON, all stated that residents were not allowed to keep shaving razors in their rooms and that razors were to be kept in the supply room. A second deficiency was identified related to improper disposal of sharps. During a blood glucose check for another resident, an LPN discarded unused lancets into the regular trash in the medication cart rather than into a sharps container. When later asked about the facility’s policy and procedure for lancet disposal, the LPN stated that lancets were to be disposed of in a sharps‑resistant container for safety purposes but did not provide an explanation for why the lancets had been placed in the regular trash. The DON stated that nurses were expected to dispose of both used and unused sharps into sharps containers for safety purposes. A third deficiency involved unsecured chemical products on housekeeping carts. On two separate observations on the second floor, a container of germicidal wipes was found left unattended on top of a housekeeping cart in a hallway, with easy access. Corporate housekeeping staff and the facility’s Housekeeping Director stated that the facility had four housekeeping carts and that all chemicals that could harm residents were supposed to be locked in a compartment on the cart, to which housekeeping staff held the key. A housekeeping staff member also stated that disinfectant wipes and cleaning supplies were to be kept locked in the cart for resident safety. These observations occurred despite the facility’s written “Nursing Home Accident Prevention and Safety Policy,” which states the facility is committed to maintaining a safe and hazard‑free environment, preventing accidents and injuries, identifying and correcting safety risks promptly, and requiring all staff to comply with safety procedures and report unsafe conditions immediately.
Plan Of Correction
The facility continues to ensure that the resident environment remains free of accident hazards as possible. IMMEDIATE CORRECTIVE ACTION Resident #29 was not adversely affected by the alleged deficient practice. Razor was immediately removed and disposed of from resident's room by nurse on 5/11/26.Germicidal wipes were immediately secured in a locked housekeeping cart on 5/11/26.Staff E was provided with 1:1 education by Director of Nursing regarding the importance of providing an environment free from hazards and accidents with emphasis on keeping hazardous items like razor secured on 5/11/26.Staff G was provided with 1 to 1 education by House Keeping Director regarding ensuring that all housekeeping chemical products are secured in a locked housekeeping cart when not in use on 5/12/2026.IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTEDAll active residents in the facility can potentially be affected by the alleged deficient practice.The Director of Nursing and/ designee conducted a facility-wide observation audit to ensure that hazardous items are locked and secured and that staff are disposing of Sharps in a Sharp Resistant Container on 05/15/2026.The Housekeeping Director conducted a facility-wide observation on 5/15/2026 to ensure that all housekeeping chemical products were secured and locked inside the housekeeping cart when not in use. No residents were adversely affected by the alleged deficient practice SYSTEMATIC CHANGES Director of Nursing initiated ongoing in-service education with staff on standards of maintaining an environment free from hazards/accidents with emphasis on keeping hazardous items like razor secured and properly disposing of sharps in sharps resistant container on 5/20/26. The Housekeeping Director and/or designee initiated ongoing in-service education on standards of maintaining an environment free from hazards/accidents with emphasis on keeping housekeeping chemical products secured and locked in a housekeeping cart when not in use on 5/20/2026. MONITORING The Director of Nursing and/or designee will conduct random observation audits to ensure that hazardous items are locked and secured and sharps are disposed in sharps resistant container weekly for 3 months. The Housekeeping Director and/or designee will conduct random observation audits to ensure that housekeeping chemical products are secured and locked in a housekeeping cart weekly for 3 months. The Director of Nursing, Housekeeping Director and/or designee will report findings of observation/audits to the quality assurance committee monthly for 3 months to ensure continued substantial compliance is achieved and maintained.
Failure to Maintain Safe and Homelike Environment Due to Rusted Bathroom Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment as required by state regulations. Specifically, during facility tours, it was noted that three resident rooms (112, 113, and 116) had over-the-toilet seats that showed visible signs of rust. These observations were made on two separate occasions, confirming the ongoing presence of the issue. The deficiency was documented through direct observation and photographic evidence. Interviews with the Director of Maintenance revealed that maintenance work orders are managed on paper, with staff responsible for reporting issues daily. Although the facility has a maintenance inspection sheet intended for preventative room checks, the Director of Maintenance admitted that these room checks were not currently being performed. Review of facility policies and inspection forms indicated that procedures for routine cleaning, disinfection, and room inspections exist, but the relevant documents were either unsigned, undated, or not being actively implemented.
Plan Of Correction
Specific Corrective Action A full inspection of all resident rooms was conducted on 7/18/2025, identifying all over-the-toilet toilet seats that had any rust or damage. Twelve new 3-in-1 over-toilet folding commodes were ordered on 7/18/2025 (Attachment A). Three seats arrived the same day and were placed in identified rooms. The remainder of the new equipment arrived on 7/25/2025, with three seats going to replace existing equipment and the remainder going to storage for future utilization. Method to Assess Other Residents A comprehensive survey of all resident rooms was conducted on 7/18/2025 to identify any other equipment of concern (Attachment 8). All residents of this facility have the potential to be affected by this practice. Systematic Review The "Resident Room Inspection" form was updated (Attachment C) to include the 3-in-1 toilet seats. Health Center Maintenance staff were educated on the SNF Room inspection policy and the new resident room inspection sheet on 7/28/2025 (Attachment D). Quality Assurance The Plant Manager or designee will complete random weekly audits for 3 months during the weeks of 7/28/25 through 9/29/2025 (Attachment E). Validation checklists will be reviewed by the Administrator or designee. Audit records will be reviewed by the Risk Management/Quality Assurance Committee until such time as consistent substantial compliance has been achieved, as determined by the committee.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident left the facility undetected through the first floor exit/entrance door and was found several blocks away by local law enforcement. The resident, who was cognitively intact but required partial assistance to walk and was receiving antipsychotic, antidepressant, and antiplatelet medications, had been admitted to the facility less than a month prior. On the day of the incident, the resident was last seen by staff in the common room in front of the nursing station and was later reported missing. The facility is located in a residential neighborhood with busy cross streets and a nearby shopping plaza, increasing the risk associated with unsupervised elopement. Facility policy required staff to promptly report and investigate all cases of missing residents, and to attempt to prevent departures in a courteous manner. However, staff interviews revealed that the resident was not observed for a period of approximately 20-30 minutes before being found by police. The resident was able to provide personal information to law enforcement, who contacted the facility and returned the resident. Documentation indicated that the resident was alert, oriented, and in good physical and emotional condition upon return, with no injuries or distress noted. The incident was recorded in the facility's abuse/neglect log and incident notes, and the resident's care plan was updated after the event to reflect the risk for elopement. Prior to the incident, there were no alarms or wander alert devices in use for this resident, and the care plan did not include specific interventions for elopement risk. The deficiency was cited under state and federal regulations requiring the facility to maintain a safe and secure environment and to provide adequate supervision to prevent such incidents.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. N110 FAC Physical Environment-Safe, Clean, Homelike (a) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; On 06/17/2025, the Director of Nursing re-educated Staff B, C, and D on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents Investigating and Reporting policies with an emphasis on adequate supervision and safety. (b) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 04/05/2025, a Quality Review audit was completed on all residents, no new residents were identified as at risk for elopement. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By 04/05/2025, Director of Nursing/designee reviewed and updated elopement binders; ensured binders were current and placed at each nursing station, therapy department, activity department, kitchen, & front desk. Elopement binders updated when necessary. By 04/05/2025, Maintenance Director/designee checked all exil doors for proper functioning to include transponder for wander guard system. Daily audit of doors for proper functioning completed for three days, followed by weekly audits. On 04/05/2025, Clinical Educator/designee initiated education of all staff on the facility's Elopement standard and guidelines, ANEMMI with an emphasis on Neglect, Alarm Response, and Wander Guard placement and functioning. Newly hired staff will receive this education during orientation. Education continues monthly. On 04/05/2025, Clinical Educator/designee initiated elopement drills for all staff participation. Drills will be completed on each shift, then move to monthly rotating each shift. On 04/05/2025, a single point of entry was set up at the front doors in the reception area. The front doors were set to remain locked at all times. To gain access, any non-employee will need to ring the doorbell for entry. Once inside, every non-employee must sign in into the visitor's fog. Everyone leaving the building must do so from the front door and be let out by the receptionist or be escorted out by a staff member with a fob. Single point of entry and these entry and exit procedures continue to be in place. On 04/05/2025, Administrator/designee initiated QAPI Plan with interdisciplinary Team, including Medical Director, participation on safety with a focus on elopement. Reviewed during QA Meeting on 04/08/2025. On 04/07/2025, Director of Nursing/designee began daily clinical review of new admissions/re-admissions and change in condition that may require increased supervision and/or risk for elopement evaluation. Admission and re-admission reviews continue during daily clinical meetings (Monday through Friday). On 04/07/2025, Maintenance Director/designee placed a Red Box/ Exit Door Alarm on every exit door to notify personnel of any unauthorized entry/exit attempts on emergency exit doors. By 07/16/2025, all employees will be re-educated by the Clinical educator/designee on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents-Investigating and Reporting policies with an emphasis on adequate supervision and safety. Newly hired employees will receive education during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The Administrator/designee will conduct a weekly Quality Review audit of residents for 4 weeks, and then every 2 weeks for 2 months to ensure compliance that supervision is adequate and interventions are appropriate, when necessary. Findings will be reported at the monthly QA/Risk Management meeting. These Quality Reviews will be reported until the committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Operations/designee when completing their Quality Systems Review to maintain compliance.
Deficiency in Maintaining a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen and nourishment rooms, as observed during a survey. In the kitchen, a milky, brown liquid with solid particles was found on the floor behind the ice machine, and debris was present under the dry storage shelf. A green film was noted in the walk-in refrigerator, and the pipes under the three-compartment sink were dirty and leaking, with a bucket of grey water underneath. Additionally, food debris and a white film were observed on the fryer basket, and a thick grease-like coating was found on the pipes and valves behind the stove. In the nourishment rooms, coffee ground-sized debris and dried food residue were observed on the counter and baseboard. Black and green debris were found under the sink in the memory care unit nourishment room. Interviews with staff revealed a lack of awareness and action regarding these issues. The Maintenance Director was unaware of the leaking pipes and the debris, while the Dietary Manager acknowledged the cleanliness issues but had not taken steps to address them. Housekeeping staff mentioned a lack of a checklist for cleaning tasks, indicating a gap in the facility's cleaning procedures.
Plan Of Correction
1. All identified areas (kitchen floor, behind/under equipment, walk-in refrigerator, and nourishment rooms) were immediately addressed and cleaned. Deep cleaning on all the affected areas was conducted. The leaking triple sink pipe was repaired, and the area sanitized. Debris and residue in both nourishment rooms were cleaned and sanitized using EPA-registered bleach wipes or appropriate sanitizing agents that were made available in nourishment rooms for as-needed cleaning. 2. A comprehensive inspection of the kitchen and all nourishment rooms was conducted by the DON, Environmental Services, and the Dietary Manager. No evidence of foodborne illness or resident harm was identified. All other high-risk food prep and storage areas were assessed for cleanliness and sanitation. 3. A detailed cleaning checklist was created and implemented for daily and weekly tasks in both kitchen and nourishment areas. It includes behind/under equipment, baseboards, and cabinet surfaces. A Deep Cleaning Schedule was established for all food service and nourishment areas and posted in each department. The TELS electronic work order system was re-trained with staff to ensure all maintenance issues (e.g., leaks) are reported immediately. Daily sanitation logs are now completed by dietary and housekeeping and reviewed by the Department Heads. The Dietary Manager and Environmental Services must perform and document weekly walk-throughs using a standardized sanitation audit tool. Housekeeping and dietary staff received re-education on facility policy "Cleaning and of Environmental Surfaces," proper cleaning procedures, frequencies, and escalation of maintenance issues, and control standards for food service areas. 4. The QA Committee will review sanitation reports monthly for 4 months and adjust procedures as needed. Random monthly audits will be conducted by the Preventionist or Designee using the sanitation audit tool. Any issues found will trigger immediate re-cleaning, retraining, and documentation. Continued compliance will be tracked and reported quarterly during QA&A meetings.
Laundry Room Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the laundry room, as observed during a tour with the Director of Environmental Services and the facility's administrator. The deficiencies included improper storage of chemicals such as detergent, bleach, iron sour, and softener, which were stored directly on the floor instead of on a pallet. Additionally, the washer bases were rusted, and the washers were draining into a two-compartment sink that had visible dirt and grime. The garbage can pallets were soiled, a large hole was observed in the wall, and one washer had dry drainage residue with no clear source identified. The Director of Environmental Services, who had been in his position for two months, acknowledged these concerns during an interview. The facility's policy on laundry area cleaning outlined a systematic approach to maintaining cleanliness, including daily, weekly, and monthly tasks. However, the observations indicated that these procedures were not being followed, leading to the unsanitary conditions noted in the report.
Plan Of Correction
The base of the washer was painted and the hole in the wall was repaired on 5/05/2025 by Environmental Services Director. The two-compartment sink was cleaned; the garbage can pallets were washed, and the residue was removed from the washer on 05/06/2025 by Environmental Services. The four chemicals—detergent, bleach, iron sour, and softener—have been elevated off the floor on a palate. No residents were affected by this deficient practice. The Environmental Services Director was educated on maintaining a clean and sanitary environment in the laundry room on 04/18/25 by the Executive Director. The laundry staff was in-service on 05/02/2025 by the Director of Clinical Services on following the cleaning schedule and using the TELS system to notify Plant Operations if repairs are needed. The Director of Environmental Services or designee will conduct audits of the laundry room to ensure that washer bases are free from rust, no chemicals are stored on the floor, garbage can pallets, two-compartment sink, and laundry equipment are clean and free from residue. Audits will be conducted daily for 1 week, then weekly for 4 weeks, then every two weeks for 2 months, and finally monthly. Findings of audits will be presented at the monthly QAPI meeting to ensure ongoing compliance.
Lack of Homelike Dining Experience in Unit Day/Dining Rooms
Penalty
Summary
The facility failed to provide a homelike dining experience for residents during breakfast and dinner meals in the day/dining rooms on both nursing units. Observations revealed that meals were served on trays with dishes, drinks, and flatware left on the trays, creating an institutional appearance. There were no centerpieces or table linens on the tables, and residents expressed that the environment felt crowded and less homelike. The facility's main dining room was not open for breakfast or dinner, leaving residents to eat in the unit day/dining rooms or their bedrooms. Interviews with staff, including the Activities Director and Certified Nursing Assistants, indicated a lack of awareness and guidance regarding the removal of meal trays to create a more homelike environment. The facility's policy on meal distribution did not address the need for a homelike dining experience. The Administrator and Regional Vice President of Operations acknowledged the issue and mentioned plans to improve the dining environment, but these actions were not part of the deficiency findings.
Plan Of Correction
1. Ensured trays and lids were removed from the tables during all meals in the day room areas, tablecloths and centerpieces were ordered on. The dining room was opened on for dinner, then scheduled to open the following day for breakfast. 2. Observed all dining areas and corrected all issues found at that time. Daily observation of the day room areas and dining room to ensure that resident meals are served in a homelike environment with tablecloths and centerpieces, as well as the trays being removed under the plate and lids removed from table. 3. Educate all staff on removing trays and lids from table for all meals with an emphasis on meals served in day rooms. Audit of two meals per day to ensure that meals are set properly on table in the dining room and day rooms, without lids on tables, tablecloths and centerpieces in place including cleanliness. The dining room is now scheduled to be opened for breakfast, lunch, and dinner according to facility policy. 4. 5 Random Quality reviews will be completed weekly, including weekends by weekend supervisor or designee. The audits will include homelike environment, such as plates and lids removed from trays for all meals and main dining room open for all meals. Audit will include observation of tablecloths and centerpieces to ensure compliance. 5. NHA/DON will conduct a quality review on mealtimes being set properly and homelike environment components are in place. This will be conducted 5x weekly for 4 weeks, then weekly for 2 months.
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