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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Unsafe and unsanitary resident rooms were observed with clutter, uncovered food, and rodent activity. A resident with schizophrenia and depression had food crumbs and meat under the bed, while another resident reported mouse droppings and hoarded food in a crowded room. Other rooms had overflowing bins, bags of belongings, and uncovered food, and staff reported that some residents refused housekeeping access and that pest control service in resident rooms was inconsistent.
Strong urine odor in Hallway B. Surveyors repeatedly observed a noticeable urine smell at the beginning of and down Hallway B, including near the entrance where multiple residents were sitting in the hall. CNA 1 and CNA 2 both confirmed the odor, and the DON acknowledged the facility was aware of the strong smell at the entrance of Hallway B and cited the facility policy that residents have the right to a clean and comfortable environment.
Multiple rooms on one unit were found with environmental deficiencies, including broken and unsecured electrical outlets, damaged and stained walls and ceilings, improvised extensions on light cords using a plastic bag and a washcloth, dripping and constantly running sink faucets with discolored grout, and a strong urine odor in one room. A review of work orders and an interview with the Facilities Director showed that only two work orders had been submitted for this unit, both generated after surveyor observations, indicating that unit staff had not routinely initiated maintenance requests for these conditions.
The facility did not maintain a safe, comfortable, and homelike environment, as evidenced by two residents with dementia and other comorbidities living in rooms with multiple wall holes, chipped drywall, missing paint, and water-stained ceilings, and by extensive uneven flooring in two main halls. Observations showed numerous divots, chipped areas around drainage covers, and partially filled floor defects near the nurses' station and along the East and South halls. A resident reported wheelchairs becoming stuck in these floor ruts, and maintenance staff confirmed both the room damage and the lack of flush flooring around drains, as well as the absence of a current repair plan.
A clogged floor drain sink in a janitor room led to black, dirty water accumulating in the drain and overflowing into a hallway. A housekeeper reported that the drain, used for disposing of mop water and cleaning chemicals, had been clogged for some time and that she had informed her supervisor. The housekeeping supervisor stated she had submitted several work orders and that housekeeping staff had been attempting to unclog the drain themselves for months, while the maintenance director reported having no active work orders for the issue and indicated that such black water can carry harmful microorganisms. The administrator stated he expects staff to submit work orders and report issues promptly.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
Unsafe and unsanitary resident rooms with clutter, uncovered food, and rodent activity
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment for 7 of 7 residents reviewed for environment. Multiple resident rooms were observed with clutter, food, and signs of rodent activity, while several rooms were not being routinely checked or serviced for pest control. The report also identified a missing light cover over one resident’s bed and a garage used for resident belongings that was filled with stored items and had no pest control in place. One resident with schizophrenia, depression, and moderate cognitive impairment had a care plan that addressed her belief that mice were her friends and directed staff to discourage food in her room. During observation, a large amount of black crumbs and two patties of what appeared to be meat were found under the bed. The infection preventionist stated staff were supposed to look for food in the room on every shift and housekeeping was supposed to clean the room twice a day. The maintenance director confirmed that bait stations in resident rooms were not serviced during one month reviewed, and the room service records showed the room was not checked during several months and had light rodent activity when it was checked. Another resident with delusional disorder and intact cognition reported finding mouse droppings on the bed and said the roommate hoarded food and garbage. The room contained stacked bins, bedside stands, an overbed table with a coffee maker and wrapped fruit tray, and a shopping bag of personal items. The maintenance director stated he had seen mouse droppings in the room and that pest control traps were present, but the room service records showed no rodent bait stations in that room. Additional residents with diagnoses including paranoid schizophrenia, PTSD, depression, bipolar depression, and homelessness had rooms observed with overflowing bins, bags of belongings, uncovered food on a plate, and crowded storage throughout the room. Several care plans did not address clutter or overcrowding, and staff stated some residents would not allow housekeeping to clean their rooms.
Strong urine odor in Hallway B
Penalty
Summary
The facility failed to provide a safe and sanitary environment in Hallway B, where a strong urine odor was repeatedly observed during the survey. On 4/27/26, 4/28/26, 4/29/26, 4/30/26, and 5/1/26, surveyors noted a strong urine smell at the beginning of or down Hallway B, including at the entrance where multiple residents were observed sitting in the hall. During interviews, CNA 1 and CNA 2 both acknowledged a noticeable urine odor in Hallway B, and the DON stated the facility was aware of a strong odor at the entrance of Hallway B and confirmed the facility policy that all residents have the right to a clean and comfortable environment.
Failure to Maintain Homelike and Well-Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Pensacola 1 unit, as evidenced by multiple environmental deficiencies observed in six resident rooms. In one room, a wall clock was broken with a large piece missing and several white patches were visible on the wall. Another room had multiple large brown marks of unknown substance on the wall that were immediately visible upon entry. A separate room had a loud, constant buzzing noise whenever the bathroom light was turned on. Additional observations included several visible water marks on a ceiling, a broken electrical plug plate, and a heavily damaged wall behind a bed. Other rooms showed further environmental issues, including a wall light over a bed that had a cord extended with a plastic bag so the resident could reach it, and an electrical outlet at the head-of-bed wall that was not secure and was visibly coming out of the wall. One room had a dripping sink faucet and very discolored grout around the sink, while another had a strong smell of urine. Yet another room had a sink faucet that was constantly running, and one bed area had a washcloth attached to the light cord to extend its reach and six large screws or hooks in the wall. Interview with the Facilities Director revealed that unit staff were expected to complete work orders for needed repairs, but only two open work orders existed for this unit, both related to issues reported during the survey, indicating that routine work orders had not been submitted by unit staff for the observed problems.
Failure to Maintain Resident Rooms and Hallway Flooring in Safe, Homelike Condition
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment by not maintaining resident rooms in good repair and by allowing uneven flooring in two hallways. One resident with atrial fibrillation and dementia was observed in a room with at least seven holes in the wall over the bed, scattered areas of missing paint on the same wall, and a large area of chipped drywall and missing paint extending approximately 36 inches up from the baseboard next to the bed. Another resident with dementia and a history of stroke was observed in a room with multiple areas of missing paint on the walls by the window and on the east wall, as well as large water stains on the ceiling above the sink. The Maintenance Supervisor confirmed the presence of the holes, missing paint, and water stains in these rooms and acknowledged there were many similar issues and no current plan for repairs or painting. The facility also failed to maintain safe, even flooring in the East and South hallways. Multiple divots were observed throughout these hallways, with drainage covers that were discolored and surrounded by chipped and cracked flooring, creating uneven divots. Additional chipped flooring divots, some partially filled with shellac, were seen near the nurses' station and in both the East and South hallways. A resident reported having seen wheelchairs get stuck in these ruts and unable to move through the hallways. The Maintenance Director confirmed that the flooring was not flush with the drainage covers and that multiple divots were present throughout the East and South hallways.
Clogged Janitor Room Floor Drain and Black Water Overflow
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment for all 89 residents when a janitor room floor drain sink on one unit remained clogged and inoperable. During observation of the 400 Unit, water was seen coming from the janitor room into the hallway, and when the door was opened, the floor drain was observed to be filled with approximately 10 inches of black, dirty water. A housekeeper reported that she had spilled water in the hall while dumping her mop bucket into the floor drain sink and had mopped it up, and she confirmed that the drain was clogged and that this sink was used to dispose of cleaning chemicals from mop buckets. The housekeeper stated she had informed her supervisor about the clogged drain, but it had not been fixed and that it had been this way for “a while.” The housekeeping supervisor reported she had made several work orders regarding the janitor room and water overflow and that she and her staff had been unclogging the drain themselves for months. The maintenance director stated that housekeeping is responsible for their department and should notify him if anything is needed, that he had no active work orders regarding water overflow, and that housekeeping should have submitted a work order for the janitor room. He also stated that the black water could carry bacteria, mold, E. coli, salmonella, and possibly Legionella. The administrator stated he expects staff to place work orders and report issues immediately so they can be addressed right away.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
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