Failure to Maintain Adequately Warm Shower Water Temperatures in East Hall
Summary
The deficiency involves the facility’s failure to ensure adequately warm shower water temperatures in the East Hall shower room, resulting in residents not receiving safe, comfortable, and homelike bathing conditions. Multiple residents who required staff assistance for showers reported that the shower water was too cold, leading some to avoid showers and instead receive bed baths or wash at the sink. One resident with congestive heart failure, weakness, and parkinsonism stated he rarely used the shower because the water was too cold and instead received bed baths. Another resident with Parkinson’s disease, asthma, and depression reported that the shower water was chilly but bearable and acknowledged refusing showers in the past due to cold water. A resident with congestive heart failure, anxiety, and atrial fibrillation described the East Hall shower room as so cold she felt like she had icicles coming off her body and avoided showers, receiving bed baths instead. A closed record review for a resident with COPD, anxiety, Type II diabetes mellitus, and restless legs showed documentation that the shower water was too cold, leading the resident to wash up at the sink rather than shower. Staff interviews with CNAs and an LPN confirmed that residents complained about cold water in the East Hall shower room and that one shower stall was cold while the other was only barely warm. Direct observation with the Maintenance Director showed shower stall temperatures of 83°F and 88°F after several minutes of running, and the sink reaching only 90°F, all below the stated minimum requirement of 105°F and the facility’s intended range of approximately 109°F to 115°F. Review of water temperature logs revealed that required weekly monitoring for the East Hall shower room was not consistently performed, with no temperatures logged for several weeks and only two recorded readings showing compliant temperatures shortly before the survey. The Maintenance Director verified the low temperatures, acknowledged the lack of recorded monitoring during the specified periods, and confirmed that the water temperatures did not meet the minimum requirement.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident requiring substantial assistance with daily living was found to have a private restroom in unsanitary condition, including a soiled bedpan on the toilet, brown particles in the toilet bowl, and a brown substance on the floor. Housekeeping staff confirmed that such conditions are often found after weekends.
A resident reported that shower rooms were not always cleaned well and had a persistent stain on her shower curtain. Observations confirmed a bowel movement on the shower room floor, a used washcloth left on a handrail, and a stain on the resident's shower curtain. Housekeeping and floor staff did not ensure prompt cleaning between uses, resulting in unsanitary conditions.
Two residents experienced deficiencies in their living environment, including cold water during bathing, heavily soiled carpeting, dust buildup, and unsanitary bathroom conditions. Staff interviews confirmed that cleaning equipment was lacking, water temperatures were below recommended levels, and maintenance issues such as non-functioning lights were not promptly addressed. These failures resulted in a living environment that did not meet facility policies for cleanliness, comfort, and safety.
Multiple residents reported and were observed to experience unclean living conditions, including overflowing trash, foul odors, and soiled items left in rooms. Environmental issues such as damaged walls, stained furniture, and lack of clean linens led to missed showers and bed baths, with staff confirming ongoing shortages and inadequate cleaning practices.
A resident with complex medical needs was found to have soiled bedrail padding and a wheelchair with visible stains and smears. An LPN and the DON confirmed the equipment was dirty and required cleaning, contrary to facility policy requiring a clean and sanitary environment.
A resident with anxiety disorder and fibromyalgia, who was cognitively intact and independent with personal hygiene, was unable to open or close the sliding bathroom door in her room because it was stuck on the track. This issue was confirmed through observations and interviews with both the resident and a corporate RN, indicating the facility did not maintain a safe and comfortable environment.
Unsanitary Resident Restroom and Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a resident's private restroom in a sanitary condition, as observed during a survey. A resident with multiple diagnoses, including Alzheimer's disease, dementia, chronic kidney disease, and a recent femur fracture, who required substantial to maximal assistance with activities of daily living, was found to have a soiled bedpan containing yellow liquid placed on top of the toilet. The toilet itself had brown particles clinging to the bowl, and a brown substance was also noted on the floor tile next to the toilet. The housekeeper confirmed the unsanitary condition of the restroom and stated that soiled debris is frequently found in resident restrooms following weekends. These findings demonstrate a failure to ensure a safe, clean, and comfortable environment for the resident, as required by regulations regarding environmental and housekeeping services.
Failure to Maintain Clean and Sanitary Shower and Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in both the shower room and a resident's room. During an interview, a resident reported that the shower rooms were sometimes not cleaned well and noted a persistent stain on her shower curtain since admission. Observations by the Housekeeping Supervisor and Maintenance Staff confirmed the presence of a quarter-sized, soft bowel movement on the floor next to the drain in the third stall of the first-floor shower room, as well as a used washcloth hanging over the handrail in the second stall. Additionally, a round stain was observed on the resident's shower curtain. The Housekeeping Supervisor stated that while housekeeping staff mop the floors each morning and scrub them weekly, floor staff are responsible for cleaning the shower room between residents. A review of a CNA's statement indicated that after giving the resident a shower, she intended to clean the shower room afterward. However, subsequent observation found no sign of the CNA or the resident in either the room or the shower area. The facility's policy requires maintaining a safe, clean, and homelike environment, ensuring that the building and equipment are kept sanitary. The failure to promptly clean the shower room and address the stain on the resident's shower curtain led to the deficiency.
Failure to Maintain Cleanliness, Adequate Lighting, and Safe Water Temperatures
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to provide a safe, clean, and comfortable environment for residents, specifically regarding water temperature for bathing and the cleanliness and maintenance of resident rooms. One resident, who was cognitively intact and dependent on staff for bathing, reported that the water in the west shower room was cold and described her bathing experience as miserable. Observations confirmed that the carpeting in her room was heavily soiled with embedded dirt and stains, and there was visible dust and missing floor molding. Housekeeping staff stated that the facility did not provide a carpet scrubber and that requests for deep cleaning equipment were not addressed by management. Maintenance records showed that water temperatures in the west shower room were below recommended levels, and staff confirmed that residents had complained about cold showers. Another resident, also cognitively intact, was observed in a room with carpeting embedded with black dirt and grime, multiple large spills, and a bathroom in unsanitary condition, including a non-functioning light, dirty sink and faucets, and a toilet and bathtub with visible grime and waste. The resident stated that staff did not offer to clean his room, and interviews with housekeeping and administrative staff revealed that while the resident sometimes refused housekeeping, he would often allow cleaning if approached by an administrator. The maintenance supervisor was unaware of the bathroom light issue, and the new administrator had not previously entered the resident's room. Facility policy reviews indicated requirements for routine cleaning, adequate lighting, and maintaining a homelike environment, but these standards were not met in the cases observed. The deficiencies affected two residents directly and had the potential to impact additional residents who used the same shower facilities. The findings were substantiated through observations, interviews, and record reviews, confirming non-compliance with resident rights to a safe, clean, and comfortable environment.
Failure to Maintain Clean, Safe, and Homelike Environment Due to Poor Housekeeping and Linen Shortages
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident complaints. Resident council meeting minutes documented concerns about staff not making beds, changing sheets, emptying trash cans, or sweeping rooms frequently enough. During interviews and observations, one resident was found with an overflowing trash can in her room, which she stated was bothersome. Further inspection revealed her room smelled of urine and feces, with a soiled brief in an unlined trash can and spilled liquids with disintegrated tissues and a toilet paper roll under the bed. Additional environmental issues included a large hole in a wall, ripped wallpaper, a handrail pulled away from the wall, a comb with hair on the floor in a common area, and a stained lounge chair. There were also significant shortages of clean linens, with linen closets lacking washcloths and having limited towels, which staff and residents confirmed led to missed showers and bed baths. The last order for washcloths had been placed weeks prior, with no pending orders for more, and staff interviews confirmed the ongoing shortage. The facility's own cleaning policy required daily cleaning tasks that were not being met. These findings were verified by the Housekeeping and Maintenance Supervisor and corroborated by multiple staff and resident interviews.
Failure to Maintain Clean and Sanitary Resident Equipment
Penalty
Summary
Staff failed to maintain clean and sanitary resident equipment for a resident with multiple complex medical diagnoses, including metabolic encephalopathy, mood affective disorder, heart transplant, cardiomyopathy, and frontotemporal neurocognitive disease. The resident, who utilized a wheelchair, had previously sustained a skin tear to the left eyelid after hitting his face on a bedrail, leading staff to place white cloth bandage padding on the bedrails as an intervention. During observations, surveyors noted that the white padding on the right side of the bedrail had a visible rust-colored stain, and the wheelchair had white cloth bandage wraps with a large patch of brown substance on the right side of the frame. The wheelchair cushion also had black and brown smears. Interviews with an LPN and the DON confirmed the presence of these stains and that nursing staff were responsible for cleaning resident equipment as needed. Facility policy required maintaining a clean, sanitary, and orderly environment, but this was not followed in this instance.
Failure to Maintain Functional Bathroom Door for Resident
Penalty
Summary
The facility failed to ensure that a resident's bathroom door opened and closed properly, resulting in a deficiency related to maintaining a safe, clean, and comfortable environment. The resident, who was cognitively intact and independent with personal hygiene but required supervision for toilet transfers and walking, was unable to open or close the sliding bathroom door because it was stuck on the track. This issue was observed on two separate occasions, and both the resident and a corporate registered nurse confirmed the difficulty with the door. The deficiency affected one resident out of sixteen reviewed for environmental concerns, with a facility census of 44. The resident's medical record indicated diagnoses of anxiety disorder and fibromyalgia. Despite being able to manage personal hygiene independently, the resident reported being unable to use the bathroom door due to it being stuck, which was verified through staff and direct observation.
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.
Trusted by long-term care providers and associations.
