Inadequate Heating, Emergency Protocol Failures, and Prolonged Hot Water Loss
Summary
The deficiency involves the facility’s failure to maintain safe, comfortable indoor temperatures and to follow its emergency protocols during periods of extreme cold, as well as its failure to provide adequate hot water throughout the building. The facility’s own Homelike Environment and Cold Weather policies require maintaining comfortable and safe temperature levels, conducting regular maintenance and inspections of heating systems, and routinely monitoring indoor temperatures when outdoor temperatures fall below 65°F. Despite these policies, surveyors observed on 1/29/26 that the St. [NAME] wing (100 Hall) was chilly, with hallway thermostats reading 64–65°F and multiple room thermostats between 62–68°F. When the Maintenance Director used a temperature gun, hallway and room air temperatures on that wing ranged from 54–63°F. Staff interviews confirmed that the wing had been cold for an extended period, with staff wearing fleece jackets and stating they could not recall when it had not been cold on that wing. Residents reported ongoing cold conditions and associated discomfort. One resident in room 117, with diagnoses including spinal stenosis, diabetes with foot ulcer, morbid obesity, and restless legs syndrome, and documented as cognitively intact with frequent severe pain and chronic lower back pain requiring opioid medication, stated that it had been cold in his room since earlier in the month and that being cold all the time made him tense, increased his back spasms and pain, and prevented him from getting comfortable. Another resident in room 106-1 stated it was always cold on the wing and that it affected his breathing. A resident in room 118 reported that the constant cold made her tense and increased her pain. The Director of Nursing could not explain why residents had not been moved to open rooms on a warmer hall or why additional heating sources had not been obtained, and stated she was not part of those conversations with corporate while the Administrator was on vacation. The Administrator later acknowledged that staff had contacted her around 2:00 a.m. when temperatures began dropping, and that the Maintenance Director had checked temperatures and reported higher readings than those later observed by surveyors, indicating a lack of effective implementation of the facility’s emergency protocol as temperatures continued to fluctuate and remain low. The deficiency also includes the facility’s failure to provide adequate hot water to the entire building, particularly on the St. [NAME] side. Residents and staff reported that there had been hot water issues for weeks, with residents from the affected side needing to come to the other side to shower, and staff using kettles to warm water for face, hands, armpits, and perineal care. On 1/30/26, surveyors measured hot water temperatures and found zero hot water on the St. [NAME] wings, with room readings as low as 15.4°F, while the other side of the building had lukewarm water in the 86.7–93.7°F range. The Administrator stated that not all mixing valves had been replaced on the St. [NAME] wings and that this side of the building had been without hot water since a prior complaint survey on 1/12/26. Multiple residents confirmed that there had been no hot water on their side for about a month. The Maintenance Director and Regional Maintenance Director stated that the St. [NAME] side had been with and without hot water throughout the month, describing the problem as intermittent and related to mixing valves in the main system, the main shower, and individual room showers, with several room mixing valves identified as broken.
Removal Plan
- In-service all staff members present on the facility's Comprehensive Emergency Manual Policy by the Administrator and Human Resources.
- In-service the Maintenance Director on the facility's Cold Weather Policy by the Administrator.
- Notify the Medical Director of the Immediate Jeopardy and update on the plan by the Administrator.
- Move residents on the affected wing to available rooms on the same wing; offer remaining residents a transfer to another facility or warmer parts of the building; provide extra blankets and warm beverages to residents who choose to stay.
- Immediately assess identified residents by the DON and Nurse Practitioner to ensure needs are met and comfort is maintained; assess all other residents by nursing staff and outside physicians.
- Assess the air handler, determine the cause of fluctuating temperatures, install new blower fans into the air handler, and complete repairs to ensure adequate hot air circulation.
- Monitor temperatures in each resident room on the affected unit every hour.
- Initiate shift-by-shift temperature monitoring and continue until extreme cold weather has abated as determined by the QAPI committee.
- Assess and continuously monitor all residents remaining on the affected unit for pain, respiratory comfort, and general comfort until heat is fully stabilized; implement interventions to address identified distress or pain and monitor effectiveness.
- Install temporary flannel window coverings to reduce heat loss in rooms on the affected wing.
- Educate all staff via phone or in-person on the Comprehensive Emergency Management Plan and the Cold Weather Policy; educate staff unavailable prior to their next scheduled shift.
- Develop and implement a plan to monitor preventative maintenance for the heating system, including regular audits of maintenance logs by the Administrator to ensure HVAC inspections and radiator filter cleanings are completed; review results during scheduled QAA meetings; continue audits.
- Implement a mandatory education schedule ensuring all staff are educated on the facility emergency policies and procedures; make training a permanent part of orientation for all new hires and conduct annually for all existing staff by Human Resources.
Penalty
Resources
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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.
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.
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.
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.
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.
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.
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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