Unauthorized Intruder Repeatedly Accesses Facility and Resident Room
Summary
The deficiency involves the facility’s failure to ensure a safe environment for residents and staff when an unauthorized male intruder repeatedly gained access to the building and entered resident and staff areas, including a resident room. One resident, identified as R94, had been admitted with anxiety disorder, major depressive disorder, and left knee pain, and was alert and oriented at the time of the incident. Around 5:00 AM in December 2025, R94 observed an unknown man enter the resident’s room, state that he was kitchen staff checking the table for breakfast, and then take the resident’s cellphone, which contained a driver’s license, debit card, health insurance card, and bus card. R94 reported that the door alarms did not sound when the man entered the facility and that the resident typically heard alarms when someone entered without using the correct code. After the theft, there were two unauthorized charges on the resident’s debit card. Staff interviews revealed that this was not an isolated security breach. An LPN reported that in December 2025, R94’s report of a man entering the room and taking the cellphone was initially considered possibly delusional due to the resident’s history of seeing a person, but during the same IDT discussion another nurse reported that the day before R94’s report, a stranger had entered the kitchen and stolen a dietary staff member’s iPhone around 5:30 PM. Security camera footage showed the same man entering through a kitchen door by following someone from behind, indicating that he was able to bypass normal access controls. The same individual was later seen twice in the parking lot, and staff contacted police on those occasions. A CNA also recalled interacting with a man who claimed he was there to pick up belongings of a discharged resident and asked for the Wi‑Fi password, which the CNA provided; during the subsequent investigation, this man was identified as the same individual seen on video breaking into the building. The Administrator’s review of the January 24–25, 2026 incident documented that during a night shift, an unauthorized individual gained access by exploiting a window on the south side of the building that was not fully seated in the locked position, allowing him to shimmy the frame open and enter an unoccupied case management office. From there, he exited into the hallway, went to the nurse station, and took a nurse’s wallet and keys. As he attempted to exit through a west door, the door alarm sounded, but he was able to reach a vehicle and flee before staff arrived. The Administrator also confirmed a prior December 24, 2025 security breach in which an unauthorized male bypassed the front lobby visitor kiosk, entered the facility, and went into R94’s room, where he removed the resident’s cellphone and attached personal items from the bedside. Investigation of that December incident showed the individual was not an authorized visitor, family member, or vendor, and that he had been able to enter the building and a resident room without being stopped at the kiosk or by staff. The DON stated that R94’s report was handled as a grievance and resolved, but there were no IDT notes related to the incident, and the Administrator was not aware of the earlier kitchen theft when first discussing the December event.
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.
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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