The oscillating fan sat on top of a transfer board that was itself balanced on the push handles of a resident's wheelchair. When questioned about the dangerous setup, Resident 7 explained that staff had removed her over-the-bed table to give to another resident, leaving the fan propped on the wheelchair handles.
The fan remained plugged into the wall outlet in this unstable position.
In the same room, inspectors discovered two positioning wedges sitting directly on the floor in a corner by the window. These therapeutic devices, designed to help residents maintain safe sleeping positions, were in direct contact with the floor rather than being properly stored.
The facility's housekeeping failures extended throughout resident living areas. In one room, inspectors found a used rubber glove, a used plastic cup, a towel, and multiple crumbs and debris scattered under a resident's bed.
Another room revealed more disturbing conditions. A Kennedy cup with its lid removed sat on the floor, containing brown liquid that had splattered between two residents' beds. The liquid had also stained the fitted bed sheet of Resident 6.
Under Resident 8's nightstand, inspectors documented multiple used tissues, napkins, and a used face mask.
Resident 7, who shared the room with Residents 6 and 8, told inspectors that housekeeping staff did not clean their room daily. "Somedays the floor is so bad, it's embarrassing," the residents stated.
The facility's maintenance problems were equally serious. In the first-floor shower room, inspectors found a large hole in the wall along the baseboard trim near the toilet. A ceiling tile was missing in front of the privacy curtain.
Water damage plagued the second floor. Near the nurses station in the East Wing, a ceiling tile displayed a 4-inch brown water stain with black stains visible within the brown discoloration.
The second floor dining room showed more extensive water damage, with three ceiling tiles containing large brown stains that resembled water damage.
These conditions violated federal requirements that nursing homes maintain safe, clean, and homelike environments for residents. The inspection was conducted in response to a complaint, suggesting ongoing problems that prompted outside concern.
When confronted with the findings, the Nursing Home Administrator and Director of Nursing acknowledged during a November 19 interview that the facility's environment should be kept in good repair and maintained in a clean and homelike manner.
The violations affected residents on two floors of the facility, indicating systemic problems with both housekeeping and maintenance services. Federal regulations require nursing homes to provide treatment and supports for daily living safely, including maintaining proper environmental conditions.
The unsafe fan placement posed immediate risks. Transfer boards are flat, smooth devices designed to help residents move safely between surfaces when they cannot stand or bear full weight. Using one as a makeshift table for an electric appliance created multiple hazards.
The widespread debris and spilled liquids in resident rooms suggested inadequate cleaning protocols. Used medical gloves and face masks left under furniture indicated poor infection control practices, while food crumbs and personal items scattered under beds showed basic housekeeping was not being performed.
The water damage visible in multiple ceiling tiles pointed to unaddressed maintenance issues that could lead to mold growth and further structural problems. Missing ceiling tiles in shower areas created additional safety and hygiene concerns.
Positioning wedges left on floors rather than being properly stored or cleaned represented another breakdown in basic care protocols. These devices are meant to prevent pressure sores and maintain safe sleeping positions for vulnerable residents.
The residents' own testimony about embarrassing floor conditions and inconsistent housekeeping services provided direct evidence of how these failures affected daily life in the facility. When residents themselves describe their living conditions as embarrassing, it indicates problems that go beyond minor maintenance issues.
The inspection documented violations across fundamental aspects of nursing home operations: housekeeping, maintenance, equipment storage, and infection control. The combination of immediate safety hazards like the unstable fan with ongoing cleanliness problems suggested broader systemic failures in facility management.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting some residents. However, the range of problems identified during a single day of inspection raised questions about conditions on days when inspectors were not present.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Broad Mountain Health and Rehabilitation Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
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