London Health & Rehab Center

Observation on 02/20/26 at 9:41 A.M. of Resident #14 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances.

When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining.

Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.

Interview and observation of Resident #14 ' s room on 02/20/26 at 11:45 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.12.

Review of the medical record for Resident #73 revealed an admission date of 01/29/25 with diagnoses of chronic diastolic heart failure, chronic obstructive pulmonary disease, acute kidney failure, dysphagia, traumatic subdural hemorrhage, and cognitive communication deficit.Observation on 02/20/26 at 9:42 A.M. of Resident #73 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances.

When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining.

Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #73 ' s room on 02/20/26 at 11:43 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.13.

Review of the medical record for Resident #74 revealed an admission date of 01/02/24 with diagnoses of cerebral infarction, aphasia, muscle weakness, and dysphasia.Observation on 02/20/26 at 9:42 A.M. of Resident #74 ' s room revealed uncovered soffits located above windows with structured covered fabric window valances.

When walking up to look behind the valance, pipes displayed various shapes and sizes with deep gray to black speckled staining.

Pipes were covered with layers of white flaking paint-like material and some discoloration appeared to be related to the layers of paint on piping.Interview and observation of Resident #74 ' s room on 02/20/26 at 11:43 A.M. with Maintenance Director #131 confirmed various staining present on pipes above resident windows located behind the window valance.Interview on 02/20/26 at 11:42 A.M. with the Director of Maintenance confirmed the discoloration does not align with a homelike environment. He stated he is unable to remedy the discoloration with paint due to recurrence.

The resolution to the issue is to install insulation and a drop ceiling to conceal the discoloration. He confirmed a contractor was in earlier in the summer season to evaluate the issue and found no immediate concerns.

However, a recommendation was made to provide an aesthetic improvement.

Interview on 02/20/26 at 12:11 P.M. with Contractor Director and Manager #500 revealed the staining is due to condensation during hot and cold months, poses no health risk to residents, and is not mold.

The pipe is covered in pipe wrap which is a fiberglass substance that provides no food source for mold and is not an opportunistic material for mold growth.

Interview on 02/20/26 at 12:15 P.M. with the Administrator revealed the facility had been aware of the issue since late summer or early fall.

The administrator stated the project is large and pending due to staffing.

The facility ensured the issue poses no health risk to residents and received vendor recommendations for aesthetic resolution including air blocks, insulation, and a drop ceiling while maintaining fireproof standards.

Review of the resident handbook dated 07/14/11 revealed the facility promotes a homelike environment and will make every attempt to accommodate reasonable requests to individualize residents ' living spaces.This deficiency represents non-compliance investigated under Complaint Number 26611454.