Facility Fails to Maintain Clean and Functional Environment
Summary
The facility failed to effectively clean and maintain its physical plant, affecting 91 residents. During an environmental tour of the facility's laundry service, it was observed that the clean laundry room had a leaking hand wash sink cold water supply valve and soiled overhead light assembly lens covers. In the soiled laundry room, transport carts were found to be etched and scored, creating non-cleanable surfaces. Additionally, the common areas, including the nurses' station and staff restrooms, were noted to have accumulated dust and dirt deposits, and several light assemblies were non-functional. In various units, multiple deficiencies were observed, including stained ceiling tiles, loose commode supports, and non-functional resident call systems. The nursing supply closets had bare and unsealed shelving units, and the emergency water supply closet was in disarray with soiled containers. Resident rooms across different units had non-functional light assemblies, missing pull string extensions, and damaged drywall surfaces. The commode base caulking in many restrooms was etched and scored, and several hand sink basins were draining slowly. The facility's policies and procedures for cleaning schedules and preventative maintenance were reviewed, revealing that routine cleaning and maintenance were not performed according to the predetermined schedule. The Direct Supply TELS work orders for the last 60 days showed no specific entries related to the maintenance concerns identified during the survey. This lack of adherence to cleaning and maintenance protocols increased the likelihood of cross-contamination and bacterial harborage, posing a risk to the safety and comfort of residents, staff, and the public.
Plan Of Correction
Element #1 Clean Laundry Room: Hand wash sink leak was fixed. Overhead light assembly clear plastic protective lens covers cleaned. Soiled Laundry: 6 new laundry transport carts were ordered. Nurses station: 6 new chairs were ordered. Staff Restroom: return-air-exhaust cleaned Shower Room (A): wand assembly corrected light assemblies functioning, hand sink basin re-secured. Call light system corrected. Nursing Supply Closets ALL now have painted, sealed shelves. Stained ceiling tiles replaced. Womens Locker Room: sink drain repaired, cove base reinstalled, Emergency Water Supply area cleaned with new shelving purchased. Staff Breakroom was cleaned including the toaster and refrigerator freezer unit. A11 - The restroom overhead light assembly was fixed. The restroom commode base perimeter was also cleaned and caulked. B1 - The restroom over sink light assembly was fixed. The restroom commode base perimeter caulking was redone. The interior and exterior commode base surfaces were cleaned. The window ledge drywall surface was repaired. The floor mounted heating grill assembly was replaced. B7 - The commode base caulking was redone. B9 - The floor mounted heating grill plate was replaced. C2 - Commode base caulking was repaired. The restroom sink was unclogged and is draining normally. C3 - The Bed 1 over bed light assembly pull string was replaced. The Bed 2 floor mounted anti-skid strips were replaced. The restroom over sink light assembly corrected and is functioning. The restroom commode base caulking was replaced. The restroom bathtub interior surface and perimeter surround was cleaned. The Bed 1 over bed light assembly pull string was added. C6 - The Bed 2 over bed light assembly pull string extension was replaced. The restroom overhead light assembly was also fixed. The restroom commode base caulking was redone. The restroom commode base seat was replaced. C-7 - The restroom commode base caulking was repaired. The restroom over sink light assembly was also corrected. The restroom overhead light assembly protective lens cover was cleaned and replaced. The Bed 2 drywall surface was further observed (etched, scored, particulate), adjacent to the footboard. The damaged drywall surface measured approximately 4-feet-wide by 4-feet-long. C9 - The restroom commode base caulking was redone. The restroom overhead light assembly was also corrected. C-10 - The restroom commode base caulking redone. The restroom hand sink basin was unclogged and is draining normally. The restroom perimeter wall/flooring coving strip was reinstalled and is no longer loose. D2 - The restroom commode base caulking was redone. The restroom over sink light assembly was also corrected. The restroom commode support was additionally tightened. D-3 - The restroom commode base caulking was replaced. The restroom overhead light assembly was also corrected. The Bed 2 drywall surface was repaired. D7 - The commode base caulking was replaced. The restroom and sink basin caulking was also replaced. The drywall surface was repaired. D-9 - The restroom commode base caulking was replaced. The restroom commode base was also tightened. The restroom commode support was additionally tightened. The restroom over sink light assembly was repaired. The restroom overhead light assembly lens cover was also cleaned. The Bed 1 over bed light assembly pull string extension was replaced. D-11 - The restroom commode base caulking was repaired. The restroom commode base was also tightened. The restroom commode support was additionally tightened. The restroom over sink light assembly was fixed. The restroom overhead light assembly lens cover cleaned. The Bed 1 over bed light assembly pull string extension was added. D-13 - The Bed 1 over bed light assembly pull string extension was added. The restroom commode base caulking was also replaced. D-17 - The restroom commode base caulking was redone. The restroom overhead light assembly lens cover was cleaned. Element 2 Residents who reside in facility are considered at risk. Facility-wide audit was completed to ensure a safe and sanitary environment is possible for all residents. Findings were entered into TELS and corrected by facility maintenance. Element 3 The Administrator has reviewed the Preventative maintenance policy and cleaning schedules policy and deemed them appropriate. Staff have been educated on the use of the TELS work order system. Staff will utilize TELS daily to submit needed work orders. Element 4 NHA or designee will audit 10 areas each week x4 weeks, then monthly to ensure proper maintenance needs have been met, and surfaces are cleanable. Results will be reviewed monthly by QAPI until substantial compliance achieved. Administrator is responsible for overall compliance.
Penalty
Resources
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A large-screen TV in the secured unit dining room was playing a loud, violent movie during meals, with screaming, gunfire, crying, and dark scenes visible to residents seated nearby. Two residents with dementia-related cognitive impairment and behavioral issues were directly affected; one became angry and complained the TV was too loud and too dark, while another repeatedly turned off the lights and struck out at an NA when blocked. An LPN, RN, AD, and DON stated the programming was not appropriate for residents with dementia and could increase anxiety or agitation.
Dirty G-tube Pump and Room Floor: A resident with Parkinson’s disease, DM, and impaired cognition was observed sleeping in bed while connected to a turned-off G-tube pump that had visible dried milk residue, and the room floor also had visible dried milk residue. A CNA confirmed the pump and floor were dirty, and an LVN stated food or milk drippings should be cleaned right away. RN review showed the care plan called for a safe environment with a floor free from spills and clutter, and the facility did not follow its cleaning and disinfection policy.
Unsafe and Poorly Maintained Environment: A hole in the ceiling on Hall 100, a detached baseboard in a shower room on Hall 300, dim lighting in the secure unit dining room, and a leaking kitchen ceiling were observed in the LTC facility. Staff and management interviews showed the issues were known or reported inconsistently, and maintenance logs did not document several of the problems. The kitchen leak was being collected in a pot near the food prep area, and the DM stated the kitchen leaked when it rained.
Unsafe and nonfunctional bathroom fixtures were observed on two nursing units and in one resident room. A resident reported a broken faucet, and staff observed a replacement knob that wiggled and did not work properly. In one shower room, the hot and cold indicators were reversed, and in another shower room, the drain cover was missing.
Unsafe and Unclean Unit Environment: The 200 unit had marred walls, chipped door trim, a large hole in a resident room wall, missing drywall near the offices, and dirt buildup on baseboards, floors, and around the elevator. The dining room and elevator area also had debris buildup, and the elevator door frame wrap was hanging off on both sides. An HSKP staff member stated the facility was down a housekeeper and floors should be cleaned daily.
Unsafe resident room conditions were identified when multiple rooms had nonfunctional A/C units, temperatures above 81 degrees, and unsealed openings around replacement units. A resident with paraplegia, polyneuropathy, chronic pain, and TBI reported living in a room without working A/C for weeks, while staff said several rooms had been hot for months and administration knew about the issue. Surveyors also observed biological growth inside one A/C unit and on a ceiling tile above a sink in a room occupied by a resident with respiratory concerns.
Loud Violent TV Programming in Secured Unit Dining Area
Penalty
Summary
The facility failed to provide a calm, comfortable, low-stimulation environment on the secured unit by allowing loud, violent television programming to be played in the common dining area. During observation, a large-screen television was placed in the center of the dining room with residents seated directly in front of and beside it, and the volume was very loud. The movie contained dark scenes that were difficult to see unless seated directly in front of the screen, along with loud screaming, hollering, gunfire, crying, and weeping throughout the program. Two residents reviewed for quality of life were directly affected by the environment. R2 had moderate cognitive impairment and diagnoses including hemiplegia, generalized anxiety disorder, mild neurocognitive disorder, and cerebral infarction. R2’s care plan identified mood and behavior alterations, a history of agitation, verbal behaviors, resident-to-resident altercations, and profanity, with interventions including redirection to a quiet area, offering music with headphones, and maintaining a consistent environment. While seated near the dining room/common area, R2 angrily stated the television was too loud and too dark to see or follow, repeatedly expressed frustration with the programming, and said the staff were "so fucking stupid" and that he needed to leave the facility. R46 had moderate cognitive impairment and diagnoses including dysphagia, restlessness, agitation, seizures, and anxiety. R46’s care plan identified altered mood and behaviors and included redirecting the resident to the day room to watch television. During the evening meal, the same loud violent movie was playing while about twelve residents ate in the dining room. R46 repeatedly wheeled to the light switch and turned the lights off, causing several residents to shout for the lights to be turned back on; after staff restored the lights, R46 turned them off again and then struck out at a nursing assistant when blocked. Staff interviews stated the movie was not appropriate for residents with dementia, could contribute to anxiety and agitation, and did not create a low-stimulation environment.
Dirty G-tube Pump and Room Floor
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for Resident 17 by not keeping the resident’s G-tube pump free of dried milk residue and not keeping the flooring in the resident’s room free of dried milk residue. Resident 17 was admitted on 8/8/2025 with diagnoses including Parkinson’s disease, diabetes mellitus, and lack of coordination. The resident’s MDS dated 4/9/2026 indicated moderately impaired cognitive skills for daily decision-making and that the resident needed partial to moderate assistance with personal hygiene and sit-to-stand. During an observation in the resident’s room on 6/29/2026 at 9:27 AM, Resident 17 was sleeping in bed and connected to a G-tube pump that was turned off. The pump had visible dried milk drippings, and the room flooring also had visible dried milk drippings. During a later observation and interview, a CNA stated that the G-tube pump was dirty with visible dry milk on it and that there was dried milk on the floor. An LVN stated that the G-tube pump and floor were supposed to always be clean and that food or milk drippings should be cleaned right away for safety and infection control. RN 1 reviewed the care plan and facility policies and stated the care plan called for keeping the resident’s environment safe with a floor free from spills and clutter, and that the facility did not follow its policy for cleaning and disinfecting resident care equipment.
Unsafe and Poorly Maintained Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in Hall 100, Hall 300, the secure unit, and the kitchen. On 6/29/2026, an observation and record review found a hole in the ceiling on Hall 100 that exposed the attic space and was approximately three inches wide. Hall 100 had 20 residents according to the facility census. On the same day, the shower room on Hall 300 had a detached baseboard along one wall, exposing the flooring underneath the sheetrock with an approximately 2-3-inch gap between the wall and flooring. Also on 6/29/2026, the secure unit dining room was observed with eight residents waiting for lunch trays while 3 of 6 lights were out, making the dining area dim. Staff opened the blinds to provide more lighting. The secure unit had 14 residents according to the facility census. During interviews, the Maintenance Supervisor said staff were supposed to enter issues in the maintenance log or report them verbally, and she stated she had reported the environmental issues to corporate staff and owners on 6/29/2026 and was awaiting a response. She also stated she was not aware of the issues before that date and that they were not in the maintenance log. On 7/1/2026, the kitchen was observed with a pot on the floor by the food prep table collecting dark, brown water from a hole in the ceiling that was approximately 6 inches wide and exposed the attic space. The area around the hole was brown from water damage. The DM stated the pot was kept there because the kitchen leaked when it rained. Record review of maintenance logs from June 2026 to July 2026 did not show the shower room on Hall 300, the secure unit lights, the kitchen ceiling hole, or the Hall 100 ceiling hole had been reported for repair.
Unsafe and Nonfunctional Bathroom Fixtures
Penalty
Summary
The facility failed to ensure a safe and functional environment on two nursing units and for one resident. Resident 1 stated that the faucet in his room was broken, and observation showed the hot water handle had been replaced with an alternate knob that was secured on the previous hardware, wiggled and flopped up and down when turned, and did not function normally to turn the water on and off, sometimes working and sometimes requiring the handle to be spun multiple times. In the [NAME] unit shower room, the faucet handle was installed incorrectly so that the hot water indicator supplied cold water and the cold indicator supplied hot water, and an employee confirmed the temperature indicators were reversed. In the University shower room, there was no drain cover over the shower drain, and an employee confirmed the drain cover was missing.
Unsafe and Unclean Unit Environment
Penalty
Summary
The facility failed to ensure a safe, sanitary, and homelike environment on the 200 unit. During observation, the unit hallways had marred walls, a resident room had a large hole in the wall by the foot of the bed, and the wall by the offices had a large chunk of drywall missing. Baseboards had dirt buildup, door trim around resident rooms was marred or had chipped paint, and the hallways had dirt buildup in corners and around the double doors. The dining room floor had debris buildup around the baseboards and in corners, the elevator floor had dirt buildup around the edges of the walls, and the wrap around the elevator door frame outside the elevator doors was hanging or coming off on both sides. Housekeeper 3 stated the floor technician had recently been let go, the facility was down a housekeeper, and floors should be cleaned daily. The Administrator provided the facility policy on safe and homelike environment with a copyright date of 2025, which stated the facility will provide a safe, clean, comfortable, and homelike environment.
Unsafe Resident Room Conditions Due to Nonfunctional A/C and Biological Growth
Penalty
Summary
Resident rooms in units 100 and 200 were not maintained in a safe, functional, and comfortable condition because multiple air-conditioning units were not operational, some room openings around replacement units were unsealed, and environmental contaminants were present in at least one unit. On 6/29/26, Resident #2 stated the room had been without working A/C since before admission, that the facility had provided a fan, and that the resident and family had added another fan because of the heat. By the end of the interview, the room temperature measured 87.8 degrees Fahrenheit. Resident #2’s record showed diagnoses including paraplegia, polyneuropathy, chronic pain, and traumatic brain injury, and the resident had a BIMS score of 15, indicating cognitive intactness. Staff interviews and observations showed the problem extended beyond one room. A CNA stated multiple rooms in the locked unit had similar A/C issues, and another CNA stated several resident rooms had not had working A/C for a while and that administration had known about the issue for months. Observations in the 200 hall identified nonfunctional A/C units in 10 resident rooms, with temperatures above 81 degrees Fahrenheit in multiple rooms, including rooms 206, 207, 216, 221, 222, 224, 225, and 229. The NHA and DON stated they were aware of A/C issues in only two rooms and said replacement units had been ordered. The report also documented environmental concerns within the room conditions. One A/C unit had visible biological growth inside it, and a large circular black area of biological growth was observed on the ceiling tile above the sink in a room occupied by a resident with documented respiratory concerns. The DOM stated replacement A/C units were smaller than the originals, leaving unsealed openings around the units that exposed residents to outside elements. The maintenance log contained no entries documenting malfunctioning A/C units in the 200 hall, and no completed room inspection checklists were available despite a preventative maintenance checklist requiring inspection of A/C units, thermostats, and filters.
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