Failure to Maintain Adequate Hot Water and Environmental Cleanliness
Summary
The deficiency involves the facility’s failure to maintain required hot water temperatures and to keep resident rooms and common areas clean and in good repair. On an environmental tour of the third floor, the Maintenance Director measured water temperatures in several occupied rooms using the facility thermometer. In one resident’s bathroom, the sink water reached only 100°F after running for five minutes and then quickly dropped to 62°F. In another room, the bathroom water did not rise above 54°F after running for over three minutes, and in a third room the bathroom water reached only 99°F after six minutes. The Maintenance Director stated that water temperatures should be between 105°F and 120°F and acknowledged ongoing concerns with the mixing valve. He reported that he ordered a rebuild kit on 12/23/25 after being made aware of hot water concerns, then went on vacation, and that the company he used was also on vacation when he returned. He confirmed that the facility did not contact an alternate company to obtain the part or service sooner. Residents and staff reported persistent problems with inadequate hot water on the third floor. One resident stated that staff had to run the water for a long time to get it slightly warm and that sometimes the water used for cleaning felt slightly warm and sometimes cold, adding that the problem had been going on a long time and that she had informed the Administrator. Another resident reported receiving bed baths with cold water. CNAs reported that residents had expressed concerns about water not getting hot enough and that staff had to let the water run for a while before it would get warm, but sometimes it could run for hours and still not get warm on the third floor. The Maintenance Director confirmed that the first and second floors had sufficient hot water if it ran long enough, but the third floor was not always reaching the appropriate temperature. The Administrator stated that the hot water issue was due to a broken mixing valve first identified on 12/23/25 and confirmed that no interventions were put in place so third-floor residents could wash or be washed with warm water. The deficiency also includes failures to maintain resident rooms and facility areas in a clean and orderly condition and in good repair. One resident, who was cognitively intact with end stage renal disease, muscle weakness, gait and mobility abnormalities, and total dependence for personal hygiene, bed mobility, and transfers, reported that his toilet had not flushed for a week, that a light above his bed had not worked correctly for several weeks, and that a socket by his bed had no cover since his admission. Observation confirmed the toilet would not flush, one of two bed lights had no bulb, and the phone jack socket was broken. The Maintenance Director stated he had removed the bulb two or three weeks earlier and had not replaced it because he was ordering new lights, and he was unaware of the broken socket. Additional observations showed significant uncleanliness and disrepair in other resident rooms and hallways. In one room, five visible floor tiles under the bed were broken with missing pieces, the floor and floor mat next to the bed were very dirty with ground-in dirt, dried spills, and apparent food particles, and there were large areas of thick black/brown substance resembling removed floor strips and remnants of a mat stuck to the floor. The dresser drawer had a broken handle, and the dresser surface had dust and dried spills. The resident stated that the facility needed to clean better and that he would like that. In another room, the floor was very dirty with ground-in dirt and mud throughout, and there were multiple trash items under and protruding from under the bed into the walkway, including used tissues, dirty clothing, crumpled papers, and wrappers, with embedded dirt and grime under and beside the trash. The resident was resting on a mattress without sheets, reported preferring to lie on sheets, and stated that the sheets provided did not fit and would not stay in place. He confirmed his room was very dirty and stated that staff only wiped the middle of the floor and did not perform deep cleaning, saying it had been that way forever. Staff interviews corroborated the poor environmental conditions. A CNA who viewed the two residents’ rooms described them as disgusting and stated that housekeeping did not do a good job. The CNA also confirmed that the third-floor halls, including around the entire nurses’ station, were scuffed with multiple large scrapes that were discolored gray, with the edges showing the tiles were originally light tan. The Administrator, observing the same rooms and hallways, confirmed the dirty floors, trash under the bed, lack of sheets on the mattress, and heavily scuffed, discolored hallway floors. The Housekeeping Manager stated that the conditions were not right and confirmed that none of the facility floors had received a deep cleaning in over a year, explaining that there was no equipment or person to perform it despite repeated requests. An LPN stated that the building was filthy and that everybody knew it. These conditions were inconsistent with the facility’s written policy on providing a safe, clean, comfortable, and homelike environment with clean, sanitary, and orderly surroundings and clean bed and bath linens in good condition.
Penalty
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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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