Widespread Environmental Disrepair and Unsanitary Conditions Throughout Facility
Summary
The facility failed to ensure a safe, sanitary, and homelike environment for all 85 residents, as evidenced by multiple observations of disrepair, unclean conditions, and inadequate equipment throughout the building. On the third floor, the dining cart was held together with duct tape, and residents were served meals in polystyrene foam containers with plastic utensils. One resident reported difficulty cutting food with a plastic fork on the disposable containers, and another resident stated being tired of eating on disposable plates. The Dietary Supervisor confirmed that disposable plates were being used because the boiler was under repair. In the memory care unit, a large section of ceiling tiles was missing after a ceiling collapse, and the Maintenance Director acknowledged the damage but stated he had to prioritize heater repairs. Additional observations showed widespread physical deterioration and non-functioning equipment in common areas and resident rooms. The main elevator had extensive scratches and gouges on the walls and dust on the ceiling grid, hallways and lobby walls were heavily scuffed, and ceiling tiles were missing or water-stained in several locations, including near a vending machine and in a second-floor shower room where a ceiling tile was crumbling. Multiple public bathrooms on all three floors were marked out of order, and a back elevator remained out of order over an extended period. There were active and recurrent water leaks, including wet blankets and caution signs in a second-floor hallway and chapel, and a burst pipe with an active leak managed with buckets and towels. The President of Plant Operations stated the building had very old cast iron pipes that could only be repaired as they broke and confirmed the crumbling ceiling and repeated pipe breaks. Within resident rooms, numerous deficiencies were documented, including rusted sinks and drains, missing laminate, crumbling or missing drywall, exposed cable and wiring, loose or falling wall bars, loose grab bars by toilets, and damaged or old furniture such as bedside tables and wardrobes in disrepair. Several residents reported issues directly: one resident had only a desk and no dresser and a slow-draining sink; another had a swollen door that was difficult to open, a non-draining sink, and loose sink lamination; another demonstrated that the foot of his bed would not raise and the headboard was detached, with a telephone outlet dangling from the wall with exposed wires. In one room, a resident’s call light was pulled out from the wall, and the resident stated she had to yell out for assistance. Other residents reported dissatisfaction with marred walls, damaged areas around sinks, and missing or inadequate furniture such as chairs and dressers. Lighting and cleanliness issues were also prevalent. Several rooms were described as very dim even with all lights on, and some light fixtures were missing covers, leaving exposed bulbs. In multiple rooms, there were stains on ceilings, apparent water damage, and what was described as dark staining potentially resembling mold. In the front lobby and adjacent hallways, there was approximately two inches of dark grime along the edge of the flooring by the walls, which remained present over multiple days until a housekeeper was observed scraping it. In shower rooms, there were piles of wet towels left on the floor on more than one occasion, and an overhead fan in a memory care shower room was covered in dust; a CNA stated she did not know who was responsible for cleaning the fan. Throughout the building, staff including the Maintenance Director, Regional Maintenance Director, and President of Plant Operations toured the cited areas and verified that the described areas had not been maintained. Handrails and safety fixtures in resident bathrooms and rooms were also compromised. One resident had a very loose handrail by the toilet with rust near the pipe and a sink with missing enamel and a sharp edge, along with exposed drywall and ripped wall areas. Another resident’s sink lacked hot water, and the wall around the sink was partially unpainted; this resident also noted the absence of a chair they wanted in the room. In common areas, chunks of wall were missing, hallway railings were marred along their length, and paint was missing in multiple locations. Across various rooms and hallways, there were chips in floor tiles, missing baseboards, missing trim, and marred or gashed doors. These conditions, confirmed by multiple staff interviews and walk-throughs, demonstrate a pattern of failure to maintain the building, equipment, and environment in a safe, sanitary, and homelike condition for residents, staff, and the public. In several instances, residents explicitly described how these environmental deficiencies affected their daily experience. Residents reported difficulty using plastic utensils on disposable plates, frustration with long-standing door and furniture problems, and concern about stains on ceilings above their beds. One resident confirmed that when turning on the sink, water came out onto the floor, and the entire sink and cabinet were not attached to the wall and could be tilted forward with a light touch. Another resident stated that the condition of the wall and area under the sink bothered him, and others expressed dissatisfaction with dim lighting and damaged surroundings. Staff interviews repeatedly confirmed awareness of many of these conditions, including broken fixtures, out-of-order bathrooms and elevators, water damage, and structural deterioration, without evidence in the report of timely correction prior to the survey observations.
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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