F0584

E

Ongoing Roof Leaks and Damaged Ceilings Undermine Safe, Homelike Environment

Hughes Springs, Texas Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment, specifically related to an ongoing leaking roof and damaged ceiling tiles in resident rooms, the dining room, and common areas. Surveyors observed multiple bulging, stained, and loose ceiling tiles in the dining room, including two bulging tiles with large brown, apparently damp stains in the far back corner above a metal cabinet, additional stained tiles in the main dining area, and a light fixture with a brown stain inside the fixture. Near the nurse’s station and in front of the ice machine leading into the dining room, several ceiling tiles had brown stains and rings of various sizes, and one tile in the hallway was loose with visible insulation. These conditions were directly observed during the survey and were associated with water intrusion from the roof.

In resident rooms, surveyors observed stained, missing, and previously leaking ceiling tiles. In one shared room, a resident reported that about three weeks earlier the ceiling along the outside wall had leaked, with multiple tiles damaged and water visibly dripping into the room; some tiles had been replaced, but one tile above the roommate’s bed remained with a large brown stain covering most of the tile. Another resident stated that the roof leaked in front of the ice machine and that water sometimes dripped into his room from the ceiling; his room contained two tiles with small brown stains near the head of his bed. A third resident in the same shared room confirmed that the corner of the ceiling near the head of her bed had leaked about three weeks earlier, with water dripping into the room and leaving more than half of one tile stained brown. In another room, two ceiling tiles were missing in one corner along the outside wall, exposing the roof, and one remaining tile was stained; in yet another room, two tiles had large faint stains, with one appearing still damp.

Staff, residents, and a family member described a long-standing roof problem and repeated episodes of leaking, particularly in front of the ice machine and in the dining room. The former Maintenance Supervisor, who had worked at the facility for three years, stated that the roof had been an ongoing issue, that he had repeatedly patched it with a flexible tar-like substance, and that there was a structural issue above the ice machine where iron beams were rusting through. He reported that residents on one hall, especially in one specific room, had to be moved due to leaks, that insulation in the dining room ceiling became soaked and dripped for days, and that tiles in the area leading into the dining room would fall because the roof could not be properly repaired. A housekeeper and a CNA both reported that tiles had fallen in the dining room and in front of the ice machine, that trash cans and floor blankets were used to catch and manage leaking water, and that the roof had been leaking for years. Administrative staff, including the MDS Coordinator, ADON, DON, and Administrator, acknowledged that the roof had leaked at times, that tiles had fallen or been replaced after storms, and that stained, missing, and leaking tiles could negatively affect residents’ feelings, mood, and perception of their home environment. The facility’s own policies on resident rights and homelike environment required a safe, clean, sanitary, and dignified environment, which contrasted with the observed and reported conditions.