Elevator Malfunction Poses Risk in Facility
Summary
The facility failed to ensure that the elevator was in safe working condition, which had the potential to cause harm to residents, staff, and visitors. During an observation, a Monitor Aide (MA) reported that the elevator frequently stopped functioning, requiring him to reset the breaker in the parking garage to restore its operation. This malfunction occurred 3-4 times during his shift, and the issue was known to the Maintenance Supervisor, Administrator, and Nursing Supervisors. A Certified Nursing Assistant (CNA) and the Director of Nursing (DON) confirmed awareness of the problem, with the CNA having been stuck in the elevator previously. The DON was in discussions with the corporate office regarding repairs. The Maintenance Assistant (MA) revealed that the elevator had been malfunctioning for at least a year, with multiple employees getting stuck daily. An urgent inspection by the elevator company had been conducted, and an invoice for repairs was provided to the Administrator. However, the elevator had not been repaired as of the report date. A review of the facility's maintenance policy indicated that the maintenance department is responsible for keeping equipment safe and operable at all times, which was not adhered to in this case.
Penalty
Resources
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Two residents with mobility impairments who used wheelchairs were not provided with enough space in their shared room to maneuver safely and comfortably. This resulted in their wheelchairs frequently bumping into each other, causing frustration and difficulty moving around, as confirmed by staff observations and resident interviews.
Cluttered Therapy Mat in Rehab Gym: The therapy mat in the Rehab Gym was observed covered with cardboard boxes, a cushion pad, inflatable balls, a paper towel roll, splints, a wooden device with plastic rings, folded linen, and staff personal items. The DOR confirmed the mat was used for resident transfers, sitting balance, and exercises, and stated the clutter limited usable space for therapy sessions. The DON stated the mat should be clear and free of clutter so residents could access therapy equipment.
Surveyors found hallways blocked by wheelchairs, geri chairs, mechanical lifts, a portable AC unit, and a linen cart, preventing direct access through the corridor. An LPN confirmed the obstruction, which had the potential to affect a small number of residents.
Resident wheelchairs were observed lined up on both sides of a hallway, blocking a direct walking path. The facility administrator confirmed the insufficient space and lack of a clear passage during staff interview.
Facility staff used the PT gym's therapy mat and surrounding area to store therapy equipment, broken items, and items awaiting disposal, making the space unavailable for resident therapy. The DOR and DON acknowledged that the cluttered environment prevented use of the therapy area for its intended purpose and did not meet expectations for a homelike, orderly setting.
Surveyors found that the therapy gym did not have adequate space or properly maintained equipment to meet residents' needs. One therapy mat was broken and used for storage, some therapy equipment was damaged or not in use, the only available ultrasound gel was expired, and an oxygen concentrator lacked service documentation. The Director of Rehabilitation confirmed these deficiencies during interviews and observations.
Failure to Provide Adequate Space for Wheelchair Mobility
Penalty
Summary
The facility failed to provide adequate space and equipment to meet the needs of two residents who both required wheelchairs for mobility. Observations and interviews revealed that the room shared by these residents did not allow sufficient space for them to maneuver their wheelchairs without bumping into each other. Both residents had medical conditions affecting their mobility, including hemiplegia, hemiparesis, generalized muscle weakness, and foot drop. Documentation indicated that both residents had intact cognition or fluctuating capacity to make decisions, and both required moderate assistance with activities of daily living. The lack of space led to repeated incidents where their wheelchairs collided, causing frustration and making it difficult for them to move around their room safely and comfortably. Staff interviews, including those with the Social Services Director and the Administrator, confirmed that the room arrangement did not accommodate the residents' needs, resulting in miscommunication and disagreements between the residents. The facility's own policy required adaptation of the physical environment to meet individual needs and preferences, but this was not implemented in this case. The deficiency was directly observed by staff and corroborated by resident statements, with specific incidents such as a water pitcher being knocked over due to the lack of space.
Cluttered Therapy Mat in Rehab Gym
Penalty
Summary
The facility failed to ensure that the therapy mat in the Rehabilitation Gym was maintained in a clean and unobstructed condition. During an observation on 9/30/2025 at 4:10 p.m., the therapy mat was seen cluttered with four cardboard boxes, a blue cushion pad, two inflatable balls, a large paper towel roll, a large bag containing splints, two leg splints, a wooden device with plastic rings, folded linen, a personal carrying bag, a cell phone, eyeglasses, and an eyeglass case. During a concurrent observation and interview on 9/30/2025 at 4:30 p.m., the DOR confirmed the items were on the therapy mat and stated the mat was used for residents to work on transfers, sitting balance, and various exercises. The DOR stated the miscellaneous items limited the amount of usable space for residents during therapy sessions and said the items should be stored in their designated areas and not on the therapy mat for resident safety and to ensure the equipment was clear and accessible for resident use. The DON later stated all therapy equipment should be accessible for resident use and that the therapy mat should always be clear and free of clutter to prevent accidents and to ensure residents could access the equipment during therapy. The facility policy titled, Rehab Space Requirements, stated rehabilitation services would be provided in a safe and suitable environment that encouraged resident participation and enabled the treating clinician to address the modalities listed on the plan of care.
Hallway Obstructions Limit Resident Access
Penalty
Summary
During an early morning tour of the facility, surveyors observed that hallways were obstructed by various items, including wheelchairs, geri chairs, mechanical lifts, a large portable air conditioning unit, and a linen cart. These items were parked along both sides of the hallway, blocking a direct path for movement up or down the corridor. A staff member, specifically an LPN, confirmed that the hallway did not provide a clear and direct path for residents to easily pass through. The facility census at the time was 57 residents. This situation was identified as a random opportunity for discovery and had the potential to affect a minimal number of residents.
Obstructed Hallway Due to Wheelchair Placement
Penalty
Summary
Facility staff failed to provide sufficient hallway space and equipment, as evidenced by resident wheelchairs lined up on both sides of the Hill Top Front Hallway, obstructing a direct walking path. This was observed during a random opportunity for discovery, with the hallway arrangement leaving no clear passage for those walking through. The facility administrator acknowledged the lack of adequate space and direct path during a staff interview. No specific details about individual residents' medical history or conditions at the time of the deficiency were provided in the report.
Cluttered Therapy Gym Limits Resident Access to Rehabilitative Services
Penalty
Summary
Facility staff failed to provide sufficient space and appropriate storage for equipment in the Physical Therapy (PT) gym, resulting in the therapy mat and surrounding area being used to store various items, including therapy balls, broken equipment, assistive devices, and items meant for disposal. Observations revealed that these items were stacked on and around the therapy mat, rendering the area unusable for resident therapy sessions. The Director of Rehabilitation confirmed that the therapy mat and its surrounding area could not be used for therapy due to the clutter and that items stored there were awaiting disposal. Interviews with facility leadership, including the Director of Nursing, emphasized the importance of maintaining a tidy, homelike, and hazard-free therapy environment, and acknowledged that the current use of the therapy area for storage was inappropriate. A review of facility policy indicated an expectation for cleanliness and order to promote a homelike environment, but there was no specific policy addressing the maintenance of uncluttered therapy areas or prohibiting the use of therapy spaces for storage.
Therapy Gym Lacked Adequate and Maintained Equipment
Penalty
Summary
The facility failed to ensure that the therapy gym had adequate space and properly maintained equipment to meet residents' needs. During observations, one of two therapy mats was found to be non-functional and used for equipment storage, making it inaccessible for resident care. Therapy equipment, including a bean bag toss game, hand weights, arm bicycles, and a therapy rainbow arch, was scattered over the broken mat. One of the eight hand weights had its protective coating chipped off, exposing the metal, and was being used as a paperweight rather than for resident care. The Director of Rehabilitation confirmed that the mat was broken, the arm bicycles were also broken and meant to be discarded, and the hand weight was not in use for therapy. Additionally, the facility failed to maintain other essential therapy equipment. The only container of ultrasound gel available for use with the ultrasound machine was found to be expired by one and a half years, which the Director of Rehabilitation acknowledged could limit the effectiveness of therapy for pain and soft tissue concerns. An oxygen concentrator present in the therapy gym did not have documentation of its last service date, raising concerns about its ability to deliver oxygen effectively. The facility's policy and procedure required that therapy equipment be safe and adequate for resident needs, but these requirements were not met as observed.
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