Flooring Hazard in Memory Care Unit Leads to Resident Injury
Summary
The facility failed to provide a safe environment for residents, staff, and visitors, particularly in the secure memory care unit, where a flooring hazard was present. This hazard was due to an incomplete floor repair in the 200 hallway, which was a high-traffic area. The flooring issue involved a missing clean-out cover that was temporarily covered with a metal sheet and tape, but not properly repaired. This inadequate repair led to a resident tripping and sustaining a serious injury, requiring hospitalization and surgical intervention. The injured resident, who had a history of difficulty walking and other medical conditions, was attempting to detach herself from tape on the floor when she lost her balance and fell. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the tape was not holding anything down, and the resident's foot got caught on it. The fall resulted in a significant decline in the resident's ability to ambulate and perform activities of daily living at her prior functional level. The facility's maintenance records showed that the flooring issue was known and documented, but the repair was delayed. The Director of Maintenance (DOM) had attempted temporary fixes and was researching a permanent solution, but the repair was not completed until after the resident's injury. The facility's failure to address the flooring hazard in a timely manner placed other residents, staff, and visitors at risk for serious injury.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Administrator and Director of Maintenance performed environmental rounds, identified areas of concern noted and reported in Electronic Maintenance System. Repairs on all items identified were completed prior to survey exit on Resident # 6 no longer resides in the facility. 2. Identification of other residents having the potential to be affected: Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards. Administrator/Designee rounded facility to survey for environmental hazards; identified environmental concerns reported via Electronic Maintenance System, addressed by priority level, and completed. 3. Actions taken/systems put in place to reduce the risk of future occurrence include: Administrator/Director of Clinical Services/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion; Director of Clinical Services/Designee re-educated staff on Accidents and Supervision Policy; Director of Clinical Services/Designee re-educated staff on Recognizing & Reporting Hazards; Director of Clinical Services/Designee re-educated staff on Redirecting Residents from Environmental Hazards; Director of Clinical Services/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm; initiation and assignment of direct care staff member as Hallway Safety Monitor for secure unit (200 Hall) for additional supervision and hazard identification. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will round to ensure facility is free of hazards twice weekly x 8 weeks; then weekly ongoing. Quality reviews will be completed once a week x 8 weeks and then every 2 weeks x 1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Removal Plan
- NHA and Plant Operations Director performed environmental rounds, identified areas of concern, and reported them in the electronic maintenance records system.
- Work orders started in order of priority for hazards causing uneven surfaces, risk hazards, and items with potential to risk resident safety.
- Summoned Corporate Plant Operations support team for assistance.
- Initiated repairs of identified areas of concern.
- Tiles in high traffic area of secure unit (200 Hall) repaired.
- 400 Hall ramp missing carpet tiles replaced with one solid carpet piece.
- Surveyors and NHA completed environmental rounds of the facility noting areas of continued concern.
- List compiled of concerns from environmental tour, all items entered in the electronic maintenance records system.
- 300 Hall clean out with uneven surface repaired.
- 99.5% of all facility staff were educated.
- Initiated and assigned direct care staff member as 'Hallway Safety Monitor' on secure unit (200 Hall) for additional supervision.
- Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards.
- NHA/Designee rounded facility to survey for environmental hazards.
- Identified environmental concerns reported via electronic maintenance records system, addressed by priority level, and repairs initiated and will be ongoing.
- NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.
- DCS/Designee re-educated staff on Accidents and Supervision Policy.
- DCS/Designee re-educated staff on Recognizing & Reporting Hazards.
- DCS/Designee re-educated staff on Redirecting Residents with from Environmental Hazards.
- DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.
- Initiation and Assignment of direct care staff member as 'Hallway Safety Monitor' for secure unit (200 Hall) for additional supervision and hazard identification.
- A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures.
- NHA/Plant Ops/Designee will round to ensure facility is free of hazards; then twice weekly; then weekly and PRN (as needed) as indicated.
- These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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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