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:
Unsanitary bathroom conditions were observed in 7 rooms, with black and dark filmy growth on ceilings, walls, doors, and door frames, along with warm, musty, foul-smelling conditions. Follow-up checks showed the growth and odors remained, and prior work orders documented mold, ventilation, and A/C concerns without completion dates recorded.
Peeling Wallpaper Left Unrepaired in Resident Room: A resident with severe cognitive impairment and diagnoses including Alzheimer's dementia, CKD, HTN, and depression was observed in a room where wallpaper next to the bed was loose and peeling away from the wall. A NA said the damage had been present for months and the resident had been pulling at it, while an LPN said they were not aware of the issue. The maintenance director said the wallpaper needed repair, but no maintenance requests were found for the room.
A facility failed to keep 4 hallways clean and comfortable, with stained carpets, food debris, urine odor, and cluttered resident rooms observed. Residents reported rooms were not cleaned routinely, one said a spill was left sticky after being wiped but not mopped, and a grievance showed food spills remained for days before cleaning. Staff said housekeeping could not always complete daily room cleaning and that staffing was limited.
Failure to maintain the sewer line and sanitary environment resulted in raw sewage backing up through toilets and shower drains into resident rooms and hallways, with wastewater also leaking into an office area. Residents reported repeated clogs, the building water supply was shut off for hours, and staff confirmed corroded piping, flushed wipes, and that no medical or clinical assessments were completed after residents were exposed to sewage and fumes.
Pest activity and unsanitary conditions were observed in resident areas and near the garbage area. A resident reported a spider on her curtain and a fly in her room, another resident reported flies during meals, and a family member reported roaches, moldy walls, and chipped paint in a resident room. Staff also observed dead insects near the kitchen exit, leaking waste at the garbage compactor, uncovered dumpsters, and unused equipment stored outdoors on muddy ground.
Failure to maintain comfortable temperatures in common areas: surveyors found the dining rooms, hallway, lobby, and kitchen at or above 81 F, with the kitchen reaching 86 F while outdoor heat index conditions were very high. Staff reported the chiller had failed the prior year, the roof unit serving the kitchen and dining room had gone out the prior week, and portable AC units were being used in hallways and dining areas; a resident said bingo was too hot and humid and hard to breathe.
Unsanitary bathroom conditions with unresolved maintenance issues
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in 7 of 60 rooms, specifically Rooms 341 through 347. During observation of the 300 Hall, the resident bathrooms for these rooms were seen with black and dark-colored filmy growth on multiple surfaces, including the ceilings, walls, doors, and door frames. The bathrooms were warm and had a musty, foul odor. Follow-up observations on multiple subsequent dates showed the black or dark growth remained present on the bathroom surfaces, and the bathrooms continued to be warm and musty with foul odors noted. Review of the Maintenance Repair/Housekeeping Logs and Work Orders/Repair Requests showed prior environmental concerns related to moisture, ventilation, water intrusion, and mold before the survey observations. One work order for a room noted mold in the bathroom after a resident complaint, another noted air filters needing replacement, windows needing cleaning, and mold on ceilings, and a maintenance log entry documented that the A/C and heat were not working in one of the affected rooms. The reviewed records did not contain documentation showing completion of the identified work, and the Maintenance Director acknowledged that the entries did not include a date of completion.
Peeling Wallpaper Left Unrepaired in Resident Room
Penalty
Summary
The facility failed to keep a resident room in good working condition for a resident who was severely cognitively impaired and diagnosed with Alzheimer's dementia, chronic kidney disease, hypertension, and depression. During observation, the resident was lying in bed with the bed positioned with its long side against the wall. Next to the bed, the wallpaper seam by the wall light was loose, and approximately 2 feet of wallpaper was peeling away from the wall, exposing a beige wall and some loose white matter where the wallpaper had been attached. During interviews, the maintenance director observed the room and stated the wallpaper needed to be repaired, and noted loose wallpaper may be a safety issue due to the possibility of lead paint in buildings, although they did not believe the facility had lead paint. A nursing assistant stated the wallpaper had been damaged for a few months and that the resident had been pulling at it and removing pieces. The assistant said staff normally notify the nurse when repairs are needed so a maintenance request can be entered. An LPN stated they had not been told about the damage and were not aware the resident was pulling on the wallpaper, and the interim DON and regional nursing consultant stated resident rooms should not have peeling wallpaper. Review of maintenance work orders from 1/1/26 through 8/5/26 showed no maintenance requests were placed for wallpaper repair in the resident's room.
Unclean hallways and inconsistent room cleaning
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in 4 of 4 hallways reviewed for physical environment, including hallways 100, 200, 300, and 400. Observation showed a large brown stain on the carpet near the nurses station on 100 hall, multiple large dark stains on the carpet on 200 hall, dark brown spots on the floor in rooms on 200 hall, dark stains with hardened substance on the carpet on the back side of 200 hall, dark stains in front of the nurses station between 200 and 300 halls, a large dark grayish spot in a doorway, a strong odor of urine at the end of 300 hall, and food particles under a table and in the sink of the dining area on 400 hall. The observation also noted multiple items on the floor in a resident room, including pillows, socks, bags, shoes, towels, books, cups, wheelchair legs, and the call light, as well as breakfast trays left on bedside tables in two rooms. Resident interviews and record review showed concerns about routine cleaning. One resident reported orange juice had been spilled on the floor and wiped with a paper towel but not mopped, leaving a sticky residue. Other residents said their rooms were not cleaned routinely, with one stating the room had been cleaned only once in two weeks and another saying the room was not cleaned on a routine basis. A resident council minute noted a request for more frequent sweeping, and a grievance documented food spills remaining on the floor for several days before the room was cleaned. Staff interviews confirmed housekeeping could not always complete daily room cleaning, that each housekeeper had about 19 to 20 rooms per shift, that only two housekeepers were working at the time, and that dining rooms should be swept and mopped after meals.
Failure to Maintain Sewer Line and Sanitary Conditions
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary for a safe, functional, sanitary, and comfortable environment when the main sewer plumbing line backed up and raw sewage containing urine and feces entered resident rooms and corridors. Surveyors observed that the flooding extended through the second-floor hallway, with wet bath towels and bedsheets used to soak up wastewater, and that the sewage also leaked through the first-floor ceiling into an administrative office. Stained ceiling tiles were later observed in a resident room, and a resident reported that a prior clogged toilet had caused the damage about six months earlier. Residents 2, 6, and 7 reported that sewage water backed up through toilets and shower drains, flooding the hallway and their rooms, and that the building water supply was shut off for several hours after the incident. Resident 6 also reported another clog the following week. Maintenance staff stated the main sewer drain backed up because of corroded cast-iron piping and flushed wipes, and confirmed that sewage entered resident rooms and that residents in wheelchairs traveled through the contaminated water. The Administrator confirmed the sewer line backed up due to pipe separation and flushed wipes, that staff tried to divert traffic and kept unaffected residents in their rooms, and that no medical or clinical assessments were conducted on residents after exposure to the sewage and fumes.
Pest activity and unsanitary conditions observed in resident areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment when bugs, flies, and spiders were observed in and near resident rooms. Resident 4, who was admitted with cellulitis of the lower limb and had a BIMS score of 15, stated she saw a spider on her curtain and a fly in her room. Housekeeping staff reported occasionally seeing dead fruit flies on the windowsill and sometimes finding spiders in resident rooms. Resident 5, who had a BIMS score of 14, stated she occasionally saw flies inside the room during lunch and dinner. Family Member 1 reported that upon arrival at the facility there were roaches in the hallway, moldy walls, and chipped paint inside the resident room. During observation, a deceased roach-like insect was seen near the exit door by the kitchen leading to the garbage area, with two similar dead insects outside the door. The garbage compactor area had liquid waste leaking toward the drain, and old manual lifts and other unused equipment were stored nearby on wet, muddy ground. Two dumpsters containing empty boxes were present without covers. Resident 6, who had a BIMS score of 14, stated flies were seen in the room during mealtimes and that she kept a fly swatter because she did not like seeing flies while eating; Resident 7 stated roaches ran around their room at night, and a fly and a spider were observed during the interview.
Failure to Maintain Safe Common-Area Temperatures
Penalty
Summary
The facility failed to ensure an air conditioning system maintained comfortable temperatures below 81 degrees F in common areas, including the dining rooms, hallways, lobby, and kitchen. Facility temperature logs showed the dining room at 86 F on one date and 81 F on another. During surveyor observations, portable air conditioning units were seen venting into hallways, the dining room, the entrance lobby, and other areas, while staff reported that the built-in heating/air conditioning units were used for heat only and that window air conditioning units had been installed in resident rooms after the chiller went out last year. Surveyors measured common-area temperatures of 80 F to 87 F in the west dining room, front hallway, main dining room, and kitchen, with the kitchen reaching 86 F while outside temperatures were 87 F with a feels-like temperature of 107 F. The Administrator reported that the roof unit that cooled the kitchen and helped cool the dining room had gone out the prior week, that the chiller had gone out last year, and that quotes were being sought for mini split air conditioning units for common areas and hallways. A resident reported leaving bingo in the main dining room because it was too hot and humid and hard to breathe.
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