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F0921
D

Unsafe Dining Room Flooring Creates Tripping Hazards for Ambulatory Residents

Sandwich, Illinois Survey Completed on 04-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the dining room floor in a safe and functional condition for nine ambulatory residents. Observations revealed two visible seams running the length of the dining room laminate flooring, with random patches of a brown, sticky substance (identified as floor glue mixed with debris) and tiny nails along both sides of the seams. The laminate flooring was puckering at various points, causing the edges to lift from the surface and creating a tripping hazard. The surveyor confirmed that the puckered areas caught her foot, and the sticky substance posed an additional fall risk. Dining room tables were placed throughout the area, increasing the likelihood of residents encountering these hazards. Interviews with residents and staff confirmed ongoing issues with the floor. One resident reported witnessing another resident fall due to the floor condition and stated that her chair legs often got caught in the puckered areas. Another resident described tripping on the sticky floor while assisting another resident, attributing the incident to the glue applied to keep the floor down. The Maintenance Director acknowledged that the laminate was installed over existing vinyl against his advice, and that he had attempted to address the recurring seam issues by nailing or gluing them down. Staff also reported that the floor was poorly installed and that both residents and staff had experienced tripping or catching their feet on the seams. Facility records indicated that the floor had been problematic for at least a month, with multiple complaints from residents.

An unhandled error has occurred. Reload 🗙