Therapy Gym Lacked Adequate and Maintained Equipment
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
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.
Staff failed to consistently provide essential supplies such as urinals, gloves, and cup tops for two residents with incontinence and chronic medical conditions. Multiple staff interviews and supply closet observations confirmed recurring shortages, with staff sometimes needing to retrieve supplies from other rooms or provide bottled water due to missing cup lids. The central supply process did not prevent these shortages, and no supply management policy was provided.
The facility failed to properly store five wheelchairs and one geriatric chair, leaving them outside in the rain, which could damage the equipment and prevent safe use. The DOR noted difficulties in maintaining wheelchairs, and a custom wheelchair for a resident was unusable due to being wet. The Maintenance Supervisor confirmed a lack of covered storage space, and the DON stated that medical equipment should not be stored outside.
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.
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.
Failure to Provide Adequate Supplies for Resident Care
Penalty
Summary
Facility staff failed to provide necessary supplies, including urinals, gloves, and cup tops, for two residents with significant medical needs. One resident, admitted with Parkinson's Disease, convulsions, and chronic kidney disease, was assessed as moderately cognitively impaired and required substantial assistance with toileting due to frequent incontinence. Observations of supply closets revealed inconsistent availability of urinals and gloves, with periods where these items were missing or in short supply. Staff interviews confirmed recurring shortages of essential supplies such as urinals, gloves, adult briefs, towels, washcloths, and sheets, with staff sometimes needing to retrieve gloves from other resident rooms or carry them in their pockets due to lack of availability. Another resident, also moderately cognitively impaired and diagnosed with hereditary and idiopathic neuropathy, arthritis, and chronic kidney disease, required peri-area cleaning with each incontinence episode. This resident reported that their size of briefs was not always available. Staff interviews across multiple shifts consistently indicated shortages of gloves, urinals, and other personal care items, with some staff noting that these shortages persisted over weekends and during night shifts. Additionally, staff reported having to provide residents with bottled water due to the absence of lids for water cups. The central supply supervisor, who had recently assumed the role, described the supply ordering and stocking process, noting that orders are typically placed weekly and that rush orders can be made if items run out. However, the process did not prevent periods of supply shortages, especially when the supervisor was not present. No facility policy regarding supply management was provided, and administrative staff were made aware of the findings during the survey.
Improper Storage of Wheelchairs and Geriatric Chair
Penalty
Summary
The facility failed to ensure that five wheelchairs and one geriatric chair were stored properly, as they were found outside under the rain. This practice had the potential to damage the medical equipment and prevent their safe use for residents. During an interview, the Director of Rehabilitation (DOR) mentioned difficulties in maintaining and keeping track of wheelchairs, as they often get lost. The DOR also noted that a wheelchair prepared for a resident was stored outside in the rain, rendering it unusable for the day due to its wet condition. The resident required a custom wheelchair, and no alternative was available. Further observations revealed that four wheelchairs and one geriatric chair were left in an outdoor area exposed to the elements. The Maintenance Supervisor acknowledged that the covered shed was full and primarily used for activity equipment, leaving no covered storage space for the medical equipment. The Director of Nursing confirmed that wheelchairs and other medical equipment should not be stored outside in uncovered areas. Additionally, the Medical Records Supervisor stated that the facility lacked a policy regarding the storage of medical equipment.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25 the Maintenance Director and Maintenance Assistant removed all wheelchairs and geriatric chairs from the patio. On 3/5/25, the facility began storing all wheelchairs and geriatric chairs inside the facility in the newly designated area. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/5/25, the Administrator and Maintenance Director made visual rounds on the outdoor areas of the facility to ensure medical equipment is not being stored in uncovered areas. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/27/25, The Director of Staff Development in-serviced Vocational Nurses (LVN), and Certified Nursing Assistants (CNA), along with the Maintenance Department and Housekeeping Department were in-serviced on having and maintaining proper covered storage for resident equipment. The Maintenance Director/designee will conduct rounds on the facility outside areas daily for 5 days weekly for 2 weeks and monthly thereafter to ensure resident equipment is not being stored in non-covered areas. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for proper storage of resident equipment for three months or until compliance is met.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
