Cracked, Uneven Doorway Transition Strips Create Mobility Hazards
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple transition strips between resident rooms and the hallway were cracked, uneven, and in at least one case higher than the ADA standard. Observations showed that the transition strip at one room entrance was approximately 0.5 inches high and made of wood, exceeding the 0.25-inch maximum vertical change allowed by ADA standards, while other strips were cracked and uneven. The Director of Maintenance confirmed that the transition strips to rooms 1, 2, 3, 4, 5, 6, 9, 10, 12, 14, 15, 16, 17, 18, 19, 20, and 21 were high, uneven, cracked, and could be difficult for residents to pass safely. The facility’s own policies required the environment to be free from accident hazards and the building to be maintained in good repair and free from hazards, but these conditions persisted. One resident reported a fall that occurred approximately one month prior while attempting to exit his room in a wheelchair. This resident, who had diagnoses including Hepatitis C, Coccidioidomycosis, and muscle weakness and a BIMS score of 15, stated he could not push his wheelchair over the “lip” at the doorway. He described turning and attempting to stand to push the wheelchair backward over the transition strip, at which point the wheelchair moved and he lost his balance, falling onto his bottom and injuring his back. He indicated that he routinely propelled himself backward in the wheelchair to get over the transition strip because the larger back wheels made it easier to cross the uneven surface, and he pointed out that the strip at his doorway was cracked and uneven. Other residents and staff corroborated that the transition strips created difficulty and potential for loss of control when moving in and out of rooms. One resident with COPD, hypertensive heart disease, dorsalgia, dementia, and a BIMS score of 11 stated that the transition strip at his room made it difficult to enter and exit and sometimes caused his wheelchair to spin or turn as he crossed it. Another resident, who used a wheelchair for seven years due to fibromyalgia and had diagnoses including sepsis, type 2 diabetes, cellulitis, and hypertensive heart disease, stated that while she could manage the strip herself, she had observed other residents going backward in their wheelchairs to cross the strips, which she believed could cause a fall, and noted that shuffling residents could trip on cracked, uneven strips. A fourth resident, with diagnoses including lumbar discitis, sepsis, type 2 diabetes, and a cutaneous abscess of the back and a BIMS score of 13, reported being unable to get past the transition strip at her doorway with a walker or wheelchair and having to call staff for assistance. Staff interviews further described the impact of the defective transition strips on resident mobility and safety. A CNA stated that pushing residents in wheelchairs over the bumpy transition strips was difficult and that some strips were more cracked and uneven than others and could cause a fall. Another CNA reported that the strips made it difficult to push residents in both wheelchairs and shower chairs, noting that the small, hard wheels of shower chairs made crossing the strips more difficult and that going backward in a wheelchair could cause it to tilt backward. This CNA also stated that the uneven strips could cause a fall when moving forward in a wheelchair or shower chair and that assisting heavier residents over the strips was more difficult and carried a higher risk of falling. The Director of Staff Development, after observing the strips to the identified rooms, stated that they were cracked and uneven, could be a fall hazard, and that the strips should be flat, smooth, and even so residents and staff could pass without difficulty. Despite these observations and statements, the Administrator asserted that the transition strips were not hazardous and attributed the reported fall to the resident’s choice to go backward in his wheelchair, while also acknowledging that the facility should provide a safe, functional, sanitary, and comfortable environment. The facility’s written policies on Safety and Supervision of Residents and Maintenance Service required ongoing identification of safety risks and environmental hazards, QAPI review of safety and incident data, and maintenance of the building in good repair and free from hazards. The ADA standards referenced in the report required floor surfaces to be stable, firm, slip resistant, and limited vertical changes in level to a maximum of 1/4 inch. The presence of cracked, uneven, and in at least one case over-height transition strips at multiple room entrances, combined with resident and staff reports of difficulty, loss of control, and a documented fall associated with these strips, demonstrate that the facility did not adhere to these standards and policies in maintaining the environment.
Penalty
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An open floor drain near the dish machine was observed without a grate, and the FSM confirmed it had no grate and was unsure how long it had been open. In the Hair Salon, the sink drain filter had a glob of hair, and 3 brushes plus a box of hair curlers had hair on them; the AD and HS both confirmed the unsanitary conditions, and the HS stated she might have forgotten to clean the salon after the beautician visit.
A resident room was observed in disrepair with unpainted wall areas, black marks, discoloration, ceiling staining, and scuffed, missing paint on the door frame, and the same conditions remained on follow-up. The memory care dining room floor also had food crumbs and debris under multiple tables; an LPN said it appeared not to have been cleaned after the prior night's meal, and the administrator confirmed the food was still present.
Leaking and Loose Faucets in Facility Sinks: During a facility tour, a beauty shop style sink was observed leaking where the faucet connected to the sink, and maintenance staff stated they were not aware it needed repair. A sink in the soiled linens room on D/F Hall was also observed with a loose swivel faucet that leaked when turned on, and maintenance staff confirmed the observation.
Sharps containers on a locked dementia unit were observed full to the point that they could not be opened, including one in a shower room with three uncapped used disposable razors sitting on top of it and another on a medication cart. The DON and an LPN confirmed the containers were unusable, and the LPN noted two residents on the unit required routine blood glucose monitoring with lancets that would need disposal in a sharps container.
Resident room walls were observed with moisture, black/gray staining resembling mildew or mold-like substance, bubbling paint, cracks, gouges, and dirty vents in multiple rooms, including B-2, B-4, B-6, B-8, B-10, and B-12. The Tel's record review showed no reports about the wall conditions for the past 6 months, and the ADM stated the moisture had been present for a while and had not previously been brought to the ADM and Maintenance Director's attention.
A resident with moderate cognitive impairment and anticoagulant use had a bedside table within reach that was observed to be broken, with an unfinished edge, exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed the table was in poor repair and accessible to the resident.
Unsanitary Hair Salon and Open Kitchen Drain
Penalty
Summary
The kitchen floor drain near the dish machine was observed on 6/09/2026 at 8:08 AM without a grate. The FSM confirmed the drain was open and stated she was not sure how long it had been without a grate. She also stated the facility had no pests and that they were waiting for the Maintenance Supervisor to start working at the facility so she could let him know about it. Later that day, the FSM stated she had told the prior Maintenance Supervisor about it a week or 2 weeks earlier, and that the new Maintenance Supervisor had started on 6/8/2026 after the former supervisor left on 6/5/2026. In the Hair Salon on 6/11/2026 at 11:07 AM, the sink drain filter contained a glob of hair, and 3 brushes in a cabinet had hair on them, along with a box of hair curlers with hair on them. The Activity Director confirmed these observations and stated Housekeeping was responsible for cleaning the Hair Salon sink. The Activity Director also stated the beautician had visited on 6/9/2026. The Housekeeping Supervisor confirmed the hair in the sink drain filter and stated she might have forgotten to clean the Hair Salon after the beautician visited that week.
Dirty resident room and unclean memory care dining room
Penalty
Summary
The facility failed to maintain a resident room in a clean, sanitary, and orderly condition for one resident, R5. During observations, R5 was lying in bed while the room showed multiple areas of disrepair: a section of wall below the mounted TV was not painted the same color as the rest of the wall, the wall across from the bed had multiple black marks and light brown discoloration, the ceiling above the window had a yellowish discolored area about the size of a basketball extending along the ceiling/wall, and the door frame had multiple scuff marks and missing paint. These same conditions were still present on follow-up observation, and R5's family member stated they had concerns about the environment, describing the facility as not clean, smelling bad, and reporting concerns about the room's smell, missing paint, and ceiling to staff. The facility also failed to keep the memory care dining room floor in a clean and sanitary condition. During observation, the floor under multiple dining tables had light-colored crumbs, brown crumbs, pieces of a white meat-like substance, and spaghetti noodles. An LPN stated it looked like the floors had not been cleaned after the prior night's meal and said housekeeping was supposed to clean the floors after meals were served. The administrator confirmed the food under the tables and stated any staff member who observed it should help clean it up, not just housekeeping. The maintenance policy stated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Leaking and Loose Faucets in Facility Sinks
Penalty
Summary
The facility failed to maintain plumbing in the building, as observed during a facility tour with maintenance employee C. On 05/27/2026 at 9:45 AM, the beauty shop style sink with a head rest and hair rinse hose was observed leaking where the faucet connects to the sink, and maintenance employee C also observed the faucet leaking and stated they were not aware it needed repair. Later, on 05/27/2026 at 10:16 AM, the sink in the soiled linens room in the D/F Hall was observed with a swivel faucet that was loose and leaking when the sink was turned on, and maintenance employee C confirmed this observation during interview at the time.
Sharps Containers Left Full and Unusable
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for residents by not maintaining sharps containers in a safe manner in two of four observed sharps containers. Record review of the facility’s Sharps Container Policy showed that the facility would use sharps containers for disposal of sharp items, including lancets, and that containers were to be sealed with tape and dated when disposed of, but the policy did not address when or how often the containers should be emptied. During observation, the sharps container in the shower room on the locked dementia unit was full to the point that it could not be opened, and three uncapped used aqua-blue disposable razors were sitting on top of the container. The DON confirmed the container should have been properly disposed of and replaced with a new one and stated the razors on top of the container could pose a potential safety hazard to residents. A second observation showed the sharps container on the medication cart for the locked dementia unit was also full to the point that it could not be opened. An LPN stated the unit had two residents who required routine blood glucose monitoring and that lancets used for blood glucose checks would need to be disposed of in a sharps container, but the container on the medication cart was not usable because it could no longer be opened. The Administrator stated she expected staff to provide for resident safety in the shower room and anywhere sharps containers were located, and confirmed that leaving uncapped or unsheathed disposable razors on top of the sharps container in the shower room could pose a safety hazard for residents.
Resident Room Walls Found Moist, Stained, and Damaged
Penalty
Summary
Resident room walls were not kept free from moisture, black/gray staining, gouges, bubbling paint, and dirt in multiple rooms. On 5/27/26 at 11:00 AM, an observation found room B-2 with dirty vents and a small gouge in the drywall; room B-4 with an outside wall that was moist and had a grayish stain about 1 foot by 1 foot resembling mildew or a mold-like substance; room B-6 with a moist outside wall, a black/gray substance resembling mildew, and several bubbles and cracks in the paint; room B-8 with an outside wall that felt moist to touch and had a blackish/gray substance about 2 feet by 2 feet resembling mildew or a mold-like substance; room B-10 with streaks and stains going down the outside wall; and room B-12 with cracks in the drywall, streaks down the wall, and bubbling paint. A record review of the Tel's program showed no report regarding the resident walls for the past 6 months. During an environmental tour on 5/28/2026 at 1:00 PM with the Administrator and Maintenance Director, the same wall conditions were confirmed in rooms B-2, B-4, B-6, B-8, B-10, and B-12. In an interview at that time, the Administrator stated the moisture on the walls in the resident rooms had been there for a while and should have been reported by staff who see the wall daily, and also stated this was the first time the walls had been brought to the Administrator and Maintenance Director's attention.
Broken Bedside Table Within Resident Reach
Penalty
Summary
The facility failed to ensure that a bedside table was in good repair for Resident #59, who was admitted with diagnoses including cerebral infarction, schizophrenia, and acute embolism. The resident’s MDS assessment showed moderate cognitive impairment, no upper body impairment, and anticoagulant use, and the care plan identified risk for bleeding related to anticoagulant medications. During observation, the resident’s bedside table was within reach and was found to have an unfinished, broken edge with approximately three inches of exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed that the bedside table was broken with rough, exposed particle board and wood chips and was within reach of the resident.
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