F0921

E

Cracked, Uneven Doorway Transition Strips Create Mobility Hazards

Fresno, California Survey Completed on 02-13-2026

Penalty

No penalty information released

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.