Failure to Repair Cracked Floor Creates Safety Hazard
Summary
The facility failed to maintain the flooring in a safe and good repair, as evidenced by the presence of a cracked floor in the hallway from the entrance to nurse station 1, in front of the rehab service room and patio. Multiple residents, including those with mobility impairments and fall risks, were observed traversing this area. The cracked floor was directly observed by surveyors, and residents as well as staff acknowledged its unsafe condition, noting the potential for falls. Resident records reviewed showed that affected individuals had significant medical histories, including diabetes, COPD, osteoarthritis, cerebral infarction, hypertension, paraplegia, and rheumatoid arthritis. These residents required varying levels of assistance with mobility and activities of daily living, and their care plans specifically called for a safe, clutter-free environment to prevent falls. Despite these documented needs, the cracked floor remained unaddressed. Interviews with residents, a Licensed Vocational Nurse, the Maintenance Director, and the administrator confirmed that the cracked floor had not been reported or repaired. The Maintenance Log contained no entries regarding the issue, and no warning signs had been placed to alert residents or staff. The facility's own maintenance policy required regular upkeep of flooring to prevent injuries, but this was not followed in this instance.
Plan Of Correction
General Maintenance How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 10/09/25, the Maintenance Supervisor (MS) repaired the crack on the hallway floor near Station 1 and the Rehabilitation Room to eliminate any potential safety hazard for residents. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 10/21/25, the Safety Committee conducted a comprehensive walk through of the facility to identify any additional cracks or floor hazards throughout all resident and common areas. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/21/25 and 10/22/25, the Director of Staff Development (DSD) and Maintenance Supervisor (MS) provided in-service training to all staff regarding the use and importance of the Maintenance Log for timely reporting and follow-up on facility repairs. - Beginning 10/22/25, the Maintenance Supervisor will conduct floor inspections 2-3 times per week for three months to monitor for cracks or hazards and ensure prompt corrective action is taken as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Maintenance Supervisor (MS) will be reporting the results of the monitoring to the QA committee and safety committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Penalty
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