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
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe and unsanitary resident rooms were observed with clutter, uncovered food, and rodent activity. A resident with schizophrenia and depression had food crumbs and meat under the bed, while another resident reported mouse droppings and hoarded food in a crowded room. Other rooms had overflowing bins, bags of belongings, and uncovered food, and staff reported that some residents refused housekeeping access and that pest control service in resident rooms was inconsistent.
Strong urine odor in Hallway B. Surveyors repeatedly observed a noticeable urine smell at the beginning of and down Hallway B, including near the entrance where multiple residents were sitting in the hall. CNA 1 and CNA 2 both confirmed the odor, and the DON acknowledged the facility was aware of the strong smell at the entrance of Hallway B and cited the facility policy that residents have the right to a clean and comfortable environment.
Multiple rooms on one unit were found with environmental deficiencies, including broken and unsecured electrical outlets, damaged and stained walls and ceilings, improvised extensions on light cords using a plastic bag and a washcloth, dripping and constantly running sink faucets with discolored grout, and a strong urine odor in one room. A review of work orders and an interview with the Facilities Director showed that only two work orders had been submitted for this unit, both generated after surveyor observations, indicating that unit staff had not routinely initiated maintenance requests for these conditions.
The facility did not maintain a safe, comfortable, and homelike environment, as evidenced by two residents with dementia and other comorbidities living in rooms with multiple wall holes, chipped drywall, missing paint, and water-stained ceilings, and by extensive uneven flooring in two main halls. Observations showed numerous divots, chipped areas around drainage covers, and partially filled floor defects near the nurses' station and along the East and South halls. A resident reported wheelchairs becoming stuck in these floor ruts, and maintenance staff confirmed both the room damage and the lack of flush flooring around drains, as well as the absence of a current repair plan.
A clogged floor drain sink in a janitor room led to black, dirty water accumulating in the drain and overflowing into a hallway. A housekeeper reported that the drain, used for disposing of mop water and cleaning chemicals, had been clogged for some time and that she had informed her supervisor. The housekeeping supervisor stated she had submitted several work orders and that housekeeping staff had been attempting to unclog the drain themselves for months, while the maintenance director reported having no active work orders for the issue and indicated that such black water can carry harmful microorganisms. The administrator stated he expects staff to submit work orders and report issues promptly.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
Unsafe and unsanitary resident rooms with clutter, uncovered food, and rodent activity
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment for 7 of 7 residents reviewed for environment. Multiple resident rooms were observed with clutter, food, and signs of rodent activity, while several rooms were not being routinely checked or serviced for pest control. The report also identified a missing light cover over one resident’s bed and a garage used for resident belongings that was filled with stored items and had no pest control in place. One resident with schizophrenia, depression, and moderate cognitive impairment had a care plan that addressed her belief that mice were her friends and directed staff to discourage food in her room. During observation, a large amount of black crumbs and two patties of what appeared to be meat were found under the bed. The infection preventionist stated staff were supposed to look for food in the room on every shift and housekeeping was supposed to clean the room twice a day. The maintenance director confirmed that bait stations in resident rooms were not serviced during one month reviewed, and the room service records showed the room was not checked during several months and had light rodent activity when it was checked. Another resident with delusional disorder and intact cognition reported finding mouse droppings on the bed and said the roommate hoarded food and garbage. The room contained stacked bins, bedside stands, an overbed table with a coffee maker and wrapped fruit tray, and a shopping bag of personal items. The maintenance director stated he had seen mouse droppings in the room and that pest control traps were present, but the room service records showed no rodent bait stations in that room. Additional residents with diagnoses including paranoid schizophrenia, PTSD, depression, bipolar depression, and homelessness had rooms observed with overflowing bins, bags of belongings, uncovered food on a plate, and crowded storage throughout the room. Several care plans did not address clutter or overcrowding, and staff stated some residents would not allow housekeeping to clean their rooms.
Strong urine odor in Hallway B
Penalty
Summary
The facility failed to provide a safe and sanitary environment in Hallway B, where a strong urine odor was repeatedly observed during the survey. On 4/27/26, 4/28/26, 4/29/26, 4/30/26, and 5/1/26, surveyors noted a strong urine smell at the beginning of or down Hallway B, including at the entrance where multiple residents were observed sitting in the hall. During interviews, CNA 1 and CNA 2 both acknowledged a noticeable urine odor in Hallway B, and the DON stated the facility was aware of a strong odor at the entrance of Hallway B and confirmed the facility policy that all residents have the right to a clean and comfortable environment.
Failure to Maintain Homelike and Well-Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Pensacola 1 unit, as evidenced by multiple environmental deficiencies observed in six resident rooms. In one room, a wall clock was broken with a large piece missing and several white patches were visible on the wall. Another room had multiple large brown marks of unknown substance on the wall that were immediately visible upon entry. A separate room had a loud, constant buzzing noise whenever the bathroom light was turned on. Additional observations included several visible water marks on a ceiling, a broken electrical plug plate, and a heavily damaged wall behind a bed. Other rooms showed further environmental issues, including a wall light over a bed that had a cord extended with a plastic bag so the resident could reach it, and an electrical outlet at the head-of-bed wall that was not secure and was visibly coming out of the wall. One room had a dripping sink faucet and very discolored grout around the sink, while another had a strong smell of urine. Yet another room had a sink faucet that was constantly running, and one bed area had a washcloth attached to the light cord to extend its reach and six large screws or hooks in the wall. Interview with the Facilities Director revealed that unit staff were expected to complete work orders for needed repairs, but only two open work orders existed for this unit, both related to issues reported during the survey, indicating that routine work orders had not been submitted by unit staff for the observed problems.
Failure to Maintain Resident Rooms and Hallway Flooring in Safe, Homelike Condition
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment by not maintaining resident rooms in good repair and by allowing uneven flooring in two hallways. One resident with atrial fibrillation and dementia was observed in a room with at least seven holes in the wall over the bed, scattered areas of missing paint on the same wall, and a large area of chipped drywall and missing paint extending approximately 36 inches up from the baseboard next to the bed. Another resident with dementia and a history of stroke was observed in a room with multiple areas of missing paint on the walls by the window and on the east wall, as well as large water stains on the ceiling above the sink. The Maintenance Supervisor confirmed the presence of the holes, missing paint, and water stains in these rooms and acknowledged there were many similar issues and no current plan for repairs or painting. The facility also failed to maintain safe, even flooring in the East and South hallways. Multiple divots were observed throughout these hallways, with drainage covers that were discolored and surrounded by chipped and cracked flooring, creating uneven divots. Additional chipped flooring divots, some partially filled with shellac, were seen near the nurses' station and in both the East and South hallways. A resident reported having seen wheelchairs get stuck in these ruts and unable to move through the hallways. The Maintenance Director confirmed that the flooring was not flush with the drainage covers and that multiple divots were present throughout the East and South hallways.
Clogged Janitor Room Floor Drain and Black Water Overflow
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment for all 89 residents when a janitor room floor drain sink on one unit remained clogged and inoperable. During observation of the 400 Unit, water was seen coming from the janitor room into the hallway, and when the door was opened, the floor drain was observed to be filled with approximately 10 inches of black, dirty water. A housekeeper reported that she had spilled water in the hall while dumping her mop bucket into the floor drain sink and had mopped it up, and she confirmed that the drain was clogged and that this sink was used to dispose of cleaning chemicals from mop buckets. The housekeeper stated she had informed her supervisor about the clogged drain, but it had not been fixed and that it had been this way for “a while.” The housekeeping supervisor reported she had made several work orders regarding the janitor room and water overflow and that she and her staff had been unclogging the drain themselves for months. The maintenance director stated that housekeeping is responsible for their department and should notify him if anything is needed, that he had no active work orders regarding water overflow, and that housekeeping should have submitted a work order for the janitor room. He also stated that the black water could carry bacteria, mold, E. coli, salmonella, and possibly Legionella. The administrator stated he expects staff to place work orders and report issues immediately so they can be addressed right away.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.