Failure to Report and Repair Broken Wall in Resident Room
Penalty
Summary
Staff failed to report or repair a broken wall in a resident's room, resulting in an environment that was not safe, functional, sanitary, or comfortable. The broken wall, which included a hole, was observed during a facility visit. The resident stated that the hole had been present since moving into the room and had not been reported to staff. Review of facility work orders confirmed that the issue had not been documented or addressed by staff. Interviews with facility staff, including a CNA, the Maintenance Director, the DON, and the Administrator, revealed that none were aware of the broken wall prior to the survey. Staff indicated that maintenance issues are expected to be reported through the facility's Equipment Lifecycle System (TELS), but this process was not followed in this instance. The Maintenance Director noted the damage was likely caused by water and acknowledged the potential for mold and pest entry. The Administrator stated that quality of life rounds had not yet included the affected room and that maintenance rounds alone were insufficient to identify all issues.