Failure to Maintain Sanitary Office Environment Due to Peeling Wallpaper and Suspected Mold
Penalty
Summary
A section of peeling wallpaper approximately 12 inches long was observed near the baseboard of the back wall in the Social Services Director's (SSD) office. When the wallpaper was pulled back, black areas resembling mold were visible on the drywall. The Director of Maintenance (DM) was aware of the peeling wallpaper but was not aware of the mold-like areas beneath it. During the survey, residents were seen stopping at the SSD office and speaking with the SSD, who kept her office door open. The SSD reported that she had notified the Administrator about the peeling wallpaper and her concerns regarding air quality in her office. She was offered the option to move to another office but did not relocate, as she did not receive confirmation that the air quality in the alternative office would be tested. The SSD also informed the Regional Director of Maintenance about her concerns. The Regional DM later acknowledged that he should have insisted on the SSD relocating so repairs could be made, but the SSD declined to move due to the amount of items in her office and her impending departure from the position.
Plan Of Correction
This plan of correction ("POC") has been prepared at the request of the Ohio Department of Health, and not because this facility agrees with and/or admits to any of the allegations contained within the notice of deficiency issued by the Department. This POC does not constitute an admission that any of the citations are legally and/or factually correct, to include the scope and severity associated thereto. For the avoidance of doubt, this facility asserts that it was in substantial compliance with all data tags cited by the Department before, during, and after the dates referenced in the notice of deficiency and the dates on which the Department conducted the survey. This POC does not establish any standard of care, contract, obligation, and/or position beyond those of a reasonably prudent nursing home, and this facility reserves the right to raise all possible contentions and defenses in any administrative, civil or criminal action or proceeding. Rolling Hills Rehabilitation and Care Center will continue to ensure employees have a clean and comfortable environment. This plan of correction serves as Rolling Hills Rehabilitation and Care Center's allegation of substantial compliance. Staff member #84 stated she had no adverse effects as a result of this deficiency, she currently does not have any signs/symptoms related to potential mold exposure. The areas of suspected mold were contained and undisturbed. Staff member #84 was immediately moved to a clean and comfortable environment on 06/05/2025 with assistance from facility maintenance and other members of the management team using proper PPE and disinfected all items that were possibly exposed using fungicide. An air quality test was performed on 06/05/2025 with no negative findings. On 06/05/2025 the office was sealed off, locked, and placed under construction. On 06/06/2025 the areas of concern were treated twice with mold armor. On 06/12/2025 another air quality test was performed with no negative findings, and the office was reopened and used for operation as of 06/16/2025. The facility followed all CDC recommendations for all potential mold remediation. A whole facility baseline audit was completed to ensure a clean and comfortable environment by the facility Administrator on 06/12/2025. There were no negative findings identified through this audit. All residents located on the unit in proximity to the social services office were assessed along with a review of their EHR by the Director of Nursing on 06/12/2025 to ensure there was no negative impact, with no negative findings. The Director of Nursing reviewed the infection control log on 06/13/2025 for signs/symptoms of respiratory concerns in the last 30 days related to potential mold exposure, with no negative findings. Interviews were initiated on 06/06/2025 and completed on 06/13/2025 with all interview-able residents by the facility Administrator and designee, to ensure no current concerns with potential mold. There were no negative findings identified. An audit of the grievance/concern log was completed over the past 90 days with no concerns from family, visitors, or staff of suspected mold in the facility. We have not received any reports by staff and/or visitors of adverse effects as a result of this deficient practice. Verbal education on the facility's best practice for reporting environmental concerns was completed on 06/10/2025 for all facility staff by the facility Administrator. A facility walkthrough will be completed weekly for four weeks by the facility administrator/designee, starting on or by the week of 06/13/2025. Results will be brought to the Quality Assurance Committee for further review and recommendations. Facility administrator will be responsible for overall compliance with this plan.