Failure to Maintain Functional Elevators Limits Resident Access and Participation
Penalty
Summary
The facility failed to ensure a properly functioning elevator system to accommodate the needs and preferences of its residents, particularly those with mobility impairments. Multiple invoices and service records indicated ongoing issues with both elevators over several months, including repeated instances where elevators were unresponsive, stuck on various floors, or required significant repairs such as motor and valve replacements. Despite ongoing maintenance and service calls, one elevator remained out of service for an extended period, while the other exhibited operational issues, such as not returning to the first floor unless a specific button was pressed on the second floor. Staff and residents were required to implement workarounds, such as posting signs instructing users to send the elevator back to the first floor, but these measures did not resolve the underlying problems. Three residents were directly affected by the elevator deficiencies. One resident with morbid obesity and a large wheelchair was unable to fit into the smaller, functioning elevator, limiting his ability to participate in activities held on the second floor. Another resident with a motorized wheelchair also could not use the smaller elevator and reported feeling isolated due to being unable to go outside or access other areas. A third resident, who used a wheelchair due to paraplegia, expressed reluctance to use the malfunctioning elevator out of concern for being trapped. Interviews with staff confirmed that the elevator issues caused delays and required additional staff intervention, and that some staff were unaware of the full extent of the problems. Observations confirmed that the majority of facility activities were held on the second floor, with only a small fraction conducted on the first floor, further limiting access for residents unable to use the elevator. Documentation and interviews revealed that the elevator company and facility maintenance were aware of the ongoing issues, but communication gaps and delays in addressing the problems persisted. The elevator malfunction also led to at least one incident where the fire department was called for a possible entrapment, although no one was found to be trapped upon their arrival.