Failure to Address Leaking Ceiling in Dining Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not addressing a leaking ceiling in the dining area during a rainstorm. Observations revealed that water was dripping heavily from the seam between ceiling planks in a side room adjacent to the main dining area, with staff placing towels and a wet floor sign to manage the immediate hazard. The leak was visible to residents, who commented on it, and the area contained a hydration cart with supplies. Staff members indicated that they had previously complained about the leak, but no formal work order had been submitted in the electronic maintenance system. Interviews with various staff, including CNAs, housekeeping, maintenance, and nursing leadership, revealed confusion and inconsistency regarding the process for reporting maintenance issues. Some staff believed only certain individuals could enter work orders, while others stated that all staff had access to the electronic system. The maintenance director confirmed that no work orders had been received for the leak, and the DON was unaware of the issue until the survey interview. The previous maintenance supervisor had attempted temporary repairs, but the leak persisted during heavy rain. Review of facility policy confirmed the expectation for a safe and comfortable environment, but the lack of timely and effective communication and follow-up regarding the leak resulted in the deficiency. No residents were reported to have slipped or been directly harmed, but the leak was noticed by residents and affected their perception of the environment. The work order log showed no record of the issue being formally reported prior to the survey.