Failure to Maintain Clean and Safe Environment Due to Unaddressed Mold and Water Damage
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by multiple air vents with black colored substances or rust-like staining, water-stained ceiling tiles, and sink cabinets with offensive odors and visible mold-like substances. During a facility tour, surveyors observed these conditions throughout the therapy area, Reflection Hallway, and various therapy offices. The therapy gym, occupational therapy area, speech therapy office, and physical therapy charting room all had vents with black or rust-like stains, and the cabinet beneath the handwashing sink in the therapy area emitted a strong musty, moldy odor with visible black substances and water stains. Water damage was also noted on the ceiling in the Reflection Hallway and around the sprinkler head in the Speech Therapy office. Interviews with residents and staff confirmed awareness of the environmental issues. A resident receiving therapy commented on the need for vent cleaning, while therapy staff reported experiencing multiple respiratory illnesses in recent months, attributing these to environmental factors such as musty and moldy smells, especially when the air conditioner was off. Staff also noted the presence of black substances on vents in the therapy gym and smaller rooms. The Rehab Director acknowledged the black substances and reported them through the facility's maintenance system, but was unaware of staff respiratory issues. The Maintenance Director stated that a new roof installation was underway, causing debris and dust, and that while housekeeping dusted vents, maintenance was responsible for deeper cleaning. However, no testing had been conducted on the black substances, and routine vent checks were documented as completed, despite the observed deficiencies. Review of maintenance logs revealed previous work orders addressing similar issues, such as suspected mold and termite pellets under the PT gym sink and requests to address black spots and stains around duct areas. Despite documentation that these work orders were completed, the conditions persisted at the time of the survey. The maintenance log lacked details on what actions were taken, and the observed deficiencies remained unresolved, indicating a failure to ensure a safe and clean environment as required.