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F0921
G

Ceiling Collapse Causes Physical and Psychosocial Harm Due to Environmental Failure

Denton, Maryland Survey Completed on 09-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe and functional environment, resulting in both physical and psychosocial harm to a resident. On the date of the incident, a pipe burst in the attic above a resident's room due to inadequate temperature control and lack of pipe insulation, causing the ceiling to collapse onto the resident. The resident, who has quadriplegia and fully intact cognitive function, was unable to move independently and was covered in water, insulation, and drywall until staff arrived several minutes later to remove them from the room. Medical records indicate that the resident was sent to the emergency room, where they were evaluated for injuries and subsequently diagnosed with cervical spine and lumbar strain, leading to ongoing pain management with various medications, including Oxycodone and later Suboxone. The resident continued to experience significant lower back pain, which was later associated with a mild disc bulge found on MRI. The incident also exacerbated the resident's pre-existing PTSD, as documented in psychological and psychiatric evaluations, with the resident expressing ongoing fear and trauma related to the event. Interviews with staff confirmed that the ceiling collapse was sudden and involved a large section of drywall, insulation, and water falling directly onto the resident. Staff described the resident as visibly upset and shaken after the incident. The resident later requested counseling and physical therapy services from providers not affiliated with the facility, citing feelings of unsafety and worsened PTSD symptoms following the event. The deficiency was directly linked to the facility's failure to maintain appropriate environmental controls to prevent pipe freezing and rupture.

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