Failure to Restrict Access to Structurally Unsound Common Area
Penalty
Summary
The facility failed to ensure a safe environment for all residents by not restricting access to a structurally unsound area after being notified by a structural engineer. On 8/22/25, the facility received a report from a structural engineer indicating that the middle common area, including the nurses station, sitting area, and access to multiple hallways and the dining room, was not structurally sound. The engineer explicitly advised that the area below the compromised framing should remain unoccupied until all deficiencies were addressed. Despite this, the facility continued to allow residents, staff, and visitors to access and occupy the area. Observations and interviews revealed that the area remained accessible and in use by residents and staff for several days after the engineer's warning. Staff were present at the nurses station, and residents were observed sitting in the main common area watching television, even though this area had visible cracks and sagging in the ceiling. Multiple staff members, including CNAs, LPNs, and the MDS Coordinator, confirmed that the area was only roped off with caution tape days after the initial warning, and even then, the tape was inconsistently maintained, allowing continued access to the unsafe area. Communication failures contributed to the deficiency. The Administrator did not review the engineer's report or contractor recommendations until several days after they were received, and the regional project manager assumed the Administrator had taken appropriate action without confirming. The maintenance director and other staff were aware of the structural concerns but did not ensure the area was fully restricted. As a result, the facility did not act promptly to protect residents, staff, and visitors from the identified structural hazard, leading to a determination of immediate jeopardy.