Failure to Address Ceiling Damage and Suspected Mold in Secure Unit
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of five halls reviewed, specifically in the secure unit hallway. Observations revealed water stains and a black substance on the ceiling, which staff members identified as resulting from a previous air conditioning leak. The black substance was described by both the LVN and DON as appearing to be mold. The Maintenance Director acknowledged awareness of the water stains but stated he had not been notified about the black substance. He indicated that the air conditioning leak had been repaired weeks prior and was waiting for the ceiling to dry before proceeding with repairs, as required by facility policy to obtain three estimates before work could begin. Interviews with staff confirmed that the issue had persisted for some time, with the LVN and DON both expressing concern about the presence of the black substance and its potential to be mold. The DON and Maintenance Director both stated that the black substance could cause respiratory issues for residents and staff if it was indeed mold. The facility's Homelike Environment policy requires a clean, sanitary, and orderly environment, which was not met in this instance due to the unresolved ceiling damage and possible mold presence.