Failure to Maintain Safe and Well-Maintained Resident Rooms and Hallways
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in multiple resident rooms and hallways. One resident’s bathroom contained two ceiling tiles with a brown substance covering about one-quarter of each tile and one tile sagging from the ceiling. In the same room, the wall across from the bed had blue construction tape over ripped wallpaper extending from the floor to about four feet up, and a three-foot by six-inch section of wall had loose floor trim pulled away, with crushed or missing drywall exposing insulation and wood studs. Ceiling tiles in two separate hallways were also observed with brown substances and damage: one hallway tile was more than half covered in a brown substance and cracked down the center, and two tiles on another hallway were more than half covered in a brown substance down the center. In another room shared by two residents, one wall’s baseboard trim was partially detached, with approximately two feet of trim pulled away and lying on the floor in the center aisle between the foot of both beds and the wall, in the path used by staff and residents to access beds and supplies. The affected residents included individuals with severe cognitive impairment and high fall risk. One resident’s MDS documented Alzheimer’s dementia, severe cognitive impairment, use of a manual wheelchair, and dependence for care, with a care plan identifying high fall risk. Another resident’s MDS documented non-Alzheimer’s dementia, severe cognitive impairment, wheelchair use, and dependence for care, also with a care plan identifying high fall risk. A cognitively intact resident in a room with damaged wall and prior leak-related work reported that the wall on their side had not been fixed and expressed a desire for repair so they would not get sick. Facility staff interviews revealed that a project manager acknowledged a prior roof leak requiring drywall and baseboard replacement in one room due to mold and stated another resident room needed similar work. The maintenance assistant described a roof line leak from an air/heat unit above two rooms that caused damage to walls, trim, and ceiling tiles, confirmed that one resident’s room still needed wall/trim/ceiling tile repairs, and admitted unawareness of the detached trim in the shared room and the damaged ceiling tiles in the hallways, despite the job description for the Maintenance Director requiring ensuring all aspects of the facility are in a good state of repair.
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