Widespread Roof Leaks, Water Damage, and Resident Fall Due to Unsafe Environment
Penalty
Summary
The facility failed to maintain the roof and interior ceilings in a safe, functional, and sanitary condition, resulting in widespread leaks and water damage throughout resident care areas. Observations on multiple halls revealed discolored, brown, and black ceiling tiles, sagging tiles, bubbling and chipping wall surfaces, rusted light fixtures, and makeshift systems such as plastic tarps funneling water into buckets at the nurses’ station. The East wing medication room and spa areas showed signs of heavy moisture damage, and numerous ceiling tiles in various halls were dried out and stained, indicating ongoing and repeated water intrusion. One cognitively intact resident had lived in a room with a large orange ceiling stain near a light fixture, measuring approximately 17 by 22 inches, with raised areas suggesting buildup or deterioration. This resident reported that the ceiling had been leaking for over a year, causing the light fixture to stop working and requiring him to move his bed and eventually be transferred to another room. Facility records confirmed that he was moved from that room due to roof leaks, and resident council minutes documented resident concerns about leaks in rooms. Another resident, with chronic pain, depression, and moderate cognitive impairment, experienced a fall in his room after slipping on water that had leaked from the roof onto the floor. An incident report and staff interviews described the resident being found on the floor near his bed with water present on the floor, and the resident himself reported that the roof had been leaking into his room for quite some time. Multiple staff members, including CNAs and the former DON, reported that the roof had been leaking for months to over a year, that residents and their belongings were getting wet, that residents were frequently moved from leaking rooms, and that leaks extended into shower rooms where residents were being dripped on during showers.
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