Health inspection·February 16, 2022

F921 §483.90(i) Other Environmental Conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. § 72637 General Maintenance. (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition, and in good repair at all times to ensure safety and well-being of patients, staff, and visitors. (b) Buildings and grounds shall be free of environmental pollutants and such nuisances as may adversely affect the health or welfare of patients to the extent (c) All buildings, fixtures, equipment and spaces shall be maintained in operable condition. The facility failed to provide a safe and sanitary environment for the facility residents, staff, and visitors by not maintaining the roof in good repair. As a result, the facility had roof leaks of rainwater from the ceilings at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, Main entrance lobby, Activity Room, and Resident Room 3146. The leaking roof had the potential to cause serious harm, injury, or death to residents, staff, and visitors. On December 14, 2021, from 4:00 p.m. to 6:00 p.m., during a general observation tour of the Sub Acute building, in the presence of the Sub Acute Nurse Manager and Accreditation Coordinator and Quality Manager, the following were observed: 1. Rainwater leaking from the ceilings at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, Main entrance lobby, and Activity Room. 2. There was rainwater leaking from the sprinkler head and ceiling in Resident Room 3146, previously occupied by 2 residents bfore the leak had happened. No residents were present in the room during the time of the observation. There were wet towels on the floor absorbing the rainwater and trash cans collecting the rainwater. 3. There were multiple small white buckets, mop buckets, small black plastic trash cans, large plastic trash can with wheels, and large commercial trash carts filled with rainwater leaking from the ceiling at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, and Activity Room. 4. There were multiple wet towels brownish gold in color absorbing the rainwater on the floor at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, Main entrance lobby, and Activity Room. 5. There were plastic tarps attached to the ceilings to catch the rainwater and large commercial trash carts and large trash cans with wheels under the tarps collecting the rainwater at the Nursing Station, North Corridor, South Corridor, East Corridor, and West Corridor. 6. There was plastic material covering equipment to prevent water damage from the exposed ceiling in the Minimum Data Set (MDS) Coordinator Room. 7. There was exposed insulation material, sprinkler piping systems, heating and ventilation ducts, wiring, and loosely hanging debris in the ceiling areas above the Nursing Station, North Corridor, South Corridor, East Corridor, and West Corridor. 8. There was ceiling tile debris inside large commercial trash carts located in the South and East corridors. 9. There were water-stained ceiling tiles in the Main entrance lobby and Activity Room. 10. There was plastic covering the cubicle walls and desk counter area from water leaking from the ceiling at the Nursing Station. On December 14, 2021 at 4:10 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), stated she observed water leaking in the corridors and at the Nursing Station when she arrived to work at 7:00 a.m., on December 14, 2021. LVN 1 also stated the building had problems for a couple of years of rainwater leaking from the ceiling due to rain. On December 14, 2021 at 4:15 p.m., during an interview, a Sub Acute Registered Nurse 1 (RN 1) stated the building had problems with rainwater leaking from the ceiling due to rain in past years. RN 1 also stated she was conducting rounds in resident rooms to monitor for any water leaks. RN 1 further stated there were no documented evidence of the rounds in resident rooms for water leaks. On December 14, 2021 at 4:30 p.m., during an interview, the Sub Acute Nurse Manager stated two residents s in Room 3146, Beds 1 and 2 of the South Wing were transferred to Room 3122 in the East Wing due to rainwater leaking from the ceiling in Room 3146. The Sub Acute Nurse Manager also stated historically rainwater leaks in other resident rooms in the South Wing other than in Resident Room 3146. The Sub Acute Nurse Manager further stated the building in general has a history of rainwater leaking from the ceiling in past years due to rain and that this the worse she has seen the rainwater leaking from the ceiling in the building. The Sub Acute Nurse Manager also stated nursing staff are conducting hourly rounds in resident rooms to look for any water leaks. The Sub Acute Nurse Manager further stated she could not provide any documented evidence that nursing staff was conducting hourly rounds in resident rooms to monitor for rainwater leaks. The Sub Acute Nurse Manager also stated the Activity Room was a designated room for visitation by family members and friends, but visits in the Activity Room has been discontinued due to rainwater leaking from the ceiling. On December 14, 2021 at 5:00 p.m., during an interview, the Facilities Manager (FM) stated the rainwater leaking in the building was due to a current natural gas line installation project that further damaged the roof allowing rainwater to enter multiple areas inside the building. The FM also stated the roof already needed repairs prior to natural gas line installation because rainwater has leaked in the building in the past. The FM stated the facility did not have a roofing contractor to repair or replace the roof. On December 14, 2021 at 5:15 p.m., during a phone interview, the Facilities Director (FD) stated the facility placed several plastic coverings over the damaged areas of the roof to temporary prevent rainwater leaking into the building. The FD also stated the facility has Environmental Services Department (EVS) staff to empty the rainwater collected in the buckets and trash bins and to remove water damaged ceiling tiles. The FD further stated the roof needs to be completely dry before any repairs on the roof begins and that the repairs may not start for another two weeks. The FD stated the facility does not have a roofing contractor or contract to repair and or replace the roof. The FD also stated the facility did not conduct a current roof assessment for the extent of the rainwater damage on the roof and inside the building after the rain event of December 14, 2021. On December 14, 2021 at 5:45 p.m., the Sub Acute Nurse Manager and Accreditation Coordinator and Quality Manager with nursing staff took action transferring residents from the South Wing to the East Wing residents rooms due to the ongoing concerns that more resident rooms in the South Wing will have rainwater leaks from the ceiling. On December 14, 2021, a review of the current census (list of residents in the facility) revealed the following resident room transfers: 1. Two residents in Room 3140 of the South Wing were transferred to Room 3126 of the East Wing. 2. One resident in Room 3142 of the South Wing was transferred to Room 3136 of the East Wing. 3. One resident in Room 3138 of the South Wing was transferred to Room 3128 of the East Wing. On December 14, 2021 at 6:30 p.m., during an interview with FM, he stated the facility will increase EVS staffing until 7:00 a.m., to ensure that all buckets, trash bins, and commercial trash carts are emptied of rainwater in a timely manner to prevent overflow of waste water onto the floors and into resident rooms and other areas while roof repair has not started yet. The FM also stated EVS staff will replace all wet towels and remove deteriorated water damaged ceiling tiles. On December 15, 2021 at 7:30 a.m., during a tour of the Sub Acute building, it was observed water was still leaking from the roof on the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, and Activity Room. On December 15, 2021 at 8:20 a.m., during a tour of the roof top, a clear plastic material covering the damaged areas of the roof surface, accumulated water near the roof drains, and pooled water near an exhaust unit were observed with the FD. On December 15, 2021 at 8:30 a.m., during an interview, the FD stated that the multiple water leaks inside the building was due to rainwater protruding through the patch work from a current project involving mounting brackets for a natural gas line installation. The FD also stated the roof has been leaking rainwater for a couple or more years every time it rains, and the roof was due for replacement. The FD further stated the rain and additional damaged to the roof due to the natural gas line installation project made the leaking of rainwater in the building worse. The FD stated that a tenting company will visit today to evaluate for placing large tents over the entire Sub Acute roof for a short-term solution. The FD also stated the facility did not have a roofing contractor or contract to repair and or replace the roof. On December 15, 2021, a document review titled, "Sub Acute Roof Findings," revealed the facility was aware of the multiple roof issues and the need to replace the Sub Acute building roof for the past 3 years. The facility failed to provide a safe and sanitary environment for the facility residents, staff, and visitors by not maintaining the roof in good repair. As a result, the facility had roof leaks of rainwater from the ceilings at the Nursing Station, North Corridor, South Corridor, East Corridor, West Corridor, Main entrance lobby, Activity Room, and Resident Room 3146. The leaking roof had the potential to cause serious harm, injury, or death to residents, staff, and visitors. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.