Facility Evaluation Report

During the Department’s investigation of Complaint # 18-AS-20231201143530 the following deficiencies were observed:

The Department’s investigation revealed that R1’s floor was lifted between laminate planks in the center of R1’s bedroom. The facility was aware of the disrepair at least two months before 08/02/2023, the day of R1’s fall, but did not repair it. There is a possibility that R1 fell and hit R1’s head as a result of tripping on this floor. R1’s Residence and Care Agreement was reviewed and states “The Maintenance Department is responsible for performing preventive, routine, and emergency maintenance throughout the Community and upkeep of the grounds.” The Americans with Disabilities Act of 1990 defines a “trip hazard” as a surface for walking with a vertical change of ¼ inch or more at any joint or crack.

It does not appear that the facility completed a reappraisal of R1 following R1’s hospitalizations for falls on 06/25/2021 and 03/19/2023.

Citations were issued, an exit interview was conducted and a copy of this report, the 809D and the appeal rights were provided to Office Manager Nicole Aguiano