GOLF VIEW REHAB & LIVING CENTER
Facility I.D. Number 0043570
2308 W. Nebraska Ave.
Peoria, IL 61604
Date of Survey 02/02/01
Incident Investigation
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible.
Each facility shall:
Maintain the building in good repair, safe and free of the following: cracks in
floors, walls, or ceilings; peeling wallpaper or paint; warped or loose boards;
warped, broken, loose, or cracked floor covering, such as tile or linoleum;
loose handrails or railings; loose or broken window panes; and any other
similar hazards.
Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.
Walls and ceilings shall have sound construction, covered with plaster or sheet rock or similar material in good repair, and free from cracks or holes to permit proper cleaning.
Buildings shall be maintained in good repair. Buildings that show signs of distress shall be repaired immediately.
These requirements are not met as evidenced by:
Based on observation and staff interview, the facility failed to maintain the nursing home physical plant in a safe condition. Facility ceilings are not being maintained in a safe condition to prevent accidents to residents, staff, and visitors. The facility has no preventive maintenance program in place to monitor the ceilings. There has been no assessment and corrective repairs done to the dining room ceiling areas since an April 2000 ceiling collapse in a resident room. Contractors have indicated to the facility that the heating system in this type ceiling construction can cause the ceiling to collapse.
Findings include:
According to the hotline call received on 1/29/01 at 8:07 p.m., the ceiling in the activity/feeder dining room caved in at 5:15 p.m. on the same date. Interview with E1 (Administrator) on 1/30/01 in the Director of Nursing's office at 9:30 a.m. confirmed that at the time of the ceiling collapse, 5 residents were present in this dining room.
During interview with E2 and E4 on 1/30/01, they confirmed that they were in the immediate area at the time and heard the ceiling collapse. During interview with E5 on 1/30/01 at 3 p.m. outside Room 27, E5 confirmed that she was "standing right under it (ceiling) when it started to fall--heard a rumbling noise twice and questioned what it was." The ceiling started to fall immediately after this. E5 immediately began to remove residents from the area. At the time of the ceiling collapse, R1, R2, R3, R4, and R5 were in the immediate area of collapse.
Emergency response personnel (summoned by 911 call) evaluated the five residents on site. R1 had a small bump on the top of the head, with no open area or bruising. R5 was found to have a red mark on the upper right shoulder area near the spine. R5 was transported to the emergency room for evaluation since she was nonverbal, and unable to indicate any injury or pain. R1, R2, R3, and R4 were taken to the main dining area to continue the evening meal with the rest of the facility population. Census at the time of the ceiling collapse was 61 with 5 residents receiving tube feedings. After E1 talked with E3, a decision was made to remove all residents from the dining room at 6:30 p.m. due to the concern of an additional ceiling collapse since this dining area has the same type of heating coil wire and ceiling construction as the activity/feeder dining room. All residents of the facility were potentially at risk since the two rooms were used for both dining and activities.
Direct observation of this area on 1/30/01 confirmed that approximately 1/3 of the ceiling had collapsed, including the ceiling tile, the metal framework supporting the ceiling tile, the sheet rock , and the dry wall attached to the sheet rock. The heating coil wire was laying on the floor. A smaller ceiling area on the opposite end of the dining room had also collapsed.
The ceiling system in this area is suspended by wire hangers from the structural steel beams, held by 2 inch steel channels. The aluminum channel framing is then attached to these steel channels to hold 3/8 inch dry wall and the heating coil which is stapled at 4 inch centers. The plastering of 3/4 inch thickness is added to cover the heating coils.
Interview with E3 (Director of Maintenance) on 1/30/01 confirmed that the electrical breakers for electrical power were shut off to this area after the ceiling collapse, due to loose electrical wires creating a safety hazard Z1 (Corporate environmental assessment personnel) stated during interview on 1/30/01 that a general contractor was on site in the facility on 1/30/01. According to Z1, the contractor told Z1 that "the heating coil in the sheet rock material of the ceiling caused the ceiling area to get very hot and bake the ceiling materials. The ceiling materials become weak and collapse."
This facility has had ceilings collapse in the front lobby area in April 1988, the South hall area in June 1989, and room 36 in April 2000. When the ceiling collapsed in room 36 in April 2000 the current owners owned the building. The current owners were aware that the current ceiling system was faulty since the April 2000 collapse. When the ceiling was repaired from the April 2000 collapse an assessment of the facility ceiling was done by a structural engineer and given to the current owners according to E1. The main dining room ceiling has been identified by the current director of maintenance as having the same ceiling construction as the activity/ dining room which collapsed.