Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment for a resident by not ensuring that the bump rail in the resident's room was properly attached to the wall and free of protruding nails, and by not replacing missing wall trim. The resident, a female with muscle weakness, lack of coordination, anxiety disorder, and mild intellectual disabilities, reported the issues to social services and the DON, but no corrective action was taken. She expressed that the room needed improvement and specifically pointed out the missing trim and dislodged bump rail with exposed nails, which she stated had been in this condition since she began living at the facility a year prior. Despite regular rounds and inspections reported by the Administrator and Maintenance Director, the dislodged bump rail and missing trim were not addressed. The Administrator and Maintenance Director both acknowledged that exposed nails from the bump rail posed a safety risk, but claimed the issue was not previously identified during their inspections. The facility's policy required regular monitoring and immediate correction of environmental issues, but the deficiency persisted, as confirmed by the resident's repeated reports and ongoing observations.