Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four of six sampled residents, as evidenced by multiple deficiencies observed during the survey. For one resident with dementia and other cognitive impairments, the wall clock at the bedside consistently displayed the incorrect time over several days. Staff interviews confirmed awareness of the issue, and facility policy required the clock to be accurate to assist with reality orientation for residents with cognitive deficits. The clock was not corrected in a timely manner, despite its importance for resident orientation. Another resident, who had decision-making capacity and was dependent on staff for several activities of daily living, experienced ongoing issues with broken vertical blinds in their room. The missing and fallen slats were left on the floor, and cardboard was taped to the window to block light, as reported by the resident and observed by staff. The resident expressed dissatisfaction with the situation, stating it had persisted for months. Staff interviews revealed that maintenance requests were not consistently made or followed up on, and the environment was not maintained in a homelike or dignified manner, as required by facility policy. A third resident, identified as high risk for falls and with severe cognitive impairment, was found to have a fall mat at the bedside that was torn and had a side table placed on top of it. Staff acknowledged that the mat should not be torn or have equipment placed on it, as this compromised its function and the homelike appearance of the room. Additionally, another resident with severe cognitive and physical impairments had wall sockets at the head of the bed that were cracked and missing covers. Staff and maintenance personnel confirmed these issues and stated that they should have been addressed immediately to maintain a safe and homelike environment. Facility policies reviewed required prompt maintenance and upkeep of resident rooms, but these were not followed in these instances.