Failure to Maintain Safe and Homelike Environment Due to Damaged Equipment and Fixtures
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents by not repairing or replacing damaged equipment and room fixtures as required. Specifically, one resident with multiple diagnoses including multiple sclerosis, diabetes, and dementia, who was totally dependent on staff for all activities of daily living and had severe cognitive impairment, was found to have a broken wall molding with a piece missing behind their bed. This issue was confirmed by both the DON and the Administrator during observations and interviews, who acknowledged that the damage had not been reported to the Maintenance Department as required by facility policy. Additionally, three other residents with severe cognitive impairments and total dependence on staff for daily activities were found to have bed rails covered with black foam padding that was ripped, gouged, and in poor repair. The exposed porous foam and bed rails were observed during a walk-through with the Subacute Director, who stated that while the padding is changed regularly, there is no set schedule for replacement. The DON confirmed that the damaged padding could potentially harbor bacteria and that all equipment should be in good repair for safety purposes. The facility's own policy and procedure on maintaining a homelike environment, last reviewed in July 2024, requires that residents be provided with a safe, clean, and comfortable environment. Despite this, the facility did not ensure timely repair or replacement of damaged wall molding and bed rail padding, as evidenced by direct observations and staff interviews.