Failure to Address Leaking Toilet Creates Fall Hazard for Residents
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for three residents with significant fall risks and cognitive impairments. Observations revealed that a shared bathroom used by these residents had water leaking from the base of the toilet, creating a slippery floor. One resident, who required supervision with ambulation and used a walker, was observed slipping while exiting the bathroom and reported that the toilet had been leaking for several months, despite notifying staff. Two other residents, both with severe cognitive impairment and a history of falls, also used the same bathroom and confirmed the presence of water on the floor for an extended period. Interviews with staff, including a CNA, the Maintenance Supervisor, and the DON, confirmed the ongoing leak and the use of the bathroom by ambulatory residents at risk for falls. The Maintenance Supervisor and Administrator were unaware of the leaking toilet prior to the surveyor's observation, despite facility policy requiring regular environmental rounds and hazard identification. The facility's failure to identify and address the leaking toilet resulted in a persistent environmental hazard for residents with known fall risks.