Failure to Maintain Safe and Homelike Environment Due to Equipment and Environmental Disrepair
Penalty
Summary
Multiple deficiencies were identified related to the facility's failure to maintain a safe, clean, and homelike environment for several residents. For one resident with epilepsy, cognitive communication deficit, and mood disorder, the bed control cord was found to have exposed and frayed wires, partially wrapped with black tape, which was not an appropriate repair. The resident and staff were aware of the issue, but it was not reported promptly to maintenance, and the improper repair was not followed up with a replacement as required by facility policy and equipment manuals. Another resident with hemiplegia, hemiparesis following a stroke, depression, muscle weakness, and a history of falls was found to have a broken baseboard in their room, with two exposed metal nails sticking out. Staff were aware of the broken baseboard but did not report it to maintenance due to being busy. The presence of the broken baseboard and exposed nails was acknowledged by staff as unsafe and not consistent with a homelike environment. Additionally, two residents with significant cognitive and physical impairments, both at risk for falls, were found to have floor mats in disrepair. One resident's floor mat had a linear tear with foam padding exposed, while another's had multiple scratches. Staff and leadership acknowledged that these conditions did not provide a homelike environment and that such issues should have been reported to maintenance for replacement. Facility policies and procedures required prompt reporting and repair of such environmental hazards, but these were not followed in these instances.