Failure to Maintain Safe and Homelike Physical Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies in the physical environment. Observations revealed that the wall to the right of a resident's bed was in disrepair, with scratches and missing paint, and the Maintenance Director was unaware of the issue until it was pointed out. The Administrator confirmed that all resident rooms were expected to be in good condition and properly maintained. Additionally, four sections of carpet, each approximately five feet long, were observed to be buckled up to four inches high in a high-traffic area on the third floor. The Maintenance Director acknowledged that these buckled carpets had been present for a significant amount of time and confirmed they posed tripping hazards, especially for residents with a shuffling gait. A resident admitted after cardiovascular surgery was found to have a bath towel draped over their window to prevent drafts, as the window could be detached and had no screen. The resident demonstrated that the window was not secure and stated it had been this way since admission. After a gust of wind dislodged the window and towel, the Maintenance Director screwed the window shut. The Maintenance Director later acknowledged that the window's arms had broken off and that the detachable window was a safety issue. He also stated there was no system in place to check or audit windows for safety and repair before or during a resident's stay.