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F0584
D

Failure to Repair Broken Window Frame Compromises Resident Environment

Palestine, Texas Survey Completed on 08-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, clean, and homelike environment for a resident by not repairing a broken window frame in the resident's room. The window frame was detached from the wall, with exposed screws and nails protruding about half an inch, and this issue was not reported or addressed until it was observed during the survey. Staff members, including CNAs and the social worker, were either unaware of the problem or had not checked the window due to closed blinds or lack of observation. Maintenance records showed no prior request for repair, and the Maintenance Supervisor was not aware of the issue until the day of the survey. The resident affected had multiple medical conditions, including schizoaffective disorder, atherosclerotic heart disease, and polyosteoarthritis, and required substantial assistance with personal hygiene and bed mobility. The facility had procedures in place for staff to report maintenance issues, such as scanning QR codes or reporting during morning meetings, but these were not utilized in this instance. Daily environmental rounds were conducted by department heads, but the deficiency was not identified or communicated, resulting in the resident living in a room with an unrepaired, unsafe window frame.

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