Failure to Provide Safe, Comfortable, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as required by policy and regulation. For one resident with heart disease, depression, and weakness, observations revealed a cluttered and cramped room with personal items, a recliner, wheelchair, and boxes stacked in the corner, leaving no space for visitors or a bedside commode. The resident expressed a desire to use their recliner and a commode but stated there was insufficient space. Staff confirmed that the room was too small for the resident's personal chair and that the privacy curtain did not divide the space equally between roommates. Another resident, with heart failure, muscle weakness, depression, and unsteadiness, was observed in a three-bed room with limited space and dim lighting. The resident's bed was positioned against a privacy curtain, and the available space was further restricted by furniture placement, making it difficult for the resident to access their nightstand or move about the room. The resident reported that the room was too small, dark, and lacked space for personal belongings or visitors. Staff interviews acknowledged that the walk-through area at the end of the bed was not usable living space and that the room did not provide adequate space for three residents, especially when mechanical lifts were needed for transfers. The facility's policy required providing adequate lighting and allowing residents to use personal belongings in a safe and comfortable environment. However, both residents experienced limitations in their living spaces, including inadequate lighting, lack of space for personal items, and insufficient room for safe care and services. These conditions were directly observed and confirmed by staff and residents, demonstrating a failure to meet the required standards for resident environment.