Failure to Repair Hazardous Window Frame in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident with severe intellectual disabilities, expressive aphasia, and hypotension. The window frame in the resident's room was observed to be frayed and splintered, with pieces of wood sticking out, on two consecutive days. Staff interviews revealed that the issue had been reported to maintenance about a month prior, and the maintenance log confirmed the report. However, the window frame remained unrepaired during the survey period. The resident was dependent on staff for all activities of daily living and was rarely or never understood, according to her care plan and MDS assessment. Staff, including a CNA and the Maintenance Supervisor, acknowledged the hazard posed by the splintered window frame, noting the potential for injury. The Maintenance Supervisor stated that repairs were typically logged and checked daily, but he was not aware of this specific issue until the survey. The Administrator confirmed awareness of window repairs needed in some rooms but was not aware that this particular window had been on the maintenance log for about a month. Facility policy requires a safe, clean, and homelike environment, but this standard was not met in this instance.