Failure to Maintain Safe and Functional Resident Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for a resident, as evidenced by two main deficiencies observed during the survey. One of the resident's windows could not be fully closed, remaining open by approximately one inch for at least a week. This allowed rainwater to enter the room, resulting in warping and water damage to the interior windowsill. The resident and their representative reported the issue to a staff member after the rain incident, but the Maintenance Director was not made aware of the problem until the survey. The Maintenance Director confirmed the damage and acknowledged that he was responsible for maintaining the building's condition but had not been notified of the window issue or the resulting water damage. Additionally, the resident's room refrigerator was found to be non-functional for an undetermined period, with temperatures recorded at 58 and 60 degrees Fahrenheit on separate occasions. The resident's representative stated she was unable to bring in outside food due to the refrigerator not working and had not reported the issue to staff. The facility's ambassador, responsible for morning rounds and identifying room concerns, noted the refrigerator temperature was high and reported it to the Maintenance Director, but was unaware of the window issue. The facility's administrator and staff discussed unreliable thermometers and the need to monitor new refrigerators to ensure proper function, but there was no clear policy for ensuring a homelike environment or functioning equipment. The resident involved had a history of repeated falls, weakness, and dementia, with moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The facility's failure to maintain the resident's environment, including the inability to close the window and the lack of a functioning refrigerator, resulted in an unpleasant, unsanitary, and potentially unsafe living space. These deficiencies were identified through observations, interviews, and record reviews, and were not addressed in a timely manner due to lapses in communication and monitoring.