Unsecured Toilets Compromise Resident Safety
Penalty
Summary
The facility failed to ensure a safe and functional environment as required by its policy, as surveyors observed that toilets in four occupied resident bathrooms were not securely fastened to the floor. This deficiency affected six residents with varying cognitive and physical abilities, including those with diagnoses such as diabetes, dementia, bipolar disorder, and Alzheimer's disease. Observations revealed that the toilets moved forward, backward, and side to side with minimal effort, and in one case, a wedge was needed to stabilize the fixture. Maintenance staff confirmed during interviews that the toilets were loose and acknowledged the potential for accidents. Medical record reviews indicated that the affected residents required different levels of assistance with transfers, ranging from independent to needing supervision or touching assistance. The unsecured toilets were found in both shared and private bathrooms, and the issue persisted over multiple observations. The facility's policy stated the environment should be safe and not pose a risk, but the lack of secure toilets did not meet this standard, as confirmed by both the Maintenance Assistant and Maintenance Director during interviews.