Failure to Maintain Safe and Comfortable Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident with multiple diagnoses, including Parkinson's disease, bipolar disorder, paranoid schizophrenia, unspecified dementia, hypertension, and chronic diastolic heart failure. The resident was noted to have impaired cognition, impaired mobility, poor safety awareness, and an increased risk of falls. During observation, two floor tiles in the resident's room were found to be raised and uneven, creating an unstable surface that contributed to the instability of furniture, including a television stand. The Maintenance Director acknowledged awareness of the uneven tiles and stated they should have been repaired earlier. Additionally, the window in the resident's room had rotting wood, peeling paint, and a non-functioning crank, resulting in a gap that allowed cold air to enter the room. The window had been in this condition for several months, and work orders submitted to address the issue were either marked as completed without full resolution or left incomplete. The room temperature was measured at 67°F, and the in-room refrigerator provided by the facility was found to be malfunctioning, with an internal temperature of 48°F, water accumulation in the freezer, and moisture along the interior edges. Staff confirmed the refrigerator was unable to maintain appropriate temperature. The Assistant Administrator was unaware of the issues with the floor, window, or refrigerator, and acknowledged these conditions posed a safety concern. The facility's Safety Policy requires preventive inspections, maintenance, and a system for communicating and addressing repair needs, but these procedures were not effectively implemented in this case.