Failure to Maintain Safe and Homelike Environment Due to Unrepaired Broken Window
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when it did not address a resident’s broken window over an extended period. A cognitively intact resident reported that the bottom half of his room window had been broken for the past two years, with jagged and sharp glass edges exposed and only a piece of cardboard covering part of it. The resident stated he had informed multiple people about the broken window but no action was taken, and he stopped feeding birds out of concern about cutting his hands on the glass. Surveyor observation confirmed the broken window with exposed sharp edges. The Maintenance Director, who had been employed at the facility for two years, stated he had never seen a work order for the resident’s window and that the resident had not reported the issue to him, suggesting the damage might have occurred before his employment. Later, the Maintenance Director reported that a housekeeper had told the housekeeping director about the broken window a week earlier but had not informed him. The facility’s Preventative Maintenance Program policy states that random rounds are to ensure all facility areas are kept clean and in safe condition, but the broken window in the resident’s room remained unrepaired despite this policy.
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