Failure to Maintain Secure, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. Three residents were housed in rooms with sliding glass doors that were broken, off track, and unable to be locked from the inside, allowing open access from outside the facility. The gates and fences surrounding the facility were also broken or missing locks, and the front and back entrance doors were found unlocked or ajar during nighttime hours, with no staff present or alarm systems in place. Staff and residents expressed concerns about safety, with several stating that anyone could enter the facility or their rooms without restriction. Additionally, the rooms of two residents were found to be infested with cockroaches. During an inspection, cockroaches were observed running from behind furniture and inside air fresheners. Both residents reported feeling dirty and uncomfortable due to the infestation, and staff confirmed the presence of cockroaches in resident rooms and drawers. The Maintenance Director acknowledged that pest control treatment had been performed in several rooms previously but admitted there was no follow-up to determine its effectiveness. The facility's own policies and job descriptions require maintaining a safe, secure, and sanitary environment, including ongoing pest control and ensuring that all doors and grounds are secure. Despite these requirements, the facility did not maintain functional locks on resident room doors, failed to secure the facility entrances, and did not effectively address pest infestations, directly impacting the residents' dignity, mood, and right to a homelike and safe environment.