Failure to Ensure Safe, Secure, and Clean Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. Resident rooms with sliding glass doors facing the outside were found to be open, unable to close, or unable to lock, leaving the rooms unsecured. The gates and fences surrounding the facility were broken or missing locks, and the front and back doors to the facility were observed to be unlocked or ajar, with no staff present or alarm system in place. Staff and residents expressed concerns about safety due to these unsecured entry points, and the Maintenance Director confirmed awareness of the broken doors and lack of locks. Residents affected by these deficiencies included individuals with intact cognition and various medical conditions such as diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, osteoarthritis, anxiety, and congestive heart failure. These residents required varying levels of assistance with activities of daily living. Both residents and their caregivers voiced concerns about the inability to secure their rooms, with personal belongings left vulnerable and a general sense of insecurity due to the facility's lack of physical security measures. Additionally, the facility failed to maintain a clean and pest-free environment in resident rooms. Multiple cockroaches were observed in the rooms of two residents, including inside personal items such as air fresheners and nightstand tables. Staff confirmed the presence of cockroaches and noted that previous pest control treatments had not been followed up to ensure effectiveness. Facility policies required ongoing pest control and maintenance of a clean, sanitary environment, but these were not upheld, as evidenced by the continued presence of pests and lack of follow-up.