Failure to Secure Facility Entrances and Exits Due to Broken Locks and Lack of Supervision
Penalty
Summary
The facility failed to ensure that entrance and exit doors were properly secured and supervised, resulting in unlocked and unsupervised access points outside of designated visiting hours. Observations revealed that both the main entrance and rear exit doors had malfunctioning locks, with the rear exit door repeatedly found propped open by objects such as a wet floor sign and an orange traffic pylon. Staff were observed exiting and reentering the building without closing the rear exit door, and the main entrance door was found unlocked and accessible from the outside. During these times, surveyors were able to enter resident hallways and common areas without encountering staff or any security measures in place. Interviews with facility staff, including a registered nurse, licensed vocational nurse, maintenance director, and operations assistant, confirmed that the expectation was for all doors to be closed and locked from the outside outside of visiting hours. However, staff were not consistently aware of the broken locks, and maintenance records did not reflect timely reporting or repair of the issues. The maintenance director acknowledged being informed of the broken rear exit lock a week prior and had only recently placed an order for a replacement. The front entrance door was also found to have a misaligned locking mechanism, preventing it from being secured. Facility policy required doors to be locked from the outside after visiting hours, but this was not being followed due to the inoperable locks and lack of supervision.