Improper Disposal of Cardboard Boxes
Summary
The facility failed to properly dispose of cardboard boxes, as observed outside the kitchen door. The facility's policy requires that food storage boxes and containers be disposed of by the end of each shift into the outside dumpsters. However, during an observation at 7:01 AM, multiple cardboard boxes were found scattered on the ground and not contained in the garbage bin. This was confirmed by photographic evidence. Interviews with staff further highlighted the deficiency. A Dietary Aide stated that someone is responsible for breaking down the cardboard boxes and taking them to the garbage container, indicating that the boxes should not be left on the ground. The Dietary Director also confirmed that the cardboard boxes were removed from the ground outside the kitchen door and acknowledged that they should not have been there.
Plan Of Correction
F-814 Dispose Garbage and Refuse property: Identify patients that were at risk and what did: Once identified by surveyor with multiple cardboard boxes on the ground and not contained in the garbage bin. The Certified Dietary manager and Registered Dietician met with staff on and to ensure that the empty cardboard boxes were no longer allowed to be left unattended and not broken down and discarded. No residents were placed at risk. How will you identify other patents that are at risk: Once identified by surveyor with multiple cardboard boxes on the ground and not contained in the garbage bin. The Certified Dietary manager and Registered Dietician met with staff on and to ensure that the empty cardboard boxes were no longer allowed to be left unattended and not broken down and discarded. No residents were placed at risk. Measures put in Place: The CDM/RD or designee created a QAPI spot check form and created a new process to Discard cardboard boxes by dietary staff. This Inservice was completed on and Additionally, a Cardboard only bin was placed on the outside of building as a general cardboard disposal location. Ali other non-dietary boxes were also detailed to be broken down and discarded in a main garbage container. How will you monitor: The CDM /RD or designee will be responsible for bringing the findings or progress to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to keep the exterior dumpster area sanitary. An open dumpster lid was observed with clear plastic bags inside, and a nearby grease trap had dark buildup, liquid pooling onto the concrete pad, and debris, trash fragments, and paper clutter around its base. Staff T and the ADM stated the dumpster lid should always be closed, while the ADM also said no one had told staff to clean the grease trap. The facility policy required dumpster lids to remain closed and the area to be clean and free of debris.
Improper Garbage and Refuse Disposal: A dumpster lid was observed open with trash littering the ground around it, and later 14 bags of dietary and nursing trash were found stacked on the ground next to empty dumpsters instead of being placed inside. An admin staff member confirmed the bags had not been put into the dumpsters after the scheduled pickup was missed.
Improperly Covered Garbage and Refuse: The facility failed to keep trash receptacles covered in the kitchen and outside in the alleyway. A 55-gallon trash can in the main food prep area had a hole cut in the lid and was overflowing, and outside trash cans had lids left open with empty box material on the ground nearby. The RNC stated the kitchen garbage cans needed a tight-fitting lid without holes and that the outside cans should always have their lids closed.
Improper disposal of garbage and refuse was observed at the main dumpster area. Multiple disposable gloves, small paper items, a plastic spoon, and a personal hand sanitizer container were found on the ground near and outside the dumpster fence, and gloves were still present on a later observation.
Improper Grease Disposal and Unsecured Refuse Storage: The facility failed to properly dispose of cooking grease and keep refuse storage sanitary. Surveyors observed dumpster lids left open, an open trash bag on the ground next to the dumpsters, and trash scattered around the area. The FSS stated used grease was frequently poured along the fence line and sometimes placed in the dumpster or run down the kitchen sinks, and the ED said the facility had a grease extraction contract but was unsure why kitchen staff were not following policy.
Improper Disposal and Containment of Garbage and Refuse: Surveyors observed an open recyclable dumpster and multiple dumpsters surrounded by broken wheelchairs, equipment parts, wooden pallets, a broken lawn chair, and other debris. A paper with a resident name and room number was also found in the grass near the dumpster area, and the debris remained on later observation.
Exterior Dumpster Area Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to maintain the exterior waste area in a sanitary condition. During an observation of the dumpster area with Staff T, the dumpster lid was open and clear plastic bags were visible inside. Next to the dumpster, a grease trap had dark buildup and liquid pooling outward from the base of the grease container across the concrete pad, with loose debris, trash fragments, and paper clutter accumulated around the base. During interviews, Staff T stated the dumpster lid should be closed at all times and was unsure who was responsible for cleaning the grease trap. The Assistant Dietary Manager stated the garbage container lid should always be closed and said no one had ever told staff to clean the grease trap. The Administrator stated the dumpster lid should be closed at all times and said they would look at the grease trap and speak to maintenance. The Maintenance Director stated the area needed to be clean and appeared to have some sort of spillage. The facility policy stated dumpster lids must remain closed when not in use and that dumpster areas must be clean and free of debris, with immediate cleanup for spills, leaks, and loose trash.
Improper Garbage and Refuse Disposal
Penalty
Summary
Garbage and refuse were not disposed of properly when the facility failed to keep a dumpster lid closed and failed to place trash bags in an enclosure. During an initial kitchen tour on 08/03/2026 at 07:42, one of two dumpsters was observed with the cover open and random pieces of trash were littering the ground around the dumpster. On 08/05/2026 at 07:45 AM, both dumpsters were empty, but 14 bags of trash containing dietary and nursing trash were stacked next to one of the empty dumpsters instead of being placed inside it. At 07:56 AM, Administrative Staff A stated the sanitation company had not picked up the garbage on 08/04/2026 as planned but had picked it up in the early morning of 08/05/2026. Administrative Staff A confirmed the garbage bags had not been placed into the empty dumpsters and were stacked on the ground next to the dumpster. The facility policy stated garbage and rubbish would be disposed of to ensure a clean and sanitary kitchen that does not encourage insects or rodents, and that all outside dumpsters would be maintained in clean and sanitary condition.
Improperly Covered Garbage and Refuse
Penalty
Summary
Garbage and refuse were not properly covered in the kitchen and outside trash area. Based on observation and interview, the facility failed to ensure garbage cans were kept closed with lids to minimize attracting pests and rodents into the kitchen. In the main food prep area, a 55-gallon trash can had a hole cut in the lid so it could not be securely closed, and the trash can was overflowing with trash. Outside the kitchen in the alleyway, the larger trash cans had two lids wide open, and some empty box material was on the ground just outside the kitchen. The RNC stated that the kitchen garbage cans need to have a tight-fitting lid without holes and that the garbage cans outside in the alley should always have their lids closed and had not.
Improper Disposal of Garbage and Refuse at Dumpster Area
Penalty
Summary
The facility failed to properly contain and dispose of garbage at the main dumpsters located in the rear of the facility. During observation on July 28, 2026, multiple disposable gloves, at least 11 in total, were seen on the ground adjacent to the dumpsters and outside the perimeter fence around the dumpster area. The same area also contained small discarded paper items, a plastic spoon, and a personal hand sanitizer container. A follow-up observation on July 31, 2026, found three disposable gloves still on the ground adjacent to the dumpsters.
Improper Grease Disposal and Unsecured Refuse Storage
Penalty
Summary
The facility failed to properly dispose of cooking grease and maintain refuse storage in a sanitary manner in the kitchen and refuse storage area. During observation, the outside refuse containers had lids left open, an open trash bag was placed on the ground next to the dumpsters, and trash was noted on the ground around the dumpster. During interview, the FSS stated the facility frequently poured used grease along the fence line and said the grease was sometimes placed in the dumpster or run down the kitchen sinks. Observation of the fence line adjacent to the dumpster showed an area devoid of plant life and grass with bare soil exposed. The Executive Director stated the facility had a contract with a grease extraction company and was not sure why kitchen staff were not following the facility policy regarding grease disposal.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to properly contain and dispose of garbage and refuse at the outside dumpster area. On July 21, 2026, surveyors observed the main dumpsters on facility property with a recyclable dumpster lid open, and next to two additional dumpsters were several broken wheelchairs, miscellaneous equipment parts, five wooden pallets, and one broken lawn chair. On July 22, 2026, the same area contained added metal framing for a pop-up tent along with the previously observed broken wheelchairs and parts, and a piece of paper with a resident identifying name and room number was found in the grass near the dumpsters and pile of broken items. Surveyors also observed debris on the ground around a single dumpster, including plastic lids, leaves, an empty crushed nutritional container, cigarette butts, three medical gloves, plastic silverware, and a plastic paint tray. On July 24, 2026, the debris around the single dumpster and the paper with the resident name and room number remained in place.
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