Improper Garbage Disposal Due to Lack of Bin Lids
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a recertification survey. Specifically, the garbage bins in the kitchen and garbage pickup area were found without lids or covers, leaving waste exposed. This was contrary to the facility's policy, which mandates that all waste be kept in lined containers with lids, leak-proof, and non-absorbent prior to disposal. Observations on multiple occasions confirmed the absence of lids on garbage bins, and staff interviews revealed that the bins have never been equipped with lids, as the waste company did not provide them. The Director of Food Service and the Housekeeping Director acknowledged the issue, and the Administrator stated that they had contacted the vendor to address the problem.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? ò The vendor was contacted on 02/12/2025 to supply the facility with 10 new metal garbage bins with covers. ò New metal garbage bins have been delivered to the facility on [DATE] & 2/27/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? ò All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? ò The facility Policy and Procedure was titled Disposal of Garbage and refuse, was reviewed and dated; no revision needed. ò All Housekeeping and kitchen staff are in-serviced on the above policy. ò New metal garbage bins with covers are being implemented. ò An audit tool is being created to ensure compliance with garbage disposal. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? ò On a weekly for one quarter, the Director of Housekeeping or designee will conduct environmental audits of the compactor room and loading dock to ensure garbage bins are covered and in good condition. Any outstanding issues will be corrected and reported to the Administrator immediately and in good condition. ò On a monthly for one quarter, the Director of Housekeeping or designee will report audit findings to the Administrator. ò On a quarterly basis, the Director of Housekeeping or designee will present audit findings to the QAPI Committee. ò The QAPI Committee will review the findings and determine if further action is necessary. 5. The title of the person responsible for correction of each deficiency: Director of Housekeeping
Penalty
Resources
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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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