Failure to Maintain Sanitary Resident Room Due to Persistent Gnat Infestation
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in a resident's room, as evidenced by persistent and significant gnat infestation. The resident, who had diagnoses including schizoaffective disorder, chronic respiratory failure, and end stage renal disease requiring dialysis, was observed to have multiple gnats flying, landing, and crawling on his breakfast tray, drink cups, straws, bedside table, and bed. Staff interviews confirmed that the gnats were always present in the resident's room, with estimates of over 40 to 50 gnats at a time. Observations on consecutive days revealed leftover food and supplement drink containers with gnats crawling on them, and gnats were also seen on the resident and his bedding. Despite repeated observations and staff awareness of the issue, there was no evidence that the facility had a pest control policy or that effective action was taken to address the infestation. The resident's care plan did not address hoarding or concerns related to room cleanliness, and staff, including nursing, housekeeping, and maintenance, either did not know what was being done about the gnats or had not been notified of the problem. Housekeeping staff noted that the resident kept food in his room but did not refuse cleaning, and the maintenance director was unaware of the infestation until informed by surveyors. The administrator confirmed the absence of a pest control policy.