Environmental and Infection Control Deficiencies Identified
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Several rooms had significant maintenance issues, such as stained and missing ceiling tiles exposing plumbing, running faucets that could not be turned off, and exposed wires from a detached telephone outlet cover. In one instance, a resident's room had a large brown stain above the bed from an old water leak, and the maintenance director was unaware of the issue. Other rooms had missing ceiling tiles in bathrooms, exposing large holes and plumbing pipes, with these conditions persisting over multiple days of observation. In addition to maintenance concerns, there were notable lapses in infection control and cleanliness. Dirty linens, towels, and incontinence pads were placed directly on the floor during care for a resident who was always incontinent and dependent on staff for hygiene. The CNA involved acknowledged this practice was improper but cited a lack of available bags. The DON confirmed that placing soiled linens on the floor was an infection control issue. Other observations included soiled incontinence briefs left on the bathroom floor, which attracted gnats, and a strong urine odor in the hallway, further indicating lapses in cleanliness and timely waste removal. Additional environmental deficiencies included a loose floor tile in a common area, a section of baseboard peeling away from the wall, chipped paint on a resident's door, and the presence of empty oxygen tanks in a resident's room. Shower rooms were found with dark mildew, rust-like stains, and ceiling tiles with blackish substances. Facility policies reviewed required clean and sanitary conditions, but these were not consistently followed, as evidenced by the ongoing issues observed and verified by staff and administration.