Failure to Maintain Effective Pest Control and Environmental Safety
Penalty
Summary
Facility staff failed to maintain an effective pest control program across all units, as evidenced by multiple observations of flies throughout resident rooms and hallways over several days. There was also a persistent strong urine odor in a hallway past the lobby, and several environmental deficiencies were noted, including missing or loose wall-mounted hand sanitizer units, missing tiles in hallways and resident rooms, and baseboards pulled away from the wall with blackish-gray residue present. Mattresses in one room were heavily stained and had a crackled appearance, and a damaged breakfast tray with sharp corners was served to a resident before being removed by staff after it was reported. Additional deficiencies included the use of plastic utensils for meal service due to staff callouts, as explained by the Dietary Manager, and repeated observations of water accumulating in a bath basin under a resident's sink over several days, indicating an unresolved leak. The resident confirmed ongoing issues with the leaking sink and reported that the problem had not been fixed despite staff emptying the pan. Another room was observed to have a footboard leaning against the wall, with a resident's bed missing its footboard, and the resident could not recall how long it had been in that state. The residents involved had complex medical histories, including conditions such as hypertension, chronic kidney disease, major depressive disorder, obstructive sleep apnea, and HIV. Cognitive assessments indicated that some residents were cognitively intact, while others had moderate cognitive impairment. Interviews with residents and staff confirmed the persistence of these deficiencies and the lack of timely resolution, as discussed during the end-of-day debriefing with facility leadership.