Widespread Environmental and Sanitation Deficiencies
Penalty
Summary
Surveyors observed multiple failures in housekeeping and maintenance services across three of four units, resulting in an environment that was not clean, comfortable, or pest-free. Numerous resident rooms and shared bathrooms contained unlabeled and uncovered wash basins, urinals, and emesis basins stored on toilet tanks or floors, with photographic evidence obtained. There were also instances of live insects, including ants and roaches, in resident rooms and common areas, as well as reports from residents and staff of ongoing pest issues. Maintenance issues included rusty raised toilet seats, broken furniture, torn wheelchair armrests, holes and gouges in walls, and malfunctioning bed controls. Extension cords not approved for use were found in resident rooms, and some personal care items and urinary catheter drainage bags were not stored in a sanitary manner. The Infection Preventionist and Maintenance Director confirmed these observations and acknowledged lapses in identifying and addressing these concerns. Pest control logs and inspection reports documented recurrent sightings of roaches and ants in various facility locations over several months, including resident rooms, the kitchen, and activity areas. The pest control technician confirmed ongoing problems with ants and roaches, attributing some issues to food in resident rooms and structural problems such as cracks in floors and damaged areas that serve as pest harborage. Housekeeping staff and supervisors reported that cleaning checklists were not consistently used, and some areas, such as grout around toilets and windowsills, were not adequately cleaned. Linen carts were found with ants crawling on clean linen, and direct care staff corroborated the persistent pest issues. In the kitchen, the walk-in refrigerator and freezer were found in unsanitary conditions, with soiled floors, black substance buildup, frost accumulation, condensation, and water pooling on the floor. There were also holes in the walls and soiled seals. The cleaning schedule was not consistently documented, and there was no log to verify completion of cleaning tasks. Communal shower rooms had missing or non-functioning shower heads, rusted metal holders, and opened bottles of body wash and shampoo stored inappropriately. Alcohol-based hand sanitizer dispensers in two units were empty and not functioning. These combined deficiencies resulted in a failure to provide a safe, clean, comfortable, and homelike environment for residents.