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F0584
E

Failure to Control Gnat Infestation Compromises Resident Environment

Sullivan, Indiana Survey Completed on 12-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, clean, and comfortable environment by not controlling a gnat infestation that affected multiple areas, including resident rooms and the dining room. Residents reported significant issues with gnats over a period of several weeks to months, with gnats found in beverages and food, and residents taking measures such as covering drinks and personal items to avoid contamination. One resident described counting multiple gnats in his coffee, while another mistook gnats for pepper on her food. Staff interviews confirmed that the infestation was widespread and persistent, with reports that the issue was communicated to administration multiple times. Resident interviews revealed that the infestation caused considerable discomfort and annoyance, with one resident covering her face at night to avoid gnats and another developing maggots between her toes, which was documented in a Skin Integrity Issue report. The report noted that this resident had predisposing factors such as a preference for independence, incontinence, fragile skin, improper footwear, and resistance to care. Staff described the infestation as severe, with gnats present in food, beverages, and throughout the facility, and expressed concerns that the facility's response was insufficient and not timely. The Administrator acknowledged being aware of some gnats in her office but was not aware of the extent of the infestation throughout the facility. She had not spoken directly to residents or staff about the issue and relied on department heads for information. The pest control company was called for additional visits, but staff felt these measures were inadequate. The facility's pest control policy outlined responsibilities for prevention, monitoring, and control, but the actions taken did not prevent or resolve the infestation in a timely manner.

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