Environmental Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment, as evidenced by multiple observations of water damage, mold, pest infestation, and structural disrepair. Surveyors observed a large ceiling stain near a resident room, which was attributed to a roof leak that had occurred about a month prior. Despite claims that duct work had been replaced, further inspection revealed that the duct work was not replaced, wet insulation was left in the attic, and there were signs of water stains and mold on drywall. Additionally, a decomposed rodent was found in the ceiling, and animal nests were observed in the attic. Staff interviews confirmed ongoing issues with rodents and water leaks, and it was verified that air from the attic circulated into resident rooms. Further deficiencies were noted in various units, including the presence of lint and mold in ceiling vents, holes drilled through ceiling soffits, and standing water with black biofilm in a utility sink. There was also a pervasive musty odor in one unit, and a vent fan with a buildup of black substance. In the dialysis unit, broken and lifting floor panels were observed, along with a persistent foul odor consistent with drain backup. Staff reported that the flooring had been damaged by a flood and that repairs had not been completed, despite repeated requests. The odor was attributed to resident body waste draining under the floors, and cleaning efforts had not resolved the issue. Additional observations included a door protector that had separated from a resident room door, creating a sharp hazard, and a privacy curtain with a large stained area of either dried blood or feces. Attempts to secure the door protector were unsuccessful until it was eventually attached with screws. The facility's Infection Preventionist's office was also found to have extensive ceiling staining from prior roof leaks. Review of facility policy confirmed that the environment was expected to be clean, sanitary, and orderly, but these standards were not met.