Failure to Maintain a Safe, Clean, and Pest-Free Resident Environment
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to provide a safe, sanitary, and homelike environment for multiple residents when flies were observed in several resident rooms. One resident with major depressive disorder, anxiety disorder, muscle weakness, and inability to walk reported that there were bugs "everywhere" in her room; surveyors observed a small fly on her privacy curtain, several small flies hovering in the air, and several flies on the wall. Another resident’s room contained several flies flying in the room, including one on the lid of a cup. In a shared room occupied by three residents with diagnoses including dementia, failure to thrive, major depressive disorder, need for assistance with personal care, difficulty communicating, muscle weakness, and lack of muscle coordination, surveyors observed extensive fly activity. One resident’s bed was unmade, with a small black fly on the pillowcase, multiple flies on the privacy curtain and wall, and a sandwich in plastic wrap on the bedside table that had multiple small flies on and inside the wrapper, as well as flies on the speaker end of his phone and on his drinking cup. Another resident in the same room was lying in bed on sheets and a bedframe with a thick yellow dried substance on the sheets, bed frame, and pooled on the floor; numerous small black flies were on his mattress, bed frame, wall, privacy curtain, and gown, with one on his pillowcase and multiple flies slowly flying around his head. A third resident in that shared room was lying in bed and unable to answer questions, while multiple small black flies were observed on the privacy curtain and flying around. Staff interviews confirmed the unsanitary conditions. A CNA and the Housekeeping Manager both acknowledged the presence of flies on multiple surfaces, including the sandwich and phone of one resident and the mattress and pillow of another, and stated that it was not supposed to be like that. The Administrator, when brought to the shared room, confirmed the presence of multiple flies and stated, "It should not be like this." The Infection Preventionist, after being shown pictures of the flies, stated that her expectation was for residents to have a safe and clean environment to prevent infections and that flies could cause GI and respiratory issues. The Assistant DON, after viewing pictures of flies on a resident’s bed and clothing and the dried tan liquid on his sheets and bedframe, stated she would not expect to see that in the facility and that it was not good for someone with depression or for anyone. These conditions were inconsistent with the facility’s written policies on infection prevention and control, pest control, homelike environment, and resident rights.
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