Failure to Maintain Clean, Homelike Environment and Safe Sharps Handling
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Homelike Environment policy. Surveyors observed in one resident room a fly strip in the middle of the room covered with bugs and another fly strip by the window with several bugs; the resident in that room reported the fly strips had been there since the previous summer and had been placed by maintenance. In the same room’s restroom, a metal bracket was observed protruding from the wall at eye level; the resident stated she did not know what metal bracket was being referenced because she could not see very well. In another room’s restroom, the vent was observed to be covered with a gray, fuzzy substance. In common areas, a ceiling vent in the hallway outside the dining rooms was covered with a thick black substance, and vents in the front lobby had a black substance on both the vent and the surrounding ceiling. Additional environmental concerns were observed on Hall 100, where walls near the nurse’s station had large areas of gouges and missing paint, and the vent above the nurse’s station had a black substance on the vent and surrounding ceiling. Review of the Housekeeping Weekly Cleaning Schedule showed no documentation that vents were included in routine cleaning. The Maintenance Supervisor acknowledged the walls should have been repaired, the vents needed cleaning, and that the fly strips and metal bar should not have been in the resident room, while the DON stated she was unaware of the fly strips and that they should not have been present. The Administrator reported that vents, which should have been cleaned by maintenance, had not been cleaned for a year. In the medication prep room on Hall 100, a sharps container was observed filled past the full line, with the wall-mount enclosure unlocked and ajar; an RN and the DON both stated the sharps container should have been changed when full and the enclosure kept locked.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.