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Based on observation, interview and document review the facility failed to ensure a sanitary environment resulting in the potential for transmission of infectious agents to all 57 patients being served by the facility at the time of survey. Findings include: (See specific tags).

(A-0749) The facility failed to maintain a sanitary environment

Based on observation, interview and document review the facility failed to maintain a sanitary environment resulting in the potential for transmission of infectious agents to all 57 patients served by the facility. Findings include:

On 12/09/2020 at 1000, during the initial tour of the facility, Accompanied by Staff C (Registered Nurse Infection Control Preventionist), the flooring outside of the elevator and the corridor leading to, and throughout the cafeteria was observed to be dull and filthy in appearance. The cafeteria floor was scattered with multiple random spots of differing size, that appeared to be dried spills that were able to be cleaned with an alcohol pad. There was debris scattered about the cafeteria floor and buildup of dust, lint and hair noted in the corners under the food line counter. A dining area with tables and chairs was noted to be carpeted and had multiple, irregular shaped dark spots, as large as two foot by two foot and many smaller. There was debris consisting of straw wrappers, food package remnants, lint, etc. scattered under the tables and about the carpeted area. At the time of observation Staff C was queried as to who was responsible for keeping the cafeteria clean, if there was a cleaning schedule, documentation indicating the last time the floor was mopped and or waxed. Staff C was also asked if the flooring appearance and cleanliness was acceptable. Staff C stated, "the house keeping department is responsible to keep the floors clean. No, the floors are not up to our standards. I will put in a work order to have them done, these floors need to be stripped and waxed".

On 12/09/2020 at 1030 during a tour of the ICU (Intensive Care Unit) the floors were observed to be dull in appearance, spattered with random areas of brownish black spatters, scuffs, debris consisting of hair, lint, paper and general filth throughout the entire unit. Two of three cardiac monitors had brown material on the touch pads that came off with alcohol swab. The closed pantry silver (stainless steel) countertops, sink, faucet, and water taps had a white/greenish hue of thick scaley build up scattered over the surface. The floor in the pantry was dull, dirty and debris was randomly scattered about. The ceiling behind and above the ice and water dispenser had a thick buildup of dust. The front cover of the ice and water dispenser was hanging open. The water and ice dispenser were checked and found to functional. Staff C was asked if the ice and water dispenser was in active use for patients. Staff C confirmed the above findings and stated "yes the ice machine and water dispenser are used for patient consumption. I will get someone in here to clean and fix this."

On 12/09/2020 at 1045 the tour progressed to the fourth floor. The "family waiting room" outside of the 30 bed In-Patient Psychiatric Unit (4 South) was inspected and found to have a foul odor, to have filthy and worn and stained carpet, littered with debris consisting of hair, lint, paper clips and paper, found under the chairs and in the corners. At the time of observation Staff C stated, "since COVID, we haven't used this waiting room for families. We will get it cleaned."

On 12/09/2020 at 1055 upon entering 4 South (locked Psychiatric Unit), the floors were observed to be buckled and lifting in multiple areas through-out the 30-bed unit. There were areas (too numerous to list) of gouges and missing flooring leaving areas open to the sub flooring and collecting dirt and debris because it was not easily cleanable. Multiple areas of flooring at the thresholds were torn and black in color, the entire unit including patient rooms, laundry room, medication room, lab room, dining area and nursing station flooring was dull, filthy and scattered with debris. At the time of tour, the area behind the nurse's station was being swept by Staff O, there was a large collection of dirt, lint, hair, paper clips and medication caps observed being swept into a large collection. Staff O was observed to sweep around three open plastic blue bins that held patient belongings, as well as around bags of clothing stored under the desk. At the time of observation Staff O was asked to run her finger across a ledge approximately four inches directly above the three open blue bins. There was an accumulation of dust and lint on the ledge that was easily moved when Staff O ran her finger over the ledge.

On 12/09/2020 at 1115, Staff O was queried regarding how often she swept and dusted in this unit (particularly behind the nurse's station). Staff O stated, "everyday" when queried further, regarding the pile of debris swept up and the dust on the ledge above the bins, Staff O stated, "no that is probably not from one day, I don't ever wipe those ledges that is not my job and I don't know who does it." An accumulation of dust on top of the shelving and behind the computers in the nurses' station was observed. The work counters in the main nurses station was observed to have large pieces of missing laminate the entire length of the counter tops, as well as chipped laminate on the work surfaces behind the station, leaving open particle board to be exposed. This issue was confirmed to be common throughout the facility wherever there was laminate. As the tour progressed in the unit it was observed that patient room doors and the casing going into patient toilet rooms were riddled with rust and erosion in the lower portions, leaving open areas as a portal for bacteria. The above findings and observations were confirmed by accompanying Staff C.

On 12/09/2020 at 1125 while observing in the 4 South dining area two large waste receptacles were observed to have a thick layer of white and brown buildup of wasted food on the outer and inner portions of the waste cans. At the time of observation, Staff C was queried as to who cleaned the waste receptacles. Staff C stated, "housekeeping empty them but we are working on trying to find an acceptable solution." Hand soap, hand sanitizer, and hand washing sinks were available throughout the facility units.

On 12/09/20 at 1415 during an interview with Staff P, it was noted that "I complete monthly rounds and switch areas. I have a check off sheet for certain things that need to be checked." Staff C stated that the environmental rounds on the patient floors are only completed every 3 months. Review of the check off sheet for the patient units confirmed that the "4 South Unit" environmental check was completed last on" 05/11/20" and there was no checkoff sheet found for the "cafeteria".