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Based on observations, interviews, and a review of policies/procedures, the facility failed to ensure the premises were clean. Observations of the medication storage room on the medical/surgical nursing unit revealed numerous items with a buildup of dirt.

The findings include:

A tour of the medication storage room on the medical/surgical nursing unit was conducted on November 9, 2010, at 10:10 a.m. Observations of the medication storage room revealed there were three medication carts in the room. The medication carts were observed to have a buildup of dirt/dried substances on the surface, base, and wheels of the carts. A medication storage refrigerator in the medication room was observed to have a buildup of dirt/dried substances on the stainless steel trim located at the base of the refrigerator. A fan was observed to be sitting on the floor of the medication room and was observed to have a heavy buildup of dust on the grill and blades of the fan. In addition, a trash container in the medication room, located adjacent to a medication cart, was observed to have a buildup of dirt/dried substances on the lid and exterior surface of the container.

Interview with the Director of Nursing (DON) on November 9, 2010, at 11:20 a.m., revealed Housekeeping staff was expected to maintain the cleanliness of the medication room, excluding the medication carts. According to the DON, Nursing staff was expected to clean the medication carts.

Interview with the Administrator and the DON on November 10, 2010, at 12:50 p.m, and a review of policies/procedures, revealed the facility did not have written policies/procedures or an established cleaning schedule to ensure the cleanliness of the medication room or the contents of the room.