Environmental Sanitation in Long-Term Care Facilities: A Focus on Regulations and Implementations

Author

Ruwan Dissanayake Dissanayake Mudiyanselage, Clemson UniversityFollow

Date of Award

12-2025

Document Type

Thesis

Degree Name

Master of Science (MS)

Department

Food, Nutrition, and Culinary Science

Committee Chair/Advisor

Dr. Xiuping Jiang

Committee Member

Dr. Dale Grinstead

Committee Member

Dr. Hannah K. Wilson

Abstract

Environmental sanitation is a fundamental component of infection prevention in long-term care facilities (LTCFs), where residents are at increased risk due to advanced age, underlying health conditions, and communal living arrangements. Despite its critical role, significant gaps remain in implementing environmental sanitation procedures and the regulatory frameworks that guide them.

This study combines two components: (1) an across-state regulatory review of environmental sanitation in LTCF regulations and (2) a cross-sectional survey assessing environmental sanitation characteristics of nursing homes (NHs) and assisted living facilities (ALFs) and Rural and Urban LTCF observation study in South Carolina (SC) . For the regulatory review study, licensing regulations for NHs and ALFs were downloaded from official government websites across all 50 US states and the District of Columbia. The provisions related to environmental sanitation were searched using key terms and then quantified to answer 4 research questions. Descriptive statistics (frequencies and percentages) were used for reviewing data analysis. For study 2, a 58-item Web-based survey was distributed to a total of 201 NHs and 285 ALFs in SC. Data was gathered, and descriptive statistics and Pearson's correlation were used for analysis.

Regulations on environmental sanitation varied widely by state. More states required infection preventionists in NHs (n=29) than ALFs (n=14), and references to environmental service workers (ESWs) were also more required in NHs (n=22) than ALFs (n=6). Similarly, infection control training was more frequently mandated for NHs (n=32 states) than ALFs (n=27). However, only a few states addressed carpet cleaning and disinfection (7 NHs, 2 ALFs) and treatment of high-touch surfaces (< 6 states in NH and ALF). In SC, 49 LTCFs responded (response rate: 10%) to our study. Most facilities (n=26) assigned more than seven rooms per ESW, and 24 reported small ESW teams (1–10 workers). Daily cleaning and disinfection of resident rooms, floors, and common areas was common; however, cleaning and disinfection frequencies of high-touch surfaces varied. Daily carpet cleaning (n=6) and chemical disinfection of carpets (n=7) were less frequently reported compared to hard surface cleaning (n=10 for tile). Area- and event-specific cleaning protocols and checklists were widely used, yet only half of the facilities conducted daily reviews to verify checklist completion. Although most (n=33) facilities required ESW training, only 22 reported incorporating competency assessments. Staff shortage was the most frequently cited barrier to effective environmental sanitation (n=11). In the rural–urban comparison, no significant differences were found among the variables. However, when comparing NHs and ALFs, significant differences were observed in the presence of infection prevention committees. Observational findings from four LTCFs in SC (two rural and two urban) further confirm survey-reported environmental sanitation policies. Daily cleaning and disinfection of high-touch surfaces, glove use, availability of environmental sanitation protocols and checklist, hard floor cleaning methods aligned with survey reported data. However, observational data gave additional insights about variation in soft-surface cleaning and differences in task delegation, where certified nursing assistants (CNAs) performed shared-device cleaning in urban facilities while ESWs did so in rural facilities.

Both regulatory data and Survey findings reveal critical gaps in environmental sanitation across LTCFs, particularly related to ESW staffing, training, and oversight of environmental sanitation protocols. Regulatory inconsistencies, coupled with insufficient emphasis on high-touch and porous surfaces, may compromise infection control if facilities rely solely on them for guidance. A standardized approach to consistent regulations, ESW training, staffing adequacy, and environmental sanitation practices is essential to mitigate healthcare-associated infections and improve care quality in LTCFs.

Recommended Citation

Dissanayake Mudiyanselage, Ruwan Dissanayake, "Environmental Sanitation in Long-Term Care Facilities: A Focus on Regulations and Implementations" (2025). All Theses. 4645.
https://open.clemson.edu/all_theses/4645