Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of pests and rodents during the recertification survey. A live rodent was found in a box trap in the dining room while residents were present, and flies were observed in various units, including near the nurse's station and in resident rooms. Additionally, roach droppings were noted on stored equipment in the atrium, and bait traps had not been updated since October 2024. Interviews with staff and residents revealed sightings of mice and flies, with some residents expressing concern about the presence of mice in their rooms. The facility's pest control policy, revised in May 2024, outlines a comprehensive program involving weekly services from an outside pest control company. However, the observations and interviews indicate that the program is not effectively implemented. Staff members, including the Director of Maintenance and the Infection Preventionist, acknowledged the presence of pests and the potential infection control issues they pose. Despite the facility's policy and procedures, the presence of pests and rodents suggests a deficiency in the execution of the pest control program.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F925 Corrective Action: The Housekeeping and Maintenance Director responded to, 2 West Dayroom, Nurses' station, room [ROOM NUMBER], 238, 239, 4 West Nursing Station, 4 West Hallway, Kitchen, and Atrium, to check all areas for flies and rodents. Any exposed food was either discarded or placed inside a plastic container. The Exterminator treated all areas on 12/26/24, 1/2/25, and 1/6/25. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The Housekeeping and Maintenance Directors immediately inspected all areas in the building; no other pest control issues were identified. Element 3 Systemic Change: The Pest Control Policy was reviewed; no changes were required. All Dietary, Housekeeping, Maintenance, Nursing (CNA's, LPN, RN's), Activities, and Rehab staff are being in-serviced on the procedure to follow when any areas within the facility require treatment. The Pest Control Company, in addition to 3 weekly visits, will be available for additional visits on an as-needed basis. An audit tool was developed to monitor compliance. Element 4 Monitoring: 3 times per week for one quarter, the Food Service Director/Designee will conduct rounds and audits for sanitation and signs of pest activity. Any adverse findings will be logged into the pest control book and reported to the administrator. For one quarter, the director of maintenance or designee will audit the environment weekly to assist in monitoring pest control service. Any issues identified will be responded to immediately, and reports will be made to the administrator weekly. The results of all audits will be reported to the QAPI Committee quarterly for 2 Quarters/six months. The QAPI Committee will determine if further action is required. Element 5 Date of Correction: (MONTH) 12, 2025 Persons responsible: Food Service, Housekeeping, and Maintenance Directors.