Administrator Failed to Oversee Effective Pest Control, Leading to Kitchen Closure
Penalty
Summary
The facility failed to ensure effective and efficient administration, as the Administrator was not involved in maintaining an effective pest control program. During multiple observations, live cockroaches were seen in the kitchen, including one immediately upon entry and at least ten under a handwash sink. Staff interviews revealed that the issue had been ongoing, with dietary staff reporting sightings to the Dietary Supervisor, who in turn reported the problem to the Administrator and the previous Maintenance Supervisor. However, the Administrator was not present at the facility during the survey, being on vacation, and was unaware of the severity of the infestation. The Vice President of Clinical Reimbursement, who was covering for the Administrator, was also unaware of any pest or maintenance issues. The facility did not have documentation of pest control services, as the previous Maintenance Supervisor, who had been the main contact with the exterminator, was no longer employed and the Administrator was not included in related communications. The lack of oversight and documentation led to the Environmental Health Services Officer mandating the closure of the kitchen due to the cockroach infestation. The Administrator's job description indicated responsibility for all facility operations, including physical operations, but this responsibility was not fulfilled in relation to pest control.
Plan Of Correction
A comprehensive inspection of the kitchen was conducted, followed by pest control services and treatment on 07/10/2025. The entire kitchen was thoroughly cleaned and disinfected by the dietary manager and housekeeping staff on 07/10/2025. On 7/10/25, a pest control log was created and is actively maintained by the acting Administrator for tracking ongoing pest management. On 7/14/25, the Facility Administrator was given a 1:1 in-service by the Regional Administrator on leadership responsibilities, including environmental services oversight. On 7/11/25, the Dietary Manager was provided with a 1:1 in-service by the facility's Registered Dietitian (RD), with emphasis on proper kitchen sanitation standards and infection control protocols. All kitchen staff received in-service training by the Registered Dietitian (RD) on 7/11/25, reinforcing sanitation procedures and safe food handling practices. How the facility will identify other residents having the potential to be affected by the same deficient practice: All 117 residents were considered at risk due to the potential health hazards related to pest infestation and the temporary closure of the kitchen. On 7/11/25, residents were monitored for any signs of gastrointestinal or allergic reactions during the affected period; no related health incidents were identified. No adverse effects were reported among residents. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: At random times, the Administrator and Registered Dietitian will conduct Kitchen Sanitation Reviews daily for 5 days, twice a week for 2 weeks, and weekly thereafter. They will use kitchen sanitation audit tools to review the kitchen and high-risk areas twice a month for three months. Any findings will be reviewed with the Dietary Manager and Administrator for further actions. The pest control vendor will provide treatments and is required to submit a written service report after each visit, which will be signed off by the administrator to confirm it has been reviewed. A comprehensive inspection of the kitchen was conducted, followed by pest control services and treatment on 07/10/2025. The entire kitchen was thoroughly cleaned and disinfected by the dietary manager and housekeeping staff on 07/10/2025. On 7/10/25, a pest control log was created and is actively maintained by the acting Administrator for tracking ongoing pest management. On 7/11/25, all staff were given an in-service on the importance of timely reporting of pest sightings as shown on lesson plan titled, "Know the Enemy: Identifying Pests for Better Control in Healthcare," under the objective: "Report and document pest sightings accurately." The in-service was completed by the clinical consultant. The facility plans to monitor its performance to ensure that solutions are sustained: Pest control reports and Kitchen Sanitation will be standing agenda items at the facility's monthly QA Committee meeting. Kitchen inspections at random times and pest control documentation will be reviewed monthly by the Facility Administrator and Maintenance Supervisor and reported to the QAPI Committee. The QAPI Committee will monitor and evaluate compliance for a minimum of three months or until 100% compliance is achieved and maintained.