Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice Immediate Action: On 07/10/2025, the facility immediately ceased all kitchen operations and posted visible signage stating "KITCHEN CLOSED FOR SANITATION." On 07/10/2025, residents and their responsible parties were notified of the kitchen closure and the interim meal service plan. The Maintenance staff, Vice President of Clinical Reimbursement, and the Registered Dietitian conducted a full inspection of the kitchen on 07/10/2025. Pest control services were contacted immediately, and treatment was performed the same day. On 07/11/2025, the facility obtained a written pest control report and recommendations based on the 07/10/2025 treatment. On 07/10/2025, the entire kitchen was thoroughly deep cleaned and disinfected by the Dietary Manager and housekeeping staff. On 07/11/2025, the Dietary Manager, Registered Dietitian (RD), and Infection Control Preventionist conducted sanitation rounds in the kitchen to verify cleanliness following the deep cleaning. All infested materials were removed and properly disposed of by kitchen staff and environmental services on 07/11/2025. Beginning 07/11/2025, the Maintenance Director scheduled and completed repairs to seal all visible gaps and crevices within 24-48 hours following the pest control treatment. Pest control services were increased to twice-weekly treatments, with services performed on 07/11/2025, 07/12/2025, 07/14/2025, 07/15/2025, and 07/18/2025. Royalty Commercial Cleaning was contracted to complete additional deep cleaning of the kitchen on 07/12/2025, 07/13/2025, 07/15/2025, and 07/16/2025. On 07/10/25 and 07/11/2025, all facility staff received in-service training from Clinical Nursing Consultants on pest prevention protocols, environmental sanitation, and identifying pest-related risks. On 07/11/2025, all kitchen staff received an in-service from the Registered Dietitian to ensure adequate knowledge of food safety practices and vermin infestation prevention. Interim Meal Service Plan During Kitchen Closure Effective 07/10/2025 On 07/10/2025, meal planning, menu modifications, and dietary adjustments were immediately implemented by the Dietary Manager in response to the kitchen closure. All residents' meals are being catered by a licensed and verified outside food vendor. A Registered Dietitian (RD) reviews and approves all catered menus in advance to ensure the following: - Menus align with individual dietary orders and resident care plans - Meals accommodate resident preferences, allergies, and cultural or religious dietary needs - Delivered meals are received, logged, and checked for appropriate holding temperatures - Meals are served by facility staff in a designated clean area using disposable service ware - Nursing staff continue to monitor and document meal intake, weight changes, hydration status, and any adverse reactions or concerns related to food quality - Mechanically altered diets (e.g., chopped, ground, pureed) and thickened liquids are prepared by the off-site kitchen in accordance with physician orders and resident care plans On 07/11/2025, all infested materials were removed and properly disposed of by kitchen staff and environmental services. Beginning 07/11/2025, the Maintenance Director scheduled and completed repairs to seal all visible gaps and crevices within 24-48 hours following the pest control treatment. Pest control services were increased to twice-weekly treatments, with services performed on 07/11/2025, 07/12/2025, 07/14/2025, 07/15/2025, and 07/18/2025. Royalty Commercial Cleaning was contracted to complete additional deep cleaning of the kitchen on 07/12/2025, 07/13/2025, 07/15/2025, and 07/16/2025. On 07/10/25 and 07/11/2025, all facility staff received in-service training from Clinical Nursing Consultants on pest prevention protocols, environmental sanitation, and identifying pest-related risks. On 07/11/2025, all kitchen staff received an in-service from the Registered Dietitian to ensure adequate knowledge of food safety practices and vermin infestation prevention. Interim Meal Service Plan During Kitchen Closure Effective 07/10/2025 On 07/10/2025, the facility dining room was converted into a temporary food service area. Housekeeping staff are responsible for cleaning and disinfecting the area before and after each meal service. Residents are not permitted to stay in the dining room at any time during this period. Signage was posted stating: "STAFF ONLY -- DO NOT ENTER" and "DINING ROOM CLOSED." All food is served using disposable kitchenware, and this practice will remain in place until kitchen operations resume. Dietary staff from California Post Acute are responsible for preparing mechanically altered meals and thickened liquids at the off-site kitchen and transporting them safely back to the facility. How facility will identify other residents having the potential to be affected by the same deficient practice All residents were considered at risk due to the potential health hazards related to pest infestation and the temporary closure of the kitchen. On 07/11/2025, the Social Services department conducted interviews with a representative sample of residents, specifically, at least 20% of cognitively intact residents, to assess satisfaction with the interim meal service and identify any related concerns. No concerns were reported. On 07/11/2025, residents were monitored for any signs of gastrointestinal or allergic reactions during the affected period; no related health incidents were identified. 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/Registered Dietitian will conduct Kitchen Sanitation inspections daily for 5 days, twice a week for 2 weeks, and weekly thereafter. Using kitchen sanitation audit tools, inspections of the kitchen and high-risk areas will be conducted 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 biweekly 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. On 07/10/2025, the facility dining room was converted into a temporary food service area. Housekeeping staff are responsible for cleaning and disinfecting the area before and after each meal service. Residents are not permitted to stay in the dining room at any time during this period. Signage was posted stating: "STAFF ONLY -- DO NOT ENTER" and "DINING ROOM CLOSED." All food is served using disposable kitchenware, and this practice will remain in place until kitchen operations resume. Dietary staff from California Post Acute are responsible for preparing mechanically altered meals and thickened liquids at the off-site kitchen and transporting them safely back to the facility. How the facility plans to monitor its performance to make sure that solutions are sustained: Pest control service logs and kitchen sanitation audit results will be standing agenda items for review at the facility's monthly Quality Assurance (QA) Committee meetings. The Facility Administrator, Maintenance Supervisor, and Registered Dietitian will present their findings and feedback regarding pest control logs and kitchen sanitation audits to the QAPI Committee during scheduled reviews. The QAPI Committee will monitor and evaluate compliance for a minimum of three months, or until 100% compliance is achieved and sustained.