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F0880
D

Failure to Follow Bed Bug Infection Control Protocols

Ottawa, Illinois Survey Completed on 06-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow recommended guidelines for infection prevention and control in response to the presence of bed bugs in the rooms of two residents. Staff discovered bed bugs in one resident's room, and although clothing was bagged and removed on one occasion, there were inconsistencies in the handling of personal items and the timing of room treatment. On a previous occasion, not all clothing or items in drawers were removed, and staff questioned whether proper treatment was performed, as another live bed bug was found later. The pest exterminator did not arrive until several days after the initial report, and during this period, one resident was isolated in the room while the other was moved to a different room. Observations revealed that personal items such as shoes, socks, and toiletries were left unbagged in the affected rooms, contrary to the facility's own policy and the pest exterminator's recommendations. Staff interviews indicated a lack of consistent education and communication regarding the proper procedures for handling bed bug infestations. Some staff were unaware of the need to shower residents before moving them out of infested rooms, and there was confusion about the appropriate steps to take when bed bugs were found. Additionally, there was no documentation in the residents' medical records regarding the discovery of bed bugs or the treatment provided. The facility's policy required that all clothing and personal items be bagged, residents be showered and dressed in clean clothing from outside the room, and that personal belongings not leave the room until deemed bed bug free. However, these procedures were not consistently followed, as evidenced by staff and resident reports, lack of documentation, and direct observation of unbagged items remaining in the rooms. The failure to adhere to established protocols contributed to the ongoing presence of bed bugs and inadequate infection control practices.

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