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F0865
F

QAPI Program Failed to Address Infection and Pest Control Deficiencies

Waterford, Michigan Survey Completed on 07-31-2025

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's Quality Assurance and Performance Improvement (QAPI) program failed to identify and address systemic issues related to Infection Control and Pest Control. During a recertification survey, surveyors observed ongoing concerns in these areas, including the presence of flying insects on all three resident floors and a lack of recent pest control documentation, with the last recorded service dated several months prior. Additionally, there was no evidence of infection surveillance for legionella or adherence to county health department guidance. In an interview, the Administrator confirmed that the Quality Assurance (QA) committee was not currently addressing Infection Control or Pest Control as areas of concern, and there were no active QAPI plans for these issues. Review of the facility's QAPI policy indicated that the committee is responsible for identifying and responding to quality deficiencies, developing corrective actions, and monitoring performance, but these responsibilities were not fulfilled in the areas identified by surveyors.

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