Failure to Implement Infection Control Program Amid Cockroach Infestation and Lack of Water Management
Penalty
Summary
The facility failed to develop and implement an effective infection prevention and control program (IPCP), as evidenced by a widespread cockroach infestation affecting all resident units, improper handling and storage of clean linens, and the absence of a water management policy to prevent Legionella and other pathogens. Surveyors observed cockroaches in multiple locations, including resident rooms, closets, bathrooms, and on clean linen carts. Food debris and soiled linens were found on floors, and residents and staff reported frequent sightings of cockroaches on personal belongings, clothing, and even on residents themselves. Documentation in pest control logs confirmed ongoing cockroach activity for several months, with staff and residents consistently reporting the problem. Interviews with staff, including CNAs, the Infection Preventionist (IP), the Maintenance Director, and the Licensed Nursing Home Administrator (LNHA), revealed a lack of coordinated response to the infestation. The IP was not involved in pest control efforts and was unaware of the extent of the problem, deferring responsibility to the maintenance department. The pest management company identified the cockroaches as German cockroaches, known for being difficult to eradicate and capable of transmitting disease. Despite recommendations from pest control service reports for improved sanitation, there was little evidence of follow-up or comprehensive action to address the infestation or to protect residents' personal belongings and clean linens from contamination. Additionally, the facility did not have a water management program or policy in place to prevent the growth and spread of Legionella. When surveyors requested documentation of water testing or preventive measures, facility management was unable to provide any evidence of such activities. The Director of Nursing confirmed the absence of a water management program, and no logs or policies were available to demonstrate compliance with infection control standards related to water safety.