F0880

E

Failure to Implement Bed Bug Surveillance and Reporting Under Infection Control Program

Lancaster, California Survey Completed on 11-18-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program and related policies when bed bugs were identified in a shared resident room. On 10/9/2025, a CNA assisting a resident in Room A around 4 a.m. observed several small red insects on the white linen covering the resident’s mattress and notified another CNA, who then informed an LVN. The LVN went to Room A, confirmed the presence of small insects on the resident’s bed, notified an RN, and completed a skin assessment that did not show signs of bed bug bites. The Infection Preventionist (IP) was later informed by a supervisor that a bed bug had been seen in Room A and went to assess the residents in that room, again not observing signs of bed bug bites.

Resident records showed that three cognitively intact residents with varying levels of dependence for activities of daily living were residing in Room A. One resident had diagnoses including type 2 diabetes mellitus, cerebral infarction, and cardiomegaly and was dependent on staff for toileting hygiene, personal hygiene, showers, and dressing. A second resident had type 2 diabetes mellitus, osteomyelitis, and muscle weakness, required supervision for toileting and personal hygiene, and needed assistance for showers, dressing, and ambulation. A third resident had a history of cerebrovascular accident with right-sided hemiplegia, end-stage renal disease, and dependence on dialysis, and required moderate to maximal assistance with hygiene and dressing but was independent in wheelchair mobility. A pest management company inspected Room A later that morning and positively identified bed bugs on one mattress, with a recommendation for heat treatment.

The IP stated that bed bugs can be transferred via clothing and linens and can cause bites, allergic reactions, rash, itchiness, and welts, but acknowledged that the facility did not initiate contact tracing between residents in Room A and staff assigned to that room, nor between those staff and other residents. The IP further stated that residents outside Room A were not assessed for bed bug bites or skin rashes, and that the facility failed to develop a surveillance and monitoring system for bed bugs after the incident. The Maintenance Supervisor confirmed that the pest control company conducts monthly inspections and that the 10/9/2025 bed bug finding was not a usual occurrence. The Administrator and Assistant Director of Nursing both indicated that bed bugs were not a usual occurrence in the facility and that failure to thoroughly inspect the facility and residents for bed bugs had the potential to affect resident safety.

Review of facility policies showed that the Infection Prevention and Control Program policy required the facility to identify, investigate, control, and prevent infections and to maintain a safe, sanitary, and comfortable environment. A separate Bed Bugs policy stated its purpose was to ensure the facility takes precautions needed to prevent, control, and manage a bed bug infestation. The facility’s Reportable Diseases and Communicable Diseases–Outbreak policies defined “unusual occurrences” as events such as epidemic outbreaks or other occurrences that threaten the welfare, safety, or health of patients, personnel, or visitors, and indicated that such occurrences should be promptly identified and reported. The Administrator stated that bed bugs were not a usual occurrence in the facility and that their identification had the potential to negatively affect resident safety and health, but the facility did not contact the Department of Public Health to report this unusual occurrence, contrary to its policies.