Failure to Integrate Ongoing Pest Infestation Issues into QAPI Activities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its Quality Assurance and Performance Improvement (QAPI) program made good faith efforts to identify and correct known quality deficiencies related to pest control. Surveyors reviewed the facility’s QAPI policy, last revised in March 2025, which described a QAPI committee/subcommittee working with facility leadership and the Quality Assessment & Assurance committee. They also reviewed 2025 quarterly QAPI meeting attendance sheets and agendas dated 4/8/2025, 7/23/2025, and 11/12/2025. These agendas documented discussion topics such as staffing, dignity, maintenance repairs, accident/incident reports, smoking compliance, pressure ulcers, antibiotic stewardship, exercise of rights, and documentation, but did not include pest control or infestation issues. During recertification and abbreviated surveys conducted in early February 2026, surveyors identified ongoing concerns about roaches and mice in the facility, as referenced in F925. Interviews with staff and residents during this period confirmed that there were continuing sightings of roaches and mice on the units. In an interview, the Administrator acknowledged being aware of these pest issues but stated that the pest problem had not been discussed as part of the QAPI program. There was no evidence that the QAPI process had been used to address or correct the pest control concerns, despite the facility’s awareness of the problem.
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