Other·August 27, 2021

F880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

F925 §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. The facility failed to maintain the kitchen in a clean, safe, and sanitary condition in which food was stored, prepared, and served in accordance with professional standards of food service safety affecting the total census of 108 residents, who received food from the kitchen by: 1. Failing to eradicate (destroy/kill) cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population). 2. Failing to eliminate harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) on the walls, buildup of debris on floors, walls and equipment, and accumulation of grease on surfaces. As a result, there was an increased potential to cross-contaminate food and food contact surfaces that could cause food borne illness (food infection from ingesting live bacteria or food intoxication from ingesting food containing toxins from bacteria) and vector-borne diseases (illnesses that results from infections transmitted to humans by insects, such as cockroaches) for 108 residents who receive food from the kitchen. During a kitchen tour on 6/28/2021, at 9:40 a.m., the following were observed and confirmed with Cook 1 at the facility's dishwashing area: 1. Three live nymph (baby) cockroaches and three dead cockroaches in two monitoring traps (sticky traps used to monitor and identify pest infested [present in large numbers] areas) on the floor under the dish machine drainboards. 2. One cockroach egg capsule and one dead cockroach on the floor under the dish machine drain board. 3. One cockroach egg capsule on and one adult cockroach walking on an encrusted electrical junction box. The adult cockroach hid between the crevices of the encrusted electrical junction box. 4. Peeling paint and encrusted debris on the wall behind the dish machine drain board and the two-compartment sink. During an interview with the Director of Maintenance (DM) and Assistant Administrator (AADM) on 6/28/2021, at 9:59 a.m. DM stated that there was no pending walls or structural work to be done in the kitchen. AADM stated that on 6/3/2021, housekeeping department along with the maintenance department conducted a deep clean including floors, walls, ceilings, and vents in the kitchen. During an interview on 6/28/2021, at 10:02 a.m., AADM stated that there was no official deep cleaning schedule for the kitchen. During a concurrent observation and interview on 6/28/2021, at 10:06 a.m., the facility kitchen was observed with AADM and DM. AADM confirmed peeling paint and debris build-up on the wall under and around the dish machine drainboard, and the two-compartment sink. DM confirmed hole on the wall around a pipe under the dish machine drain board. DM stated that the hole "needs to be closed". Both AADM and DM confirmed observation of egg capsules, live, and dead cockroaches at the dish washing area. DM disposed of the monitoring traps containing dead and live cockroaches. During an interview with DM and AADM on 6/28/2021, at 10:22 a.m., DM stated the cockroaches were coming out because of the heat. DM stated that the presence of cockroaches can get people sick, especially from food eaten from the kitchen. DM explained, the facility has a contract with a pest control company who comes and conducts monthly pest control service. AADM added, the pest control company had been contacted to come to the facility for treatment (application of pesticides used to kill, repel, or control pests). During a concurrent observation and interview with AADM on 6/28/2021, at 10:31 a.m., the kitchen was observed. A nymph cockroach was observed walking on the wall next to the electrical junction box at the dish washing area. AADM stated, the cockroach might be coming from the encrusted electrical junction box (an enclosure housing electrical connections). During a concurrent observation and interview with DM on 6/28/2021, at 10:34 a.m., the kitchen was observed. A nymph cockroach was observed walking on the floor by the kitchen two-compartment sink. Observed gaps on top and bottom of wall covering next to the two-compartment sink. The DM confirmed findings. Observed the DM step on the nymph cockroach. During a concurrent observation and interview on 6/29/2021, at 8:30 a.m., the kitchen was observed with the administrator ADM, AADM, DM, and Environmental Health Specialist (EHS [A health inspector responsible for ensuring food provided for human consumption is safe and free of contamination]). Observed were two live nymph cockroaches observed under the dish washing machine, and one live adult cockroach behind the dish washing machine. During a concurrent interview, DM confirmed one live nymph cockroach, however, he was not able to observe the other two live cockroaches. During an interview with the Infection Preventionist Nurse (IP) on 6/29/2021, at 8:49 a.m., the IP stated, her role in the kitchen included ensuring staff have good handwashing practices, proper dishwashing, check of food preparation areas, ensuring proper food/refrigeration temperatures, and pest monitoring. IP stated she conducted kitchen rounds about two to three times a month with the Kitchen Supervisor. IP stated that in resident care areas, rounds were conducted to ensure cleanliness and proper hand hygiene by staff. IP stated, she had not seen pests in resident care areas. During an interview on 6/29/2021, at 9:28 a.m., with EHS, EHS stated that she observed one live nymph cockroach that went behind the bubbly paint above the dish washing sink sprayer; one live nymph cockroach on the wall under the sprayer, and one live cockroach behind the dish machine drain board in the kitchen. The EHS explained, there could be more nymph cockroaches on the wall behind the bubbly paint. She also stated that the facility's kitchen was closed and that a Compliance Review Hearing (meeting between the facility's owner or representative and the Environmental Health Supervisor to discuss non-compliance) was scheduled on 6/30/2021, at 11 a.m. The EHS will be conducting a re-inspection of the facility's kitchen on 6/30/2021. A review of the EHS' Official Inspection report dated 6/29/2021, indicated the following: 1. "One live nymph cockroach on the wall at the metal flashing (thin pieces of impervious material installed to prevent the passage of water into a structure) and the paint on the wall that is bubbled and peeling. Nymph cockroach went under the bubbled paint." 2. "One nymph cockroach behind the scrap sink on the wall underneath the sink moving towards the scrap on the wall at the peeling paint." 3. "One small cockroach behind the wash machine on the wall running to the scrapped paint on the wall." 4. "Continue to self-close for another 24 hours until a re-visit is done by a Public Health Officer to check for more cockroaches." During an interview on 6/29/2021, at 10:56 a.m., with Housekeeping 1 (HSK 1), HSK 1 stated that she had seen cockroaches in the breakroom where staff eats their lunch, about two weeks ago. HSK 1 stated that there were traps and bait gels (insecticide used to control pests) placed to help get rid of the cockroaches. During an interview on 6/29/2021, at 11:13 a.m., Housekeeping Supervisor (HSKS) stated housekeeping has a monthly deep cleaning schedule, employee breakrooms were cleaned three times daily, and housekeeping does not include pest monitoring. The HSKS added, if housekeepers see cockroaches, the practice was to inform the maintenance department and the pest control company. During an interview with Pest Control Technician 1 (PCT 1) and Pest Control Technician 2 (PCT 2) on 6/29/2021, at 11:21 a.m., PCT 1 admitted presence of cockroaches in the facility, primarily cockroaches that comes from plumbing. PCT 2 stated that he started providing pest control services to the facility on November 2020 and comes to the facility to conduct pest monitoring/treatment two times a month, once during the day and once during the night, and that he inspected the kitchen, laundry area, and nursing stations at night. PCT 2 explained, he had started seeing nymph cockroaches in the kitchen in November 2020 and recommended to the facility to increase services, deeper treatment, and better sanitation. During an interview with the Registered Dietician 1 (RD 1) on 6/29/2021, at 12:20 p.m., RD 1 stated that she comes to the facility two times a week for about 16 to 24 hours. Her role includes resident care and nutrition, clinical charts, monthly kitchen audits, tray line check, and in-services to dietary staff. The RD stated, the facility needed a full-time staff to manage the kitchen. During a concurrent observation and interview with the AADM on 6/29/2021, at 1:00 p.m., a gap greater than one fourth of an inch was observed on the exterior door next to the Disaster Food Storage room (leading to Station 2 hallway). The AADM stated that the gap will be fixed. During an interview on 6/30/2021, at 9:58 a.m., ADM stated he was not able to locate the binder containing the kitchen "Daily Cleaning Scheduled Form" completed by dietary staff. During a kitchen observation with the DM on 6/30/2021, the following were observed: 1. At 10:33 a.m., there was a hole around a pipe under the kitchen preparation sink. The DM stated the hole will be sealed. 2. At 10:45 a.m., there were crevices on the wall outside the walk-in refrigerator. The DM stated, the gap will be sealed. 3 At 10:46 a.m., there were crevices between the wall and tiles inside the dry storage room. The DM stated, the gap will be sealed. During a concurrent interview and record review with DM on 6/30/2021, at 1:15 p.m., Pest Control Service Inspection Report from 1/14/2021 to 6/25/2021 were reviewed. The DM denied seeing cockroaches in the facility but confirmed having known of cockroach issue based on the report. DM explained, noted cockroach activities on the report were the pest control technician's own observations. He claimed that he reviews the pest control service inspection report and works on pest control technician's recommendations. DM also stated that he had previously notified ADM and AADM of the issues. DM explained, first it was the kitchen that had cockroach problem and then the breakroom. A review of the facility's document titled, "Sanitation and Food Safety Checklist", dated 4/12/2021, indicated the following: - The oven and grill needed cleaning. - There were "chipped paint throughout". - Pest activity noted by dish machine area. - Kitchen needed deep cleaning. A review of the facility's document titled, "Sanitation and Food Safety Checklist", dated 5/18/2021, indicated that there were "chipped paint throughout" and the kitchen needed deep cleaning. A review of the facility's document titled, "Sanitation and Food Safety Checklist", dated 6/22/2021, indicated that the walls needed cleaning and there were "chipped paint throughout". A review of the facility's document titled, "Nutrition Services Sanitation/Food Safety Checklist", the document indicated recommendations for the facility to clean and repair physical plant/equipment noted on: - 4/30/2021, 4/23/2021, 5/20/2021, 5/14/2021, and on 6/3/2021 to clean/repair floors, walls, and ceilings. - 4/30/2021, 4/23/2021, 4/16/2021, 4/2/2021, 5/21/2021, 5/14/2021, 5/7/2021, and on 6/3/2021 to clean/repair cooking equipment. A review of "Service Inspection Report" from the facility's Pest Control Company indicated the following: 1) Report dated 1/5/2021, 1/14/2021, 2/10/2021, and 3/2/2021 indicated cockroach activity in Nursing Station 3 breakroom. a) On 1/5/2021, pest control technician recommended for possible disposal of refrigerator due to cockroaches "being deep within the fridge". b) On 1/14/2021, report also indicated dead cockroaches were found in the kitchen. 2) Report dated 2/25/2021, 3/30/2021, 4/8/2021, 4/20/2021, and 5/21/2021, indicated cockroach activity in the kitchen. a) On 4/20/2021, the report indicated cracked tile/grout opening under the water booster allowing cockroaches to enter the building and if holes were sealed and cracked/burst pipe were not fixed, cockroaches may go to different areas of the building. b) On 5/21/2021, report also indicated that due to cracked opening on floor, cockroaches continued to enter the building. 3) Report dated 6/25/2021, indicated monitor boards for cockroaches were replaced. 4) Monthly Service Inspection Report from 1/5/2021 to 4/20/2021, indicated pest control technician's recommendation to replace weather stripping to avoid pest introduction in the kitchen. 5) Monthly Service Inspection Report from 1/5/2021 to 6/25/2021, indicated pest control technician's recommendation to: a) Clean and sanitize drains due to drain build up in the kitchen. b) Seal gaps, cracks, and void in tiles inside the kitchen. c) Mop up water due to excessive water in the kitchen dishwash area. During a concurrent observation and interview with Cook 1 on 6/28/2021, at 9:24 a.m., the following were observed in the facility's kitchen: 1. Grease accumulation on the floor and on the side of the range (combination of stove and oven). 2. Debris and grease accumulation on a space between the stove and the oven. 3. G