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Based on observation, interview, and record review, the facility did not meet the Conditions of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs as evidence by:

1. The facility failed to have an effective pest control program by having presence of insects (cockroaches) and pests (rodents) in the facility's kitchen that provided meals (breakfast, lunch, and dinner) to the three hundred thirteen patients. (Refer to a 750).

2. The facility failed to have a sanitary kitchen environment that was free of grease, trash, debris, and gaps for rodent (mouse) and or pest to enter in the facility's kitchen and trash and debris in the facility's cafeteria that provided meals to the three hundred thirteen patients. (Refer to A 750).

The cumulative effect of the deficiency resulted in the hospital's inability to ensure the Conditions of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs was met. The facility's kitchen was temporarily closed due to insects (cockroaches) and pests (rodents) infestation from 2/9/22 to 2/21/22.

Based on observation, interview, and record review, the facility failed to ensure the three hundred thirteen patients in the facility that received meals (breakfast, lunch, and dinner) from the facility's kitchen were free from sources and transmission of infection from insects (cockroaches) and pests (rodents) by failing to:

1. Have an effective pest control program and ensure insects and pests are not found present and trapped in the kitchen.

2. Have an effective pest control program to maintain a clean and sanitary environment free of grease, trash, debris, and gaps for rodent (mouse) and or pest to enter in the facility's kitchen and trash and debris in the facility's cafeteria.

These deficient practices resulted the closure of the facility kitchen on 2/9/22 by the local health department. The presence of insects and pest in the kitchen had the potential to spread communicable diseases (as infectious diseases, illnesses that result from the infection, presence and growth of pathogenic biologic agents (a microorganism that causes or can cause diseases) from an individual human or other animal host) carried and or transmitted by waste products and contaminated surfaces.

On 2/9/21 at 2:53 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the facility's Director of Risk and Quality (DRQ), VP Quality (VPQ), Quality Manager (QM), Associate Administrator, Assistant Chief Nursing Officer (ACNO), Regional Administrator, Chief Operating Officer (COO), Regional Chief medical officer (CMO), Regional VP Quality, Hospital Administrator, Chief executive officer (CEO), and Director Food and Nutrition 1 (DFN 1).

On 2/10/22 at 4:19 p.m., the IJ was lifted after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The elements of the IJ Removal Plan were verified and confirmed through observation, interview, and record review. The IJ was removed in the presence of the facility's DRQ, QM, Associate Administrator, ACNO, Regional Administrator, COO, Regional VP Quality, Hospital Administrator, CE), DFN 1, VP Clinical OP, and Regional Director.

The acceptable removal plan was as follows:

1. On 2/9/22, the facility provided meals to their patients using outside service vendors until 2/21/22 when the facility plans to reopen their facility kitchen.

2. On 2/9/22, members of the hospital leadership revised the facility's policy and procedure, titled, "Pest Control INF.050," to include a pest management program, which included the monitoring, recording, and reporting pest activity to their immediate supervisor. The facility kitchen staffs were to submit an incident report to the office of Quality and Risk Management. The facility developed a perimeter rounding checklist and schedule.

3. On 2/9/22, a multidisciplinary team (involving several academic disciplines or professional specializations in an approach to a topic or problem) met and developed an action plan to address the cleaning and repair of the kitchen. Cleaning protocols were reviewed by the multidisciplinary team and updated to include the preventative strategies to minimize the risk of rodent activity. The detailed plan included the closing of the kitchen and repair of all interior and exterior structural gaps to prevent rodent activity.

4. On 2/9/22, the first interior kitchen cleaning was completed, and the facility implemented monthly interior and exterior power washing and deep cleaning schedule.

5. On 2/10/22, a Pest Control Master Quality Plan Checklist was developed to include a focused emphasis on pest activity during cleaning.

6. On 2/10/22, the facility had a mandatory staff education on the following topics: Revised Pest Control Policy, Recognition of pest activity, required actions when pest activity is observed, and Reporting Requirements.

Findings:

1. During an observation, on 2/8/22 at 10:40 a.m., insects (appears like a cockroaches) were observed trapped on pest glue traps that were placed in kitchen area under the steam kettles (self-contained versions of the large stockpot used for range top cooking).

During an interview on 2/9/22 at 9:40 a.m., DRQ stated, the local health department Environmentalist arrived at facility, on 02/08/2022 around 3:45 p.m., and closed the kitchen area staring breakfast service, on 2/9/2022, due to Environmentalist's observation of pest droppings and cockroaches on traps.

During an interview, on 2/8/22 at 10:38 a.m. Kitchen Staff 1 (KS 1) 1 stated observing a live rat, on 2/8/2022, in the kitchen area.

During an interview, on 2/8/22 at 10:50 a.m., KS 2 stated observing a live rat this morning (2/8/22) in the dish room area, under the facility's kitchen sink.

A review of the facility's Customer Service Reports (pest control service records) from 6/28/21 to 2/8/2022 for the facility's kitchen indicated that 7 of 21 pest control reports, dated 8/30/21, 10/4/21, 10/7/21, 10/15/21, 10/20/21, 2/1/22, and 2/8/22, indicated rats were noted during service.

A review of the facility's Customer Service Report, dated 8/30/21, indicated that at the kitchen interior, rats were noted during service and a rodent was caught in a trap.

A review of the facility's Customer Service Report, dated 10/4/21, indicated at the kitchen interior rats were noted during service and three rodents were caught in traps.

2. During an observation on 2/8/2022 at 10:30 a.m. to 10:50 a.m., the following were observed in the facility's kitchen:

a. Under the steam kettles, an accumulation of grease and debris that included seven large glue traps with an accumulation of grease, trash. Food debris were observed on the steam kettles.

b. There was a gap greater than half an inch (1/2" X [a unit of length, separates the length and width dimensions] 22") between two stainless steel wall mounted plates behind the steam kettles in the kitchen where a rodent could enter the kitchen.

c. There was a gap greater than half an inch (3/4" X 2") at the door to the exterior in the dishwasher room where a rodent could enter the kitchen. The gap was at the bottom corner of the door between door and door frame.

d. The lamp for facilitating the monitoring of stored product and cleanliness in the facility's second walk-in refrigerator failed to light. The refrigerator contained prepackaged bottles of milk shakes.

During an observation on 2/8/2022 at 11:00 a.m., at the cafeteria, there was an accumulation of trash and debris at the space between a hand wash sink and reach in refrigerator. The cafeteria shares a wall and two opened doors with the kitchen at the time of the observation.

During an observation on 2/9/2022 at 10:58 a.m. in the kitchen with the Executive Chef, the top stainless-steel surface of one of two steam kettle had five rough cuts creating a condition where the surface was no longer smooth and easily cleanable. There were dark grease and dirt deposits within the cuts.

During an interview, on 2/9/22 at 10:58 a.m., the Executive Chef stated that the cuts were made to the surface cover of the kettle to create a door to access the on and off valve of the kettle, because the missing part that controls the on off valve was no longer available.

A review of facility's inspection report, titled, "Retail Food Inspection Report", inspection date 2/8/22, indicated a routine inspection service, with action for, "Permit or license suspended/ facility closed." Inspection report indicated, "Observed multiple rodent droppings 20 plus on the floor behind the stove in the kitchen; observed 15 plus rodent droppings on the floor behind the oven and the steam cookers; observed rodent droppings on the electrical circuit on the wall next to the food prep table." Inspection report also indicated, observed multiple dead and dying cockroaches 12 plus on the glue traps behind the stoves; observed multiple dead cockroaches 14 plus on the glue traps behind the oven; observed 6 plus dying cockroaches on the glue traps behind the steam cookers."

A review of facility's policy and procedure titled, "Infection Prevention and Control 2021 Plan," effective 1/2021, indicated a purpose to serve as, "A guide for the activities of Infection Prevention and Control." The policy indicated, "The goal of the organization-wide infection prevention and control program is to identify, prevent and reduce the risk of endemic and epidemic healthcare-associated infections for all patients, staff, and visitors."

A review of facility's policy titled, "Pest Control," effective date 5/2012, indicated a purpose to "Provide a sanitary, rodent and pest free environment." The policy objective was to, "Assure regulatory guidelines are followed and patient safety maintained."