Failure to Implement Bed Bug Policy and Ensure Proper Cleaning
Summary
The facility failed to ensure they have a bed bug policy/procedure to prevent outbreaks, failed to ensure that staff report bed bug observations, and failed to remove bed bug excrement/eggs from the wall in residents' rooms prior to resident placement. This deficiency was observed in the case of a resident who was transferred to a room on the 5th floor, which had been previously treated for bed bugs. Despite the treatment, bed bug excrement and eggs were still present on the wall adjacent to the resident's bed. The resident, who had a BIMS score indicating intact cognition, reported the presence of bed bugs and pointed out the excrement on the wall to the surveyor. The Licensed Practical Nurse and Certified Nursing Assistant also observed the dark spots on the wall but did not report them or take action to clean them up. The Director of Nursing acknowledged the presence of bed bug litter but cited short staffing in the housekeeping department as the reason for the uncleaned wall. The housekeeping staff could not recall if they were made aware of the bed bug eggs and excrement on the wall. The facility's pest control invoices indicated that bed bug treatments were conducted, but the facility lacked a specific policy or procedure for bed bugs. The Director of Nursing confirmed that there was no corporate policy for bed bugs. The facility's pest control policy stated that the building should be kept free of insects, and the housekeeping policy required environmental surfaces to be cleaned and disinfected according to CDC recommendations. However, walls were excluded from the list of non-critical surfaces to be disinfected. This lack of a specific bed bug policy and failure to ensure proper reporting and cleaning of bed bug excrement and eggs led to the deficiency affecting the resident and potentially other residents in the facility.
Penalty
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The facility did not follow a pest control contractor’s high-priority recommendation to patch a hole under a bathroom sink that was large enough for rodent entry in a resident’s room. A maintenance supervisor acknowledged the hole remained unrepaired due to competing project deadlines, despite staff reporting rodent sightings in two residents’ rooms through the work order system and nursing staff indicating they would notify maintenance of such issues. Administrative staff reported that rooms were checked weekly and that pest control recommendations were expected to be addressed immediately, and the facility’s pest control policy required an ongoing program to keep the building free of insects and rodents, but the identified structural entry point was not corrected.
A facility failed to maintain an effective roach control program and sanitary waste management, as evidenced by staff reports of frequent roach sightings, a resident’s report of daily roaches in his room and on his bed and wheelchair, and direct observation of multiple roaches in that resident’s room. Housekeeping and maintenance leaders acknowledged that roach sightings are often reported but admitted they do not review pest sighting logs on the units and sometimes do not request as-needed pest control visits after sightings. The dumpster area was found with open, overflowing containers and scattered food waste, in direct conflict with facility policies requiring sealed trash bags, closed and clean dumpsters, and environmental conditions that prevent insect harborage.
Surveyors found that the facility did not maintain an effective pest control program in the main kitchen dish room, where multiple sticky traps were full of fruit flies and additional fruit flies were observed while staff were washing dishes. Review of pest-control logs showed repeated crack and crevice spray treatments to the kitchen and related areas over several months, yet fruit flies remained present in the dish room. The Dietary Manager acknowledged that the pest control program in the main kitchen was not effective, and the deficiency was cited under applicable state regulations for licensee and administrator responsibility.
Surveyors found that the facility did not maintain a pest-free environment in two private resident shower rooms and two main shower rooms, where dead and live ants and water bugs were observed on the floors. Housekeeping staff reported cleaning private showers every other day and notifying maintenance when pests were seen, but one aide acknowledged not cleaning a private shower because it was not used and they had only recently learned it existed. The Director of Maintenance described ants as an ongoing issue, stated that a pest control vendor provided monthly treatments, and reported that water in the two private showers was run weekly, while a maintenance staff member stated they ran water monthly and that it had last been run about six weeks earlier, relying on the Director of Maintenance to contact the pest control vendor when pests appeared.
Facility staff did not maintain an effective pest control program in the kitchen, as evidenced by surveyor observations of multiple live flies at the juice counter and dishwashing areas during a tour. Pest control reports from an external vendor months apart documented repeated needs for general cleaning under and behind cooking equipment, along walls, around floor drains in the dish room, and under the juice counter due to food debris and uncleaned areas. During an interview, the corporate chef and kitchen manager acknowledged the presence of flies and the observed conditions.
The facility failed to maintain an effective pest control program, as gnats, roaches, mice, and other pests were repeatedly observed and reported in resident rooms, bathrooms, dining areas, and the kitchen. Surveyors noted gnats around urine-filled urinals on a bedside table, in the kitchen near an open freezer, and on dirty dishware in a unit dining room, as well as a cracked bathroom light fixture containing a dead moth. Exterior doors near the kitchen, courtyard, and parking lot were repeatedly propped open with objects, contrary to expectations stated by the DON, Dietary Manager, and Maintenance Director, allowing pests to enter. A resident reported seeing a mouse and cockroaches in his room, with a mouse glue trap observed there, while another resident reported a mouse in her window and mouse droppings in both the window and on a meal tray. STNAs described ongoing problems with gnats and large roaches and stated that routine pest control spraying and glue traps had not resolved the issues.
Failure to Implement High-Priority Pest Control Recommendation for Rodent Entry Point
Penalty
Summary
The facility failed to follow its pest control program and the pest control contractor’s high-priority recommendations regarding a structural opening that could allow rodent entry. A Pest Control Monthly Report dated 02/24/26 documented a high-priority recommendation to patch a hole in the wall under a bathroom sink, near the floor, that was large enough for rodent entry. On 03/24/26 at 11:32 AM, an observation of Resident 5’s room showed that the hole under the sink was still present. On 03/24/26 at 12:05 PM, the Maintenance Supervisor confirmed that the hole remained and stated he had not had time to fix it due to other assigned projects and deadlines. On 03/31/26, a CNA reported that when staff see mice or rodents in Resident 5’s room or Resident 18’s room, they enter this information into the facility’s work order system (TELS) so maintenance can address it. A licensed nurse stated she would call the Maintenance Supervisor immediately if there was a problem. An administrative nurse stated the facility had a program to ensure all rooms and equipment were kept in good condition and that rooms were checked weekly. Administrative Staff A stated she expected any pest control recommendations to be followed up on immediately. The facility’s undated Pest Control policy documented that the facility maintains an ongoing pest control program to keep the building free of insects and rodents, with maintenance services assisting as appropriate, but the documented high-priority recommendation to patch the hole in Resident 5’s room had not been implemented.
Failure to Maintain Effective Roach Control and Sanitary Waste Management
Penalty
Summary
The facility failed to maintain an effective pest control program to eliminate roaches, affecting one of three residents reviewed and potentially all 247 residents. A housekeeping aide reported seeing roaches during routine cleaning, most recently about one week prior on the fourth floor, and stated she uses roach spray in resident rooms when she sees many roaches and reports sightings continuously to the Administrator. Another housekeeping aide reported last seeing roaches about two months earlier in resident rooms and stated that after he reports sightings to the Administrator, the pest control company typically comes the following week. During observation of a resident in his room, the resident reported seeing roaches daily, especially at night, and stated he could not eat food in his room without roaches crawling into it and that roaches were on his bed and chair at night and felt as if they were biting him. At that time, the surveyor observed multiple roaches crawling under and on the resident’s motorized wheelchair and on the wall near the bathroom. When this was brought to the housekeeping aide’s attention, he acknowledged they were roaches and commented that they appeared because there was “company,” indicating awareness of an ongoing roach presence in the environment. The Housekeeping Director stated that staff and residents frequently report roach sightings to him and the Maintenance Supervisor, that pest control visits occur bimonthly and as needed, and that there is a pest control sighting book on each unit. However, he admitted that he and the Maintenance Supervisor do not check these books and that only the pest control company reviews them during bimonthly visits, meaning there could be unaddressed sightings. He also acknowledged seeing a roach in the pantry one week earlier and killing it without contacting pest control for an as-needed visit. The Maintenance Supervisor confirmed that staff and residents report sightings to him and the Housekeeping Director, denied knowledge of the pest control books, and reported seeing a roach in a shower room about a month earlier without notifying pest control until their next scheduled visit. Additionally, inspection of the dumpster area revealed open and overflowing dumpsters with trash and old food scattered from the ramp to the dumpster, contrary to the facility’s policies requiring sealed trash bags, closed and clean dumpsters, and grounds free of debris, as well as the pest control policy assigning responsibility for coordinating pest control and maintaining conditions that prevent insect harborage.
Failure to Maintain Effective Pest Control in Main Kitchen Dish Room
Penalty
Summary
Surveyors determined that the facility failed to maintain an effective pest control program in the main kitchen dish room, as evidenced by the presence of numerous fruit flies despite ongoing pest-control treatments. During an observation on 3/26/26 at approximately 9:35 a.m., three gold fly sticky traps in the dish room were found to be full of fruit flies, and additional fruit flies were observed in the area while staff were actively washing dishes. Review of pest-control logs from 9/17/25 through 2/11/26 showed multiple crack and crevice spray treatments to the kitchen, dish room, dining room, maintenance hall, and other areas on specified dates, but these measures did not prevent the continued presence of fruit flies in the dish room. In an interview at 10:00 a.m. on the same day, the Dietary Manager confirmed that the facility had failed to maintain an effective pest control program in the main kitchen. No residents or specific patient conditions were mentioned in the report. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 207.2(a) Administrator's responsibility.
Failure to Maintain Pest-Free Conditions in Resident and Main Shower Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a pest-free environment and an effective pest control program in multiple shower areas, including two private resident shower rooms and two main shower rooms. During observations on 3/17/2026, dead and live insects, including ants and water bugs, were found in the private shower room of one resident room, and dead ants were found on the floor of another resident room’s private shower. Additional observations the same day revealed little black ants crawling on the floors of the Unit A and Unit C main shower rooms located across from specified resident rooms. These findings showed the presence of pests in resident shower areas that should have been maintained free of infestation. Interviews with staff revealed gaps in cleaning and maintenance practices related to these shower rooms. Housekeeping staff reported that private showers were cleaned every other day and that they notified maintenance when pests were seen, but one housekeeping aide stated they had been employed for about three months and only learned of one private shower a week prior, and had not cleaned it because it was not used. The Director of Maintenance stated that ants had been an ongoing problem attributed to residents dropping food, and that a pest control vendor provided monthly treatments, including a visit on the morning of 3/17/2025. The Director of Maintenance also stated that water in the two private showers was run weekly, while a maintenance staff member reported that they ran water in those showers monthly and that the last time water was run was about a month and a half earlier. Maintenance staff also indicated they relied on the Director of Maintenance to contact the pest control vendor when pests were observed, as they were not permitted to use spraying chemicals themselves.
Failure to Maintain Effective Kitchen Pest Control and Sanitation
Penalty
Summary
Facility staff failed to maintain an effective pest control program to keep the kitchen free of pests, specifically flies. During an initial kitchen tour on 03/24/2026 at approximately 10:15 AM, surveyors observed multiple live flies at the juice counter and dishwashing areas. Review of a pest control report from Bay City Pest Management Co. Inc. dated 02/19/2026 documented that, although the kitchen was inspected, general cleaning was needed under equipment on the cooking line, along the wall and floor drain under the 3-compartment sink in the dish room, and in the corner area of the floor under the juice counter. A prior pest control report dated 07/18/2025 similarly noted that the floor area along the wall under counters and behind cooking equipment needed to be cleaned due to a lot of food debris, and that a small center drain on the cooking line needed cleaning. During a face-to-face interview on 03/24/2026 at approximately 10:15 AM, the Corporate Chef (Employee #7) and Kitchen Manager (Employee #6) acknowledged the observations of flies in the kitchen. No residents or their clinical conditions were mentioned in the report, and the deficiency centers on environmental sanitation and pest control practices in the kitchen area.
Failure to Maintain Effective Pest Control and Environmental Practices
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and rodents, despite having a pest control contract and invoices showing routine service. Surveyors observed gnats in multiple areas of the facility on several days, including around urinals in a resident room, in the kitchen near an open double reach-in freezer, and on dishware in a unit dining room sink and tray. A cracked overhead bathroom light fixture in another room contained a large dead moth. Staff and residents reported seeing gnats, roaches, and mice in the facility, and invoices confirmed that pest control services were being provided for various pests including mice, rats, spiders, water bugs, silverfish, and roaches. Multiple observations showed that exterior doors were repeatedly propped open, allowing pests to enter the building. The kitchen delivery and emergency door was held open with a milk crate, creating a gap between the doors, and the kitchen back door was again observed held open with a milk crate on another day. Two side doors leading to the courtyard and toward the kitchen were observed open with wind blowing into the building, and a side door facing the parking lot was held open with two chairs, despite posted signs instructing that the door not be used. The Director of Maintenance, Dietary Manager, and DON each stated that these doors were expected to remain closed except during specific uses, and acknowledged that open doors allowed pests to enter and potentially contaminate food. Residents and staff provided additional accounts of pest activity. One resident reported seeing a mouse come from under a chair in his room, as well as cockroaches on the walls disappearing into ceiling tiles and gnats; a mouse glue trap was observed behind a chair in that room, and the resident stated he had reported the issue and pest control had sprayed. Another resident reported finding a mouse between the screen and window in her room, later seeing mouse droppings in the window, and receiving a meal tray with mouse droppings. STNAs reported seeing large roaches in hallways, ongoing problems with flies and gnats in dining rooms, and complaints from residents and families about gnats, while also stating that pest control spraying did not seem effective. The DON acknowledged that one resident did not like staff touching his belongings, which contributed to urinals with urine being left on a bedside table with gnats flying around them, and stated the facility should be kept clean and as nice as possible for residents.
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