Pest Control Deficiency Leads to Resident Wound Infestation
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of maggots in a resident's left heel wound. The resident, a male with anoxic brain damage and type 2 diabetes mellitus, was admitted to the facility with multiple pressure injuries, including a deep tissue injury on the left heel. Despite daily wound care orders, the resident was found to have maggots in the heel wound upon hospital admission, indicating a severe lapse in pest control and wound management. Observations and interviews revealed that flies were present throughout the facility, including in resident rooms and common areas. The pest control service had been addressing fly issues, but the measures were insufficient to prevent the infestation. The facility's pest control contract and service statements indicated ongoing fly problems, with recommendations for additional fly lights and treatments. However, the facility's actions, such as replacing glue boards and applying fly bait, were inadequate to control the fly population effectively. Interviews with facility staff and hospital personnel highlighted a lack of awareness and response to the pest issue. The facility's Director of Nursing and Administrator acknowledged the presence of flies but did not fully understand the potential harm to residents. The Maintenance Director was not adequately informed or trained on pest control measures, relying solely on the pest control company's guidance. This lack of effective pest control and staff awareness contributed to the resident's wound infestation, demonstrating a significant deficiency in maintaining a safe and sanitary environment.
Removal Plan
- Facility was inspected for flies to include all resident rooms by maintenance director and Administrator.
- All windows in facility were checked to ensure they are closed properly.
- All window screens in facility were inspected by maintenance director and administrator to ensure they are installed properly.
- Administrator and Maintenance director have placed standing fans at the front door and 100 hall door to help prevent flies from coming into facility.
- Fly bags were placed externally around the facility to help prevent flies from entering facility.
- 100% skin sweep was completed and all wounds assessed by DON and ADON, no issues related to flies noted.
- Pest control treated for flies.
- Medical Director was notified of the immediate Jeopardy situation.
- Admin and DON identified residents who choose or prefer to have their windows open and will complete a weekly inspection of their windows screens to ensure they are in good condition and installed correctly.
- In-services were initiated by the RCN for all staff regarding removing flies, identifying open windows and torn window screens, and notifying the Administrator and Maintenance Director immediately.
- In-service was initiated for all staff regarding pest control, window screens, windows and entry points and reporting these items to the Administrator and DON.
- In-services were initiated by the RCN for the Administrator and Facility Maintenance director regarding inspecting facility windows and window screens.
- In-service was initiated with Admin and Maintenance Director by RCN regarding their responsibility for reviewing maintenance care logs 5 times a week to ensure issues with pest control, screens, windows or points of entry are addressed appropriately.
- In-service was completed by RCN with HR coordinator regarding providing education on pest control to all new hires.
- Admin/Designee will conduct rounds in facility 5 times a week to ensure that all windows are closed, and window screens are installed properly.
- Admin/Designee will complete interviews with 5 staff members weekly x 6 weeks and periodically thereafter to ensure that staff are reporting the presence of flies appropriately.
- DON and Tx nurse will conduct weekly skin checks and wound rounds x 6 weeks and periodically thereafter to ensure no issues with flies.
Penalty
Resources
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The facility failed to maintain an effective pest control program and a clean, sanitary environment on one hall, where live cockroaches were repeatedly observed in a resident’s room and reported by multiple residents and staff. A resident stated that cockroaches were present all the time, including in the bed and on the walls, and CNAs reported seeing cockroaches on the bedside table and in the bed when delivering meal trays. An LPN had previously documented that the room was treated by an exterminator after insects and bugs were observed throughout the room, and another LPN confirmed the ongoing presence of live cockroaches. Two other residents reported seeing cockroaches in the same hallway. Despite these observations, review of multiple pest control invoices over several months showed no documentation of cockroaches as a target pest, contrary to the facility’s written pest control policy requiring an ongoing program to eliminate insects and rodents.
Surveyors identified a persistent cockroach and insect infestation throughout the facility, with dead insects observed in dining and common areas and a live cockroach seen in a shower room. Multiple residents reported seeing cockroaches in their rooms, hallways, and near the kitchen, with some killing several roaches daily and describing the building as heavily infested. Staff, including maintenance and dietary leadership, acknowledged ongoing cockroach problems, and a severe infestation was found in the room of a hoarding resident, requiring targeted extermination, while pest control records showed repeated treatments focused on cockroach eradication.
The facility did not maintain effective pest control, resulting in persistent flies, gnats, and mice in resident rooms and common areas. Staff and residents reported frequent pest sightings, and staff used fly swatters during care. Despite recommendations from the pest control vendor for more aggressive treatment and environmental repairs, the facility relied on in-house remedies, leaving several issues unresolved.
Multiple residents were observed with flies and gnats in their rooms, including one with flying insects on their bed and another with fly paper and a fly swatter due to a persistent fly problem. Staff and an administrator confirmed the presence of pests and pest control devices not supplied by the facility, indicating a lack of effective pest control measures.
Multiple residents were observed with house flies present in their rooms, including flies on bed covers and windowsills, and one resident was seen swatting at flies near her face. Staff confirmed that flies were a persistent issue throughout the facility. Pest control records showed ongoing fly activity linked to poor sanitation in resident bathrooms, with recommendations for regular cleaning and sanitizing not adequately implemented.
The facility did not ensure the kitchen was free of pests, as multiple gnats were observed around the dishwasher and trash cans. Both the Administrator and a Dietary Aide confirmed the ongoing issue, which had persisted for several weeks, in violation of the facility's pest control policy. This affected all residents except for three who did not receive food from the kitchen.
Failure to Maintain Effective Pest Control and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary environment free from pests on the C hall, affecting the room of Resident #42 and potentially all 12 residents residing on that hall. On two separate observations, live cockroaches were seen in Resident #42’s room. Resident #42 reported that he sees cockroaches all the time, that they sometimes crawl in his bed and keep him from sleeping, and that he sees them on the walls. A progress note dated 10/03/25 by LPN #182 documented that Resident #42’s room had been treated by an exterminator after insects and bugs were observed throughout the room. LPN #129 confirmed that there were currently live cockroaches in Resident #42’s room, and CNA #210 and CNA #132 reported seeing cockroaches crawling on his bedside table and in his bed when delivering his meal tray. Two other residents (#26 and #34) also reported seeing live cockroaches in the C hallway. Review of pest control invoices dated 09/18/25, 10/06/25, 11/14/25, 12/30/25, 01/09/26, 01/30/26, and 02/20/26 showed no documentation of cockroaches as a target pest, despite the ongoing observations and reports of cockroaches in Resident #42’s room and the C hallway. The facility’s pest control policy, last revised in May 2008, stated that the facility shall maintain an effective pest control program and an ongoing program to continuously eliminate insects and rodents, but the documented presence of cockroaches and lack of corresponding identification on pest control invoices demonstrated a failure to implement this policy effectively.
Widespread Cockroach and Insect Infestation Throughout Facility
Penalty
Summary
The facility failed to maintain an environment free from pest infestation, specifically cockroaches and other insects, affecting resident rooms, hallways, dining, shower, and common areas. Surveyors observed multiple dead insects, including those resembling spiders and cockroaches, along the walls near windows in the first-floor dining room and on a second-floor windowsill near the memory care entrance. A live cockroach was observed crawling up the wall in the third-floor shower room, and German cockroaches were identified in at least one resident room and by the Regional Maintenance Director. Pest control work orders over several months documented repeated treatments of individual rooms and common areas, with the primary focus on cockroach eradication. Multiple residents reported ongoing cockroach activity throughout the building. One resident stated that roaches were so prevalent that it felt like the residents were living with them, describing roaches coming out when housekeeping mopped and climbing walls, causing fear they would fall on her. Another resident reported seeing cockroaches in her room, hallways, and coming from the kitchen, killing about half a dozen per day and wishing the entire building had been fumigated. Other residents described seeing one or two cockroaches in their rooms but more in hallways, feeling the insect issues were bad, or saying the place was “roached out” with roaches everywhere, especially at night. A resident reported seeing roaches come from under her bed, and another called the cockroaches his biggest complaint because they were repulsive. The Maintenance Director and Dietary Supervisor acknowledged cockroach issues, though they felt the situation was improving, and the Regional Maintenance Director reported finding a cockroach infestation in the room of a hoarding resident, requiring exterminator intervention.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure effective pest control, resulting in the presence of flies, gnats, and mice in multiple areas, including resident rooms and common spaces. Staff interviews revealed that excessive numbers of flies were present in the halls, and both staff and residents reported frequent sightings of mice, particularly in two residents' rooms. Staff resorted to using fly swatters during medication passes and in resident rooms, and residents who were able kept fly swatters at hand. Reports of mice in resident rooms were made to administration, and staff noted that the pest control measures in place were not effective. Observations confirmed the presence of multiple flies and gnats in at least one resident's bedroom, with flies seen on drinking cups and bedside tables. Residents reported direct encounters with mice, including a mouse on a bed and daily sightings in their rooms. Maintenance staff acknowledged ongoing issues with mice and flies, and stated that organic peppermint oil spray was used in an attempt to address the problem, but mice continued to be seen. The pest control vendor had provided recommendations for more aggressive treatment, but the facility opted to try in-house remedies instead. Review of pest control records showed that while monthly standard services were performed, several recommendations from the pest control vendor remained unaddressed by the facility. These included repairing door gaps, fixing water leaks, cleaning debris, and cutting overgrown vegetation, all of which were identified as the facility's responsibility. The facility's pest control policy stated that appropriate chemicals and methods would be used to control pests, but the ongoing presence of pests and unaddressed recommendations indicated a failure to maintain an effective pest control program.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by multiple observations and interviews involving three residents. One resident with a history of psychosis, schizophrenia, and narcolepsy was observed in bed with flying insects on his sheet and privacy curtain, which was confirmed by the Activities Director. Another resident, who was cognitively intact and diagnosed with alcohol-induced pancreatitis, essential tremor, and major depressive disorder, had fly paper hanging from the ceiling with several dead insects and kept a fly swatter in bed. This resident reported a significant fly problem, stating that a nurse had provided the fly trap about a month prior, and described the area under his bed as a "graveyard" for dead insects. Staff and the Administrator confirmed the presence of the fly paper and dead insects, with the Administrator noting that the facility did not supply such pest control devices. A third resident, also cognitively intact and with diagnoses including cerebral infarction, diabetes mellitus, psychotic disorder, vascular dementia, and hypertension, was observed with multiple gnats and flies in his room. The resident stated that flies or gnats were always present in his room. Further observation confirmed flies on his comforter and gnats on his pillow, which was verified by a housekeeper. These findings demonstrate a lack of effective pest control measures in the facility, directly affecting the living conditions of the residents involved.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of house flies in several resident rooms. On multiple occasions, flies were seen on windowsills, bed covers, and flying around residents, with one resident observed swatting at flies near her face while awaiting meal service. Residents reported persistent fly presence in their rooms, and staff confirmed that flies were a recurring issue throughout the facility, particularly in certain rooms. Review of pest control records indicated that the facility had been treated for fly activity in both the kitchen and resident rooms. The pest control company identified poor sanitation in resident bathrooms, specifically the presence of urine and fecal matter, as a contributing factor to the fly problem and recommended regular cleaning and sanitizing. The facility's pest control policy required frequent treatments and prompt reporting of pest issues, but monitoring and sanitation practices were not sufficient to prevent ongoing fly activity.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
The facility failed to maintain a kitchen environment free of pests, as required by its pest control program policy. During an observation of the kitchen, multiple gnats were seen around the dishwasher and trash cans. Both the Administrator and a Dietary Aide confirmed the presence of gnats in these areas, with the Dietary Aide stating that the issue had persisted for several weeks. The facility's pest control policy indicated an obligation to eradicate and contain common household pests, but the ongoing presence of gnats demonstrated non-compliance with this policy. This deficiency affected all residents except for three who did not receive food from the kitchen.
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