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
Below are regulatory guidelines relevant to this citation:
Pest control was not effective in resident areas and the kitchen. Surveyors observed flies in resident rooms, hallways, and the dining area, and a roach was seen in a resident care area and in the kitchen near the handwashing sink and food processor. Residents, CNAs, the Dietary Mgr, the Maintenance Director, the DON, and the Administrator all reported seeing pests, and the pest control log documented roaches and rats in multiple areas, including the kitchen.
The facility failed to maintain an effective pest control program. Ants were observed in one resident’s room and bed and in another resident’s room, and one resident had multiple ant bites documented. Staff also observed roaches crawling on kitchen walls, floors, and around freezers, with trash and food debris present behind the equipment. Interviews and record review showed pest control service interruptions and inconsistent handling of the pest issues.
Failure to maintain an effective pest control program was cited after surveyors observed numerous flies throughout the facility, including in resident rooms, bathrooms, dining areas, and around resident food. An IP confirmed the fly problem, and the DOM acknowledged the facility had a fly issue despite routine pest control visits and prior logs showing fly activity throughout the building.
Failure to maintain an effective pest control program was identified in multiple units. Staff and residents reported roaches, gnats, and flies throughout the facility, including in resident rooms, hallways, and the dining room, and surveyors directly observed flying insects and a roach-like insect in several areas. Pest control logs showed a recent roach treatment, but insects were still present during observations.
Pest control was ineffective, and cockroaches were observed in the kitchen, dining room, and resident rooms. A live cockroach was seen in one resident room, and traps in the kitchen contained dead cockroaches. Residents reported seeing roaches in the kitchen, dining room, and their rooms, while the DC, MD, DM, and DON all acknowledged ongoing cockroach activity and complaints from residents.
Failed Pest Control Program Allowed Flies in Food and Resident Areas: The facility did not maintain an effective pest control program to keep the kitchen, dining room, common areas, and Hall 2 free of pests. Surveyors observed flies in the food pantry, cooking areas, puree process area, steam table, and drinks cart, and flies were also seen around residents in the sitting area by the dining room, including one fly inside a resident’s coffee cup. A resident and a family member reported ongoing fly problems, while the MS and ADM gave inconsistent accounts about the issue and whether pest control covered flies.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects, rodents, and other pests. Surveyors observed flies in resident areas on Hall 400 and Hall 200, including a fly in a resident’s room and a fly landing on a blanket covering another resident. Residents on both halls reported seeing flies in their rooms and dining areas, and one resident’s representative reported seeing medium-sized roaches around a window. Staff interviews confirmed that flies had been seen in the building and in resident rooms, and that staff were expected to report pests to nursing or maintenance so treatment could be arranged. A CNA stated flies were seen in the building, especially near the side door by the patio used by residents who smoked, and another CNA stated flies were sometimes seen in resident rooms and were reported to the charge nurse or maintenance. The Maintenance Director stated there had been an issue with flies the prior month and that staff would swat flies in the morning. The DON and Administrator both stated staff were expected to notify maintenance or leadership when pests were seen, and the Administrator stated the facility used fly lights, treated the dumpster area, and bought fly swatters when weather changed. In the kitchen, surveyors observed a fly flying around and landing on the food processor, and a roach crawling on the baseboard and floor near the handwashing sink. The Dietary Manager stated she had seen flies and had seen one shortly before the observation, and she acknowledged that flies could contaminate food. Record review showed multiple pest sightings documented in the pest control log, including roaches in resident rooms, the nourishment room, and bathroom, as well as rats in the kitchen. Pest control service reports documented treatment for flies in hallways and placement of snap traps in the kitchen for reported rats.
Pest Control Program Failed to Keep Ants and Roaches Out of Resident Areas and Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program to keep ants out of Resident #8’s room and bed, ants out of Resident #4’s room, and roaches out of the kitchen. Resident #4 had diagnoses including osteoarthritis, COPD, anemia, and hypertension, and was cognitively intact with a BIMS score of 13. During an observation in his room, black ants were seen crawling on the floor and in his bed, and he stated he had noticed ants in the room for a few days. Staff later acknowledged the ants had been present in his room over the weekend and that pest control had been contacted. Resident #8 had diagnoses including type 2 diabetes, osteoporosis, dementia, and hypertension, with a BIMS score of 11 and assistance needs for ADLs. Staff observed ants in his room on the floor, along the baseboard, at the head of the bed, and on the wall, and he was moved to another room. A skin assessment documented multiple ant bites on his body, and he reported that the ants had been in his room since the prior Friday, that they were in his bed, and that he had been bitten. Staff notes also documented ants in his room and that he initially refused to move. Record review showed the facility’s pest control services had been suspended at one point because of an outstanding balance, and staff interviews reflected confusion about the timing and extent of pest issues in the resident rooms. On a later observation in the kitchen, multiple roaches were seen crawling on the wall, floor, and around the freezers, with trash and food debris behind the freezer. The dietary manager stated the roaches had gotten out of hand and were everywhere in the kitchen, and the administrator also observed roaches, trash, and food debris in the area.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by numerous flies observed throughout the building during a complaint survey. Surveyors observed a fly on the baby doll held by a resident on the dementia unit, flies in the back dining area and the 500 hallway, and a fly buzzing in a resident room and sitting on a toilet seat in the resident bathroom on the 100 hallway. The Infection Preventionist confirmed there was a fly problem after seeing several flies during the tour and in resident bathrooms. Additional observations showed flies around resident food in the A/B day room while residents were eating lunch, and flies were also seen in the conference room where surveyors were located. The next morning, a resident eating breakfast on the dementia unit had a fly flying around his/her head and food. The Director of Maintenance stated the pest control company came every 2 weeks, but he was unsure what had been treated and acknowledged the facility had a fly problem that had been bad the day before. Pest control logs documented flies at the nurse's station and in multiple resident rooms on the Chase unit in March, and another log documented flies throughout the whole building in May. An invoice from late May documented verbal report of fly activity throughout the building, while a later invoice noted no concerns were reported at that visit.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program in 3 of 3 units reviewed. During interviews, staff reported seeing roaches, gnats, and flies and stated they usually just killed them. Residents also reported ongoing pest activity throughout the facility, including gnats, roaches, and flies in rooms and hallways, with one resident stating sticky tape had been placed but bugs were still seen. Another resident reported seeing roaches in the room every night, and a third resident stated roaches and bugs were seen all over the facility, including during the day. Observations confirmed the presence of insects in multiple areas. Three black flying insects were seen in the main dining room, a black flying insect was observed flying around a resident’s head and breakfast tray in the resident’s room, and an oblong brown insect approximately 1 inch long was seen moving quickly from under a bedside dresser to underneath the bed in another resident’s room. Four fly traps were also observed in the conference room. The Maintenance Director stated pest control had been at the facility the prior Friday, and the pest control logs showed a treatment for roaches on 6/26/2026. The facility policy stated housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Pest Control Program Failed to Keep Kitchen and Resident Rooms Free of Cockroaches
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free from pests in the kitchen, dining room, and resident rooms. Observation in the kitchen found two Catchmaster Mouse and Insect Super Glue Traps on the floor by a trashcan, with one trap filled with dead cockroaches and another trap containing two dead cockroaches. A live cockroach was also observed in the right corner of Resident #2’s room by the door stopper. The facility’s pest control policy stated that the building shall be kept free of insects and rodents through an ongoing pest control program, with services provided by a licensed exterminator. Residents and staff described ongoing cockroach activity throughout the facility. Resident #3 said the cockroaches were horrible and had been seen on the walls in the kitchen and in the dining room while eating. The DC reported seeing three live cockroaches in one day, including two in the kitchen and one in the dining room, and said she had seen an average of three cockroaches a day for about a year. The MD said residents, including Residents #4 and #5, had complained about cockroaches and that he had heard there were cockroaches in the kitchen. Resident #4 said she had seen one or two cockroaches a day in her room for about a month, and Resident #5 said she saw a roach in her room and felt scared when she saw bugs. The DM and DON also acknowledged the presence of water bugs or cockroaches in the kitchen and other areas of the facility.
Failed Pest Control Program Allowed Flies in Food and Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the kitchen, dining room, common areas, and Hall 2 free of pests. During observations, a fly was seen in the food pantry and cooking areas during the initial kitchen tour, and later several flies were observed in the kitchen during the puree process, landing on kitchen counters and food preparation areas. During the food serving line observation, several flies were also seen landing on the steam table and drinks cart. In the dining and sitting areas, flies were repeatedly observed around residents and resident items. A fly was seen crawling over the lip and inside a resident’s coffee cup, and later 3 to 4 flies were observed around a resident in the sitting area by the dining room, with a family member waving flies off the resident’s face. Another resident was later observed in the same area with 3 to 4 flies flying and landing on him. A confidential resident stated that many flies had been noticed in the facility, that the administrator had been told about them, that fly swatters were supplied to residents, and that pest control had not been seen for flies. The maintenance supervisor stated he had not noticed the flies and did not know of a risk to residents, while the administrator stated pest control came to the facility but was not sure whether flies were covered and said the flies were horrible everywhere right now. Record review showed a pest control log with an entry for ants treated in Rooms 44-47 and a later signature with location, issue, witnessed by, and additional description left blank. The facility policy stated it maintained an ongoing pest control program to ensure the building was kept free of insects and rodents.
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