F0925 F925: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F

Failure to Maintain Effective Pest Control Program for Flies

Burlington Health And Rehabilitation CenterBurlington, Wisconsin Survey Completed on 08-13-2025

Summary

The facility failed to maintain an effective pest control program to address a significant fly infestation throughout the building. Multiple residents reported ongoing issues with flies in their rooms, common areas, and the dining room. Residents described using personal items such as washcloths and underwear to swat at flies, and some purchased their own fly traps due to the persistent problem. Surveyors directly observed flies in resident rooms, hallways, the dining area, conference room, and kitchen, including flies landing on food and residents during meals and treatments. Staff were also seen using fly swatters in attempts to control the flies. The facility's pest control program required a written agreement with an outside pest service for regular visits, appropriate use of chemicals, and a reporting system for pest issues between scheduled visits. However, record review revealed that the facility did not have pest control service visits for several months, specifically in May, June, and February of one year and July of the previous year. The Maintenance Director was unaware of the fly issue and stated that pest control visits occurred monthly, but this was not supported by documentation. Residents and staff consistently reported the fly problem, with some residents noting that flies landed on their food and bit them, and others stating that the issue was worse near exit doors or in rooms previously occupied by other residents. During the survey, flies were observed in the kitchen, where dietary staff attempted to cover food to prevent contamination. Resident council members also raised concerns about the large number of flies and the cleanliness of the facility. The persistent presence of flies was noted by surveyors throughout the entire survey period, affecting all areas of the facility and all residents present at the time.

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Resources

Below are regulatory guidelines relevant to this citation:

See other F0925 citations
Pest Control Program Not Effective
E
F0925 F925: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Short Summary

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.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Pest Control Program Failed to Keep Ants and Roaches Out of Resident Areas and Kitchen
E
F0925 F925: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Short Summary

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.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Maintain Effective Pest Control Program
E
F0925 F925: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Short Summary

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.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Maintain Effective Pest Control Program
F
F0925 F925: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Short Summary

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.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Pest Control Program Failed to Keep Kitchen and Resident Rooms Free of Cockroaches
E
F0925 F925: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Short Summary

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.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failed Pest Control Program Allowed Flies in Food and Resident Areas
E
F0925 F925: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Short Summary

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.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
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