Failure to Maintain Effective Pest Control Resulting in Maggots in a Stage 3 Pressure Injury
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program and to keep the environment free of pests and rodents, resulting in a resident being found with maggots in a left buttock stage 3 pressure injury. The resident was an adult male with a history of seizures, type 2 diabetes mellitus with hyperglycemia, and hemiplegia/hemiparesis, with documented moderate cognitive impairment (BIMS 12). His MDS showed he was always incontinent of bowel, required substantial assistance with bed mobility, did not use mobility devices, and had range-of-motion impairment on one side of both upper and lower extremities. Clinical records showed that on a prior date a CNA reported the wound on his bottom had reopened, but the resident declined to allow the nurse to assess it. A subsequent NP wound note documented a left buttock stage 3 pressure ulcer with slough and moderate serosanguinous drainage, and orders were in place for specific wound care including cleansing with Dakin’s solution, application of collagen with silver, and a silicone bordered superabsorbent dressing. On the date of the incident, CNAs providing a bed bath reported seeing maggots on the resident and in his feces while he was being turned and cleaned. One CNA stated she was told by a nurse that the resident needed to be changed because he smelled and maggots were found in his groin area; upon pulling down the covers, she observed maggots in the groin area and then moved to wash the resident’s hair. Another CNA reported that while giving the bed bath, they saw maggots on the resident and in his feces and continued with the bath. The DON was informed of the maggots by an LVN, although the DON did not personally witness the insects. The resident later stated that he had previously had issues with flies in his room and that he had notified several staff members, including the DON and the Administrator, about the flies before insects were identified in his wound. Environmental observations by surveyors revealed multiple conditions that could allow pest entry and presence in the facility. A dead fly was observed on the window ledge in the resident’s room. Facility-wide, more than three window screens per hall were missing or ill-fitting, one lobby window had no screen and was partially open, and another window had a torn screen and was open several inches. The exit door at the end of one hallway had a gap between the bottom of the door and the floor. A box with one side cut out, a blanket, and what appeared to be a bowl with food were observed outside an exit door. A dead roach was found in a kitchen cabinet under a sink. Some exit doors lacked flying insect traps, and a dining room exit door was observed propped open during an outdoor activity. Staff interviews indicated that the Administrator had only one reported pest issue in the prior month, pest control was not notified when maggots were found on the resident, and the DON and Administrator reported not having heard concerns about flies in the recent past. The facility’s pest control policy required that windows be screened at all times, but surveyors confirmed torn, missing, and open windows that could allow pests to enter, supporting the finding that the facility failed to maintain an effective pest control program.
Removal Plan
- Upon identification of maggots in Resident #1's left buttock stage 3 pressure injury, nursing staff cleansed the wound, removed all visible insects, and applied a clean, secure dressing.
- The attending physician was notified and wound care orders were reviewed and implemented by the DON.
- Resident #1 was assessed for signs of infection and discomfort and monitored per nursing protocol by the DON/designee.
- An insect fan was placed in the resident's room to reduce fly exposure.
- Emergency pest control services were contacted to provide additional services.
- The Administrator and Maintenance Director conducted a facility-wide inspection.
- All missing, torn, or ill-fitting window screens were repaired, replaced, or secured.
- The DON/Nursing Administration conducted a visual assessment of all residents with wounds to ensure they were free of pests.
- The Administrator notified the Medical Director of the Immediate Jeopardy.
- The Regional Director of Operations in-serviced the Administrator and DON on prompt reporting of insects/environmental concerns, updating the pest control log, maintaining screened/closed windows, monitoring wounds for contamination risks, pest control policy requirements, and prompt follow-up on resident complaints.
- All staff received education on prompt reporting of insects/environmental concerns, maintaining screened/closed windows, monitoring wounds for contamination risks, and pest control policy requirements.
- A post-education quiz will be conducted to determine competency; staff will not be able to work until the quiz is passed with a grade of 100%.
- Education and competency will be incorporated into new hire onboarding.
- Maintenance will complete weekly documented inspections of all windows and screens; deficiencies will be corrected immediately or the window taken out of service.
- Routine pest control services will continue as scheduled.
- Pest control logs will be reviewed weekly by the Administrator or designee.
- Any evidence of insect activity will trigger immediate treatment including prompt assessment, wound protection, removal of insects, physician notification as needed, and immediate environmental and pest control interventions.
- The DON/designee will conduct weekly audits of residents with open wounds to ensure wounds are clean, covered, and free from environmental exposure; findings will be documented and reviewed through QA/QAPI.
- The Administrator and DON will conduct weekly environmental rounds to verify sustained compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Roach Infestation and Dining Room Sanitation Issues A resident reported seeing cockroaches in the dining room for about a year, and staff later observed roaches crawling in the dining room and near food stored in cabinets. Food debris, open cereal, and covered plates with meal remnants were found in the dining room, along with buildup, missing caulking, warped surfaces, and other areas where pests could be present. Staff also reported seeing roaches in the kitchen and dining room, while the facility had recently changed pest control vendors and had limited documented pest control follow-up.
Pest control was not effective in key areas of the facility, including a hallway, a resident room, and the kitchen. Staff and leadership observed flies in the kitchen, on a snack box, and around a resident during wound care, and the Dietary Manager said the back door did not seal properly. The Maintenance Director, RN, DON, and Interim Administrator all acknowledged ongoing fly sightings and pest control concerns, and vendor reports noted the need to repair or replace the kitchen rear exit door and replace fly light bulbs and starters.
An ineffective pest control program allowed roaches to remain present in a staff bathroom and a resident’s room. Residents and staff reported the problem was ongoing, with roaches seen in rooms and bathrooms, often at night, despite weekly pest control treatments for German roaches and general pests. The DON, maintenance director, and Administrator all acknowledged the persistent roach issue in the facility.
Ineffective pest control allowed gnats to be seen in a resident’s room and throughout common areas, including the dining area, nurses station, and conference room. The resident complained about gnats in the room, and the Administrator, DON, and Corporate Nurse stated the issue may have been related to recent roof repairs.
Pest Control Deficiency in Kitchen: Several fruit flies were observed throughout the kitchen, including inside and around open containers of powder thickener and flour. The NHA confirmed the findings during interview.
Surveyors found an ineffective pest control program with flies, gnats, and other insects observed in resident rooms, hallways, and the kitchen. Residents reported flies in their rooms and on food, and one resident said insects repeatedly landed on him while he was in bed. In the kitchen, staff and surveyors noted gnats near food prep areas, leftover food, an uncovered garbage bin, and dirty, wet conditions under the dishwasher and around a drain, despite the facility’s policy for an effective pest control program.
Roach Infestation and Poor Dining Room Sanitation
Penalty
Summary
The facility failed to implement effective and timely pest control measures to reduce and/or eliminate a roach infestation in the dining room and kitchen areas. A cognitively intact resident with diagnoses including CHF, pulmonary edema, hyperlipidemia, and a thyroid disorder reported seeing cockroaches in the dining room for about a year and said she had previously caught some while staff were present. During observation, a roach was seen crawling across the dining room floor near the sink, and later another roach was observed crawling alongside a covered plate stored in a cabinet under the dining room sink. The dining room environment showed multiple conditions that were observed alongside the pest activity. Food debris was noted on the dining room floor after lunch, including noodles, lettuce, and carrot pieces. Under the sink cabinet, a clear plastic bin without a cover contained a covered plate with lunch remnants, and the plate cover had a hole with condensation inside. The floor near the refrigerator and lower cabinets had black buildup and crumb-like debris. Additional observations found a napkin, spoon, and Cheerio under the refrigerator, a red-colored buildup under the refrigerator, missing caulking around the sink, a section of backsplash pulled away from the wall, warped countertop material, black discoloration around the sink, and staining on the cabinet bottom. Open cereal boxes with unsealed inner bags and another covered plate with lunch remnants were also found stored in cabinets. Staff interviews confirmed ongoing pest sightings and inconsistent control measures. A dietary aide stated roaches were frequently seen in the kitchen and sometimes in the dining room, and that fruit fly traps were everywhere. Housekeeping staff said old food had been found under the refrigerator and that it had not looked cleaned in a while. The Director of Maintenance confirmed the worn countertop and missing caulking and stated the facility had recently switched pest control companies. The new pest control vendor reported it had only just begun service and had placed traps, while facility documentation showed earlier pest control reports noting straggler roaches and later no pest activity. Additional documentation on pest control measures and facility policies was requested but not provided.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program to keep Station 1 hallway, Resident #6's room, and the kitchen free of flies. On observation, 2 flies were seen flying and landing on the wall near the soiled utility room on Station 1 hallway. In the kitchen, 3-5 flies were observed on the snack box and another 4-5 flies were flying around the kitchen. The Dietary Manager stated she was aware of the fly problem in the kitchen and attributed it to the back door not having a proper seal, and said the Administrator was aware and in the process of purchasing a blower over the door. She also stated staff were responsible for keeping the door closed at all times to prevent flies from entering the kitchen. During wound care in Resident #6's room, a fly was observed flying around the room while the resident was in bed and unable to answer questions. RN J stated she had noticed the fly in the room and said staff were to write pest sightings down for the exterminator. The Maintenance Director stated he had noticed flies and that staff were to record sightings in the pest control book for treatment by pest control. The Interim Administrator stated the facility was trying to address the pest control issue and that a new frame and door had been approved for the kitchen. The DON stated flies could irritate residents and that pest control had come out to treat some resident rooms for flies. The facility's pest control reports noted recommendations to repair or replace the kitchen rear exit door to ensure proper closure and to replace fly light bulbs and starters, and a later report documented specialized fly control service and bulb replacement in the kitchen light unit.
Pest Control Program Ineffective With Ongoing Roach Presence
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by roaches being observed in a staff bathroom in the lobby and in a resident’s room. During a tour, a live light brown roach approximately an inch long was seen on the floor of the staff bathroom next to the reception office, crawling toward the commode and then back toward the cabinet below the sink. In Resident #44’s room, a roach the size of a pea was observed crawling on the floor toward the hallway door and was stepped on by housekeeping staff. Resident #44 stated she saw roaches of that size 2 to 3 times a week in her room and larger roaches a couple of times a month. Record review showed the pest control company had provided weekly services over many months, including spot treatments in bathrooms, resident rooms, dining rooms, the kitchen, and interior and exterior doorways for German roaches and general pest control, with dead roaches noted in the dining and storage area in hall two. Interviews with residents and staff described the problem as ongoing, with residents reporting roaches were seen more at night and in rooms, and a nursing aide stating she had seen roaches in resident rooms and reported them to nursing. The maintenance director stated the roach problem was ongoing and persistent, the DON stated roaches continued to show up in resident rooms, and the Administrator stated he had noticed the problem and believed the exterminator was not doing a good job.
Ineffective Pest Control Allowed Gnats in Resident and Common Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, and gnats were observed in resident rooms and common areas. During an interview with Resident #71, the resident complained about gnats in the room, and while the resident was being interviewed, gnats were visible throughout the room and on bedside trays. Additional observations throughout the building found gnats in the dining area, nurses station, and conference room. When interviewed, the Administrator stated that recent roof repairs had stirred up the gnats, and the DON and Corporate Nurse were present and agreed with that explanation.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to prevent accumulations of fruit flies in the kitchen. During a tour of the kitchen on July 29, 2026, several fruit flies were observed throughout the kitchen, including inside and around open containers of powder thickener and flour. The Nursing Home Administrator confirmed these findings during interview.
Ineffective pest control with insects observed in resident rooms and kitchen
Penalty
Summary
The facility failed to provide effective pest control services. Survey observations found flies, gnats, beetles, centipedes, and other insects in resident rooms, hallways, and the kitchen, along with strong odors and cobwebs in some areas. The deficiency was cited for 9 of 9 residents reviewed for pests in the facility, including residents who reported seeing insects in their rooms and on their food, and one resident who said flies were seen in his food and repeatedly landed on him and his blanket while he was lying in bed. Several residents described ongoing insect activity in their rooms. One resident said he sees flies sometimes and has let maintenance know, while another said there are always lots of flies when trying to eat and that the flies come out of the walls. In a shared room, multiple flies were observed landing on a resident while he slept, and other residents in that room said they saw insects and wanted them removed. Surveyors also observed multiple flies and gnats in resident rooms on repeated occasions. In the kitchen, surveyors observed a sticky floor, multiple gnats and flies near the food prep area, stove, and dishwashing machine, leftover food near the dishwashing sink, and an uncovered garbage bin near the food prep area. A heavy amount of limescale, food particles, dirt, and standing or pooling water were noted under the dishwasher, and staff reported gnats coming from a floor drain. Staff and the pest control technician stated the kitchen had recurring pest concerns, with pest control services provided monthly or as needed, and the facility's own policy stated it was to maintain an effective pest control program with regularly scheduled visits to prevent infestation.
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