F0925

J

Failure to Maintain Effective Pest Control Resulting in Maggots in a Stage 3 Pressure Injury

Floresville, Texas Survey Completed on 01-04-2026

Penalty

Fine: $21,645

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.