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:
Failure to control pest activity and maintain sanitary conditions. Live pests were observed in resident rooms and a common area, and residents reported seeing roaches in their rooms for months. Pest logs documented repeated roach sightings, pest control reports noted heavy German roach activity and recurring entry points such as cracks, voids, and gaps around pipes, and a critical work order for pest control and hole closure was never completed. The Administrator confirmed live pests were present, and the DPO stated the repair recommendations were not being addressed.
Failure to Maintain Effective Pest Control Program: The facility did not maintain an effective pest control program after staff reported noises in the ceiling and attic, and records showed wildlife inspections identifying multiple entry points for squirrels, raccoons, and birds. Surveyors observed large holes and gnaw marks in the soffit/fascia area, along with additional openings large enough for squirrels to enter. Facility documentation and interviews confirmed trapped wildlife, including raccoons and a squirrel, while the facility policy stated it maintained an ongoing pest control program to keep the building free of insects and rodents.
The facility failed to provide effective and consistent mice control for multiple residents. A resident reported seeing mice daily in a shared room, including under beds and moving between roommates’ belongings, and staff confirmed sightings were entered in the pest log. However, surveyors found no glue boards or RDUs in one room that was documented as treated, and only one RDU with no glue traps in another room, while vendor service records did not match the facility’s documentation. The facility did not follow its pest control policy requiring an effective pest control process.
Pest control was not effective in keeping flies out of resident care and dining areas. Flies were observed at the nurses' desk, in resident rooms, and in the dining room, including landing on a resident while he was in bed and on another resident's personal items. Staff said flies were a recurring issue, especially when doors were opened for smoking access, and the facility's policy called for an effective pest control program for seasonal pests such as flies.
An ineffective pest control program allowed live cockroaches and cockroach remains to be found in the kitchen. The RD reported the local health dept found roach remains under the hot food service area, and the REHS observed live and dead cockroaches under the steam table and near the dish machine, resulting in a red tag closure. Staff also reported seeing roaches in the kitchen for months, and the DM stated the kitchen had not been inspected for pests for several months.
Ongoing pest control failures were documented after residents and staff reported mice, roaches, and possible bed bugs in multiple rooms and common areas. A resident described mice droppings in dresser drawers, on clothing, and in room corners, while staff observed the droppings and confirmed ongoing mouse complaints. Other residents reported mice running around at night, mice living under dressers and in clothes, and one resident reported bugs, red bite marks, and black dots on sheets. Surveyors also observed a hole in a resident’s wall where mice were entering and exiting, and the admin and maintenance director acknowledged ongoing pest problems.
Failure to Control Pest Activity and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to maintain a sanitary environment by effectively preventing and controlling pest activity. Live pests were observed in multiple resident rooms and common areas, including a pest next to Resident #79’s bed, two live brown insects in Resident #48’s room, a live insect on the wall behind Resident #48’s bed, a live insect on the wall behind Resident #45’s bed, an elongated light brown insect in front of the business manager’s office, and a small brown pest on Resident #79’s laundry basket. Resident #79, Resident #11, Resident #71, and Resident #104 each reported seeing roaches in their rooms, with Resident #11 and Resident #71 stating the facility had not come in to spray for months. The Administrator confirmed the presence of live pests in the facility. Record review showed repeated pest sightings and unresolved building conditions that could allow pest entry. The pest sighting log for May and June 2026 documented roaches 18 times in two of four hallways. Pest control reports noted German roach activity in every treated room, with an actual count of 100 on 4/10/2026, and repeated recommendations to address debris, gaps around pipes, cracks or damage to walls, and voids in baseboards. Observations also identified loose baseboards behind Resident #96’s bed and in Resident #28’s bathroom, along with a small hole in the wall above the floor in Resident #28’s bathroom. A critical work order for the dietary kitchen noted the need for pest control and holes to be closed, but the status was set to be completed and was never completed. The Director of Plant Operations stated they were not aware of or working on the repair recommendations from pest control.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program. Review of the facility’s environmental safety and maintenance documentation noted a concern about possible pests in the attic. During interviews, the Central Supply Clerk/Housekeeper reported that raccoons had been trapped at the facility, squirrels had been heard in the ceiling of the MedBridge B Unit, and droppings had been found in the attic. The same staff member also reported finding a hole in the courtyard area in February 2026 and stated it was not repaired by the Maintenance Director. During observation, surveyors saw a large gaping hole where the soffit and fascia connected above the gutter, with gnaw marks on the fascia. The hole was estimated to be about the size of a basketball. A 2-foot-long piece of vent from the soffit was observed on the ground, and another hole was seen in the opposite corner behind a bush, extending from the ground to the roof and large enough for a squirrel to enter. Another small hole was also observed in the back of the building near room [ROOM NUMBER], which the staff member stated was large enough for a squirrel to get into and could allow animals to travel down the 300 Hall. Facility records showed a wildlife inspection and estimate from one pest control vendor identifying entry points for squirrels, raccoons, and birds, and a later service agreement with another vendor for wildlife trapping in the attic. Service reports documented multiple trapped animals, including raccoons, a gray squirrel, and a cat. The Administrator stated staff had reported noises in the ceiling and that a pest control company was contacted, and he acknowledged a roof hole where squirrels entered. The facility policy stated it maintained an ongoing pest control program to keep the building free of insects and rodents.
Inconsistent Pest Control Treatment for Resident Rooms
Penalty
Summary
The facility failed to provide effective and consistent mice control for residents in the building, affecting five residents in the sample who were receiving pest control treatment. A housekeeper stated that a resident reported a mouse sighting, and the sighting was entered in the facility’s Pest Control Sighting Log. One resident stated that mice of different colors were seen every day in the room, including under the beds at night, and described mice moving from one roommate’s trash can near the window to another roommate’s laundry bin and nightstand area by the door. The three residents in that room were identified as roommates. The Maintenance Director stated that flat glue boards were placed under vents and behind doors in rooms where mice were reported, and that RDUs were sometimes placed in residents’ rooms. However, when surveyors and the Maintenance Director inspected the room, there were no RDUs, flat glue boards, or other pest control treatment present, despite the room being listed in the Pest Control Sighting Log as treated for mice. The pest control service inspection report showed the vendor visited the room but did not service it, even though the log indicated treatment. In another room occupied by two residents, there was only one RDU and no glue traps, and the service inspection report again showed the vendor visited but did not perform the treatment that was documented in the facility log. The facility failed to follow its Pest Control policy dated 7/3/2025, which states it is the facility’s policy to ensure an effective pest control process in the building.
Pest Control Program Failed to Control Flies in Resident and Dining Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the North Station nurses' desk and North Dining Room free from flies, and to keep the Central Station nurses' desk and Central Hall dining room free from flies. During observation, flies were seen circling and landing on the North Station nurses' desk and flying into the hall, and flies were also observed in Resident #1's room landing on personal items. The pest control binder documented prior fly issues in resident rooms, including multiple rooms listed on 04/14/26 and a fly issue in a resident room on 03/03/26. On the Central Hall, a fly was observed flying around Resident #4 while he was in bed, and he stated the flies bothered him, had gotten worse, and were everywhere. Three flies were also observed flying around the Central Hall dining room during lunch service. Staff interviews stated flies were a recurring issue, especially when doors were opened for residents to go to the smoking patio, and that pest control visited weekly. The facility's pest control policy stated it was the policy to maintain an effective pest control program and to use indoor and outdoor methods for seasonal pests such as flies.
Pest Control Program Failure in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, and live cockroaches and cockroach remains were found in the kitchen. During an interview, the Registered Dietician stated that the local health department found roach remains inside the panel below the hot food service area on 5/20/26, and the kitchen was closed by public health until pest control was completed and the kitchen was deep cleaned. The Director of Maintenance stated the kitchen had not been inspected for pests from 12/1/25 until 5/20/26. Staff interviews also described seeing roaches in the kitchen before the pest control visit. One cook stated he had seen an occasional live roach, and another cook stated he had seen live roaches in the kitchen and had not seen new traps or pest control going through the kitchen for several months until the 5/20/26 visit. The Registered Environmental Health Specialist stated she observed live cockroaches and cockroach remains under the steam table and issued a red tag closure of the kitchen. The inspection report documented live, dying, and dead cockroaches under the steam table, near the dish machine, and in monitor traps, and the pest control invoice noted old insect monitors were removed and new ones placed around the kitchen.
Pest Control Failure With Ongoing Mice, Roaches, and Possible Bed Bugs
Penalty
Summary
The facility failed to provide effective pest control for multiple residents, with survey findings documenting ongoing mice, roach, and possible bed bug activity in resident rooms and common areas. Pest control invoices showed repeated treatments on the third, second, and fourth floors, as well as in laundry rooms, pantry, kitchen, locker room, basement, dining rooms, nursing stations, and several fourth-floor rooms. Rodent traps were also placed on multiple nursing floors and the basement, yet resident and staff reports continued to describe active pest problems. During observation and interview, a resident stated that mice had been in the room since December 2025 and that roaches were still present. The resident described mice droppings in dresser drawers, on clothing, and in personal items, and reported that garbage cans were not emptied daily, floors were not swept and mopped daily, and food waste remained in the room. Surveyors observed black pellets consistent with mice droppings in the dresser drawer, on clothing, in room corners, and along the baseboards. Staff members, including LPN, housekeeping, and maintenance personnel, confirmed the presence of mice droppings and acknowledged ongoing mouse complaints in the facility. Additional residents reported mice running around their rooms, mice living under dressers and in clothes, and glue traps that were not working. One resident reported bugs in the room for about a month, red bite marks, and black dots on sheets, while the administrator stated the facility did not have bed bugs but would call the exterminator to check the room. Surveyors also observed a hole in a resident’s wall at the head of the bed, and the resident reported that mice came in and out of the hole and that the issue had been ongoing for months. The administrator and maintenance director acknowledged ongoing mouse and roach problems and stated that staff and residents had reported sightings of mice.
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