Failure to Maintain Effective Pest Control Resulting in Cockroach Infestation on Units and Residents
Summary
The deficiency involves the facility’s failure to maintain a pest‑free environment and to operate an effective pest control program, resulting in ongoing cockroach infestation in resident care areas and on residents. Pest control invoices from December documented weekly services and aerosol treatments on the 100 and 200 halls, but did not state the reason for treatment, what pests were being treated, or details of the specific applications. One invoice noted evidence of German cockroaches in a specific room, yet there was no documentation of staff reports of cockroach activity or targeted follow‑up. Staff interviews consistently described a longstanding, significant cockroach problem beginning in the prior summer or fall, with heavy activity in October, November, December, and January, particularly on the 100 and 200 halls. One resident, identified as having moderate cognitive impairment and requiring a wheelchair and supervision with bathing and dressing, experienced a change in condition with altered mental status and was transferred to the ED. EMS documentation for this transfer indicated that, during assessment in the facility, live insects consistent with cockroaches were observed on the resident’s body and in his bed. EMS personnel reported that when they questioned staff about a bug problem, staff confirmed that the facility had a cockroach infestation and stated there was nothing that could be done about it. The ED provider note also documented that the resident arrived with insects on him and was immediately cleaned by nursing staff. Multiple staff members, including NAs and nursing staff, reported observing cockroaches on residents, in resident beds, on medication carts, on walls, ceilings, floors, and other surfaces, and behind refrigerators and in HVAC units. Several NAs stated that cockroaches had been present "everywhere" on the 100 and 200 halls, including on resident clothing and in rooms where residents ate meals and food was often spilled. Staff also reported that housekeeping was only present during daytime hours, that over‑the‑counter household sprays were used between exterminator visits, and that everyone in the facility was aware of the pest problem. Despite this, staff frequently did not submit work orders or formal reports, assuming administration and maintenance already knew. The Maintenance Director initially denied recent pest problems but later acknowledged a cockroach infestation in November and December, primarily on the 200 hall, and admitted he had been told at some point that cockroaches had been found on residents. He stated he did not contact the pest control company, adjust the pest control program, or implement any monitoring after learning this. He also reported that he did not participate in QAPI, had no records of pest‑related work orders, and largely relied on word of mouth rather than a documented system. The Administrator similarly acknowledged frequent cockroach sightings in October and November, recognized that the contracted pest control provider was not effective, and confirmed that there was no work order system for pests, no room audits for pest activity, and reliance on word‑of‑mouth reporting and over‑the‑counter sprays by housekeeping. A pest control specialist from a new company later described the facility as heavily infested with active German cockroach activity at the time of his initial evaluation, confirming the extent of the infestation.
Penalty
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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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