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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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.
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.
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.
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.
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.
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.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects, rodents, and other pests. Surveyors observed flies in resident areas on Hall 400 and Hall 200, including a fly in a resident’s room and a fly landing on a blanket covering another resident. Residents on both halls reported seeing flies in their rooms and dining areas, and one resident’s representative reported seeing medium-sized roaches around a window. Staff interviews confirmed that flies had been seen in the building and in resident rooms, and that staff were expected to report pests to nursing or maintenance so treatment could be arranged. A CNA stated flies were seen in the building, especially near the side door by the patio used by residents who smoked, and another CNA stated flies were sometimes seen in resident rooms and were reported to the charge nurse or maintenance. The Maintenance Director stated there had been an issue with flies the prior month and that staff would swat flies in the morning. The DON and Administrator both stated staff were expected to notify maintenance or leadership when pests were seen, and the Administrator stated the facility used fly lights, treated the dumpster area, and bought fly swatters when weather changed. In the kitchen, surveyors observed a fly flying around and landing on the food processor, and a roach crawling on the baseboard and floor near the handwashing sink. The Dietary Manager stated she had seen flies and had seen one shortly before the observation, and she acknowledged that flies could contaminate food. Record review showed multiple pest sightings documented in the pest control log, including roaches in resident rooms, the nourishment room, and bathroom, as well as rats in the kitchen. Pest control service reports documented treatment for flies in hallways and placement of snap traps in the kitchen for reported rats.
Pest Control Program Failed to Keep Ants and Roaches Out of Resident Areas and Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program to keep ants out of Resident #8’s room and bed, ants out of Resident #4’s room, and roaches out of the kitchen. Resident #4 had diagnoses including osteoarthritis, COPD, anemia, and hypertension, and was cognitively intact with a BIMS score of 13. During an observation in his room, black ants were seen crawling on the floor and in his bed, and he stated he had noticed ants in the room for a few days. Staff later acknowledged the ants had been present in his room over the weekend and that pest control had been contacted. Resident #8 had diagnoses including type 2 diabetes, osteoporosis, dementia, and hypertension, with a BIMS score of 11 and assistance needs for ADLs. Staff observed ants in his room on the floor, along the baseboard, at the head of the bed, and on the wall, and he was moved to another room. A skin assessment documented multiple ant bites on his body, and he reported that the ants had been in his room since the prior Friday, that they were in his bed, and that he had been bitten. Staff notes also documented ants in his room and that he initially refused to move. Record review showed the facility’s pest control services had been suspended at one point because of an outstanding balance, and staff interviews reflected confusion about the timing and extent of pest issues in the resident rooms. On a later observation in the kitchen, multiple roaches were seen crawling on the wall, floor, and around the freezers, with trash and food debris behind the freezer. The dietary manager stated the roaches had gotten out of hand and were everywhere in the kitchen, and the administrator also observed roaches, trash, and food debris in the area.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by numerous flies observed throughout the building during a complaint survey. Surveyors observed a fly on the baby doll held by a resident on the dementia unit, flies in the back dining area and the 500 hallway, and a fly buzzing in a resident room and sitting on a toilet seat in the resident bathroom on the 100 hallway. The Infection Preventionist confirmed there was a fly problem after seeing several flies during the tour and in resident bathrooms. Additional observations showed flies around resident food in the A/B day room while residents were eating lunch, and flies were also seen in the conference room where surveyors were located. The next morning, a resident eating breakfast on the dementia unit had a fly flying around his/her head and food. The Director of Maintenance stated the pest control company came every 2 weeks, but he was unsure what had been treated and acknowledged the facility had a fly problem that had been bad the day before. Pest control logs documented flies at the nurse's station and in multiple resident rooms on the Chase unit in March, and another log documented flies throughout the whole building in May. An invoice from late May documented verbal report of fly activity throughout the building, while a later invoice noted no concerns were reported at that visit.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program in 3 of 3 units reviewed. During interviews, staff reported seeing roaches, gnats, and flies and stated they usually just killed them. Residents also reported ongoing pest activity throughout the facility, including gnats, roaches, and flies in rooms and hallways, with one resident stating sticky tape had been placed but bugs were still seen. Another resident reported seeing roaches in the room every night, and a third resident stated roaches and bugs were seen all over the facility, including during the day. Observations confirmed the presence of insects in multiple areas. Three black flying insects were seen in the main dining room, a black flying insect was observed flying around a resident’s head and breakfast tray in the resident’s room, and an oblong brown insect approximately 1 inch long was seen moving quickly from under a bedside dresser to underneath the bed in another resident’s room. Four fly traps were also observed in the conference room. The Maintenance Director stated pest control had been at the facility the prior Friday, and the pest control logs showed a treatment for roaches on 6/26/2026. The facility policy stated housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Pest Control Program Failed to Keep Kitchen and Resident Rooms Free of Cockroaches
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free from pests in the kitchen, dining room, and resident rooms. Observation in the kitchen found two Catchmaster Mouse and Insect Super Glue Traps on the floor by a trashcan, with one trap filled with dead cockroaches and another trap containing two dead cockroaches. A live cockroach was also observed in the right corner of Resident #2’s room by the door stopper. The facility’s pest control policy stated that the building shall be kept free of insects and rodents through an ongoing pest control program, with services provided by a licensed exterminator. Residents and staff described ongoing cockroach activity throughout the facility. Resident #3 said the cockroaches were horrible and had been seen on the walls in the kitchen and in the dining room while eating. The DC reported seeing three live cockroaches in one day, including two in the kitchen and one in the dining room, and said she had seen an average of three cockroaches a day for about a year. The MD said residents, including Residents #4 and #5, had complained about cockroaches and that he had heard there were cockroaches in the kitchen. Resident #4 said she had seen one or two cockroaches a day in her room for about a month, and Resident #5 said she saw a roach in her room and felt scared when she saw bugs. The DM and DON also acknowledged the presence of water bugs or cockroaches in the kitchen and other areas of the facility.
Failed Pest Control Program Allowed Flies in Food and Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the kitchen, dining room, common areas, and Hall 2 free of pests. During observations, a fly was seen in the food pantry and cooking areas during the initial kitchen tour, and later several flies were observed in the kitchen during the puree process, landing on kitchen counters and food preparation areas. During the food serving line observation, several flies were also seen landing on the steam table and drinks cart. In the dining and sitting areas, flies were repeatedly observed around residents and resident items. A fly was seen crawling over the lip and inside a resident’s coffee cup, and later 3 to 4 flies were observed around a resident in the sitting area by the dining room, with a family member waving flies off the resident’s face. Another resident was later observed in the same area with 3 to 4 flies flying and landing on him. A confidential resident stated that many flies had been noticed in the facility, that the administrator had been told about them, that fly swatters were supplied to residents, and that pest control had not been seen for flies. The maintenance supervisor stated he had not noticed the flies and did not know of a risk to residents, while the administrator stated pest control came to the facility but was not sure whether flies were covered and said the flies were horrible everywhere right now. Record review showed a pest control log with an entry for ants treated in Rooms 44-47 and a later signature with location, issue, witnessed by, and additional description left blank. The facility policy stated it maintained an ongoing pest control program to ensure the building was kept free of insects and rodents.
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