F0925

F

Failure to Maintain Effective Pest Control Resulting in Cockroach Infestation on Units and Residents

Wilmington, North Carolina Survey Completed on 03-18-2026

Penalty

No penalty information released

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.