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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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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