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
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Pest control bait stations were not consistently monitored or serviced, and several resident rooms had clutter, food, or signs of rodent activity. A resident with schizophrenia and depression had food debris under the bed and a room that was not checked for months, while another resident reported mouse droppings and mice in the room. The maintenance director said there was no master list of bait stations, and the pest control company filled them only when management requested it.
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
The facility failed to maintain an effective pest control program when multiple live and trapped roaches and spiders were observed in the rooms of two cognitively intact residents. One resident, admitted for surgical aftercare, had live and trapped pests in her room and reported that bugs were found there often, expressing that she felt hurt and uncomfortable. Another resident with essential HTN reported a roach crawling onto her foot while she was in bed and stated she felt uncomfortable. An activities assistant confirmed the observed pests, an LN verified pest presence via photographs and described the situation as unsanitary with potential for allergic reactions, and the DON stated that rooms were expected to be clean and free of pests despite a written pest control P&P intended to keep the building free of insects and rodents.
Ineffective Pest Control Program in Kitchen: A roach was observed crawling on the kitchen wall behind the handwashing station during the lunch meal. Staff reported roaches had been seen on and off near sink areas, and pest sighting logs documented multiple roach sightings. The pest control company provided monthly service, and the DON/maintenance leadership acknowledged the ongoing kitchen pest issue and that monthly treatment was thought to be working.
The facility failed to maintain an effective pest control program, as multiple cognitively intact residents reported large flying roaches in their rooms, bathrooms, and shower areas, and a visitor also reported seeing roaches. Surveyors directly observed roaches on a bathroom floor in one resident’s room, along with standing water and roach bait houses, after the resident had previously complained to housekeeping about room cleanliness and roaches. Two residents in another room reported wasp nests by their window for several weeks, and surveyors confirmed two nests and a gap between the screen and window that allowed insect entry. Leadership was informed of an additional gap at a hallway-to-courtyard threshold that could admit insects, and it was determined that pest control services had lapsed for two months due to unpaid invoices, while pest control logs had been destroyed and left blank, omitting documentation of roach sightings and the wasp nests.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to ensure bait stations were monitored and serviced to prevent or reduce pest problems for residents reviewed for environment. The report identified that the pest control company came monthly and would fill bait stations in resident rooms only when management told them to do so, and the maintenance director stated there was not a master list of which rooms had bait stations. The maintenance director also verified that during 4/2026 none of the bait stations in any rooms were serviced. For one resident with schizophrenia, depression, and moderate cognitive intactness, the infection preventionist stated the resident was trying to feed the mice. During an observation, a large amount of black crumbs that looked like chocolate cake and two patties of what looked like white meat were found under the bed. The room service summary showed the room was not checked in 4/2026, 3/2026, 1/2026, 12/2025, or 11/2025, and was checked in 2/2026 with light rodent activity noted. The maintenance director stated housekeeping was supposed to clean the room after breakfast and lunch. Other residents reviewed had cluttered rooms and food or belongings that could contribute to pest concerns. One resident with delusional disorder reported mouse droppings on the bed, mice in the room, and that the roommate hoarded food; the maintenance director stated he had seen mouse droppings in that room, but the service summary showed no rodent bait stations in the room. Another resident with paranoid schizophrenia had several plastic bags on the floor with uncovered pie on a plate, and the service summary showed no bait stations in the room. Additional residents with psychiatric diagnoses had overflowing bins, crowded rooms, or food brought to rooms, and the owner stated uncovered pie in a resident room was not okay because of pest control concerns. The DON stated cluttered rooms could attract bugs and lead to pest problems.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of multiple live and trapped pests in the rooms of two cognitively intact residents. Resident 1, admitted with a diagnosis including encounter for surgical aftercare and assessed as cognitively intact on an MDS dated 2/5/26, was observed in her room where a live roach was seen on the floor and a live brown spider approximately one inch in length was seen on the sliding door. Additional pests were observed on traps in the same room: two roaches on a trap under the bed, and two one‑inch black spiders and a roach on a trap under a wooden cabinet by the sliding door. During this observation and interview, Resident 1 became angry and stated she felt hurt and uncomfortable having to sleep with pests in her room, and reported that the facility was not clean and that bugs were found in her room often. An Activities Assistant, present during the observation, confirmed the presence of the live spider, the live roach on the floor, and the trapped roaches and spiders in Resident 1’s room. Resident 2, admitted with a diagnosis of essential hypertension and assessed as cognitively intact on an MDS, reported during an interview in her room that a roach had crawled onto her foot while she was in bed and then crawled away in the room on a recent Saturday. Resident 2 stated she felt uncomfortable in the facility. A Licensed Nurse later confirmed the presence of pests in Resident 1’s room via photographic record review and stated that the presence of pests is unsanitary and that a resident could get an allergic reaction from a bug bite if spiders are present, and that pests can make a resident feel uncomfortable with care. The DON stated the expectation is for residents’ rooms to be clean and free of pests. A review of the facility’s pest control policy indicated the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents, which was not achieved based on the observed and reported pest activity in resident rooms.
Ineffective Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the kitchen free of roaches. During an observation on 4/28/2026 at 11:03 am, a roach was seen crawling on the kitchen wall behind the handwashing station during the lunch meal. A Dietary Aide stated she had not recently seen roaches in the kitchen, but in the past she reported them to the administrator, and said roaches can spread disease and are unsanitary. During interviews, staff reported that roaches had been seen on and off in the kitchen, usually near sink areas, and that they were killed and reported to the dietary manager. The pest control company service manager said the facility received monthly service and that common areas including the kitchen were treated, with staff using a log for pest sightings; he said extra visits were not made unless there were multiple sightings or an infestation. The Maintenance Supervisor and Administrator both acknowledged the pest control program, stated they were aware of roaches in the kitchen on and off, and noted that monthly treatment was thought to be working. Record review showed pest sightings documented on 1/08/2026, 2/10/2026, 4/01/2026, 4/20/2026, and 4/24/2026, along with monthly pest control invoices and a facility policy requiring an effective pest control program.
Failure to Maintain Effective Pest Control and Document Pest Activity
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program to prevent and address roaches and other pests, resulting in multiple resident complaints and direct observations of pests by surveyors. During a Resident Council meeting with the President and four other regular attendees, all participants agreed the facility was not a safe, clean, comfortable, and homelike environment. Several cognitively intact residents, as evidenced by Brief Interview for Mental Status (BIMS) scores of 14–15, reported seeing large flying roaches throughout the facility, including in their rooms and shower areas, and described the shower room as unclean. One resident stated roaches crawled on ceilings and walls and made it difficult to sleep and reported not seeing pest control treat their room. Another resident, who had a BIMS score of 0 but was described by staff and through interviews as alert and oriented times four, reported that flying roaches were present during the day and night and that the problem had worsened since construction began. A visitor in the dining room also reported seeing roaches in the building and expressed concern that the older section of the facility needed attention. In one resident’s room and bathroom, surveyors directly observed four roaches on the bathroom floor (two dead and two alive on their backs), and the Maintenance Director did not remove them during the observation. The same room contained two roach bait houses and a plastic container under the toilet’s on/off valve that had collected standing water, which the Maintenance Director acknowledged was related to a flooding bathroom and likely attracted roaches. The resident reported having told housekeeping about how dirty the room was and that roaches crawled and flew around the room and bathroom; when the surveyor and housekeeper re-entered the bathroom later, roaches were again observed and then removed by the housekeeper. Additional pest-related issues were identified on another unit, where two residents in a shared room reported the presence of wasp nests by the window and stated the nests had been there for about three weeks and that staff were aware. Visual inspection revealed two wasp nests between the screen and glass, one with multiple round, greyish-white egg-like sacs and a live wasp on an empty cell, and a second smaller nest, along with a quarter-inch gap between the outside screen and the window that allowed outside air to be felt and contained what appeared to be a dead wasp. During the end-of-day debriefing, facility leadership was informed that a gap at the threshold from the hallway door to the courtyard could be a point of entry for insects and roaches. It was also noted that contracted pest control services were not completed for two months due to a lapse in vendor payment processing, and that the Maintenance Director had destroyed pest control logs across all units, leaving them blank and failing to document the roach sightings and the wasp nests reported by residents and observed by surveyors.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
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