Health inspection·January 22, 2026

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 2 (Resident #1's room and Resident #3's room) of 5 residents room reviewed for pestThe facility did not ensure Resident #3's room was free of roaches and Resident #1's room was free of gnats. This failure could place residents at risk for uncomfortable environment.Findings included: Record review of Resident #1's face sheet dated 01/21/26 reflected, Resident#1 was admitted to the facility on [DATE]. Resident #1 was diagnosed with but not limited to, Cerebral palsy (a group on conditions that affect movement and posture), unspecified, major depressive disorder (Mod disorder that significantly impacts daily life) recurrent, unspecified and anxiety disorder (mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation).Record review of Resident #1 MDS, dated [DATE] reflected Resident #1 had a BIMS score of 11 which showed moderate cognitive impairment.Record review of Resident #3's face sheet dated 01/21/26 reflected, Resident #3 was admitted to the facility on [DATE]. Resident#3 was diagnosed with but not limited to, Parkinson's disease without dyskinesia, without mention of fluctuations (disease of the nervous system) mild neurocognitive disorder (early-stage condition featuring slight but noticeable declines in memory, language, or thinking skills that exceed normal aging) due to known physiological condition without behavioral disturbance.Record review of Resident #3's MDS, dated [DATE] reflected Resident #3 had a BIMS score of 9 which showed moderate cognitive impairment.Requested policy on physical environment and pest control on 01/21/26 at 10:29 am to the Admin and DON by email.During an interview and observation on 01/21/26 at 10:40 a.m., Resident #3 and Resident #4 were roommates and were interviewed together. Resident #3 said she had roaches and they kept coming back. Resident #3 said she had talked with the Admin about the roaches. Resident #3 said the roaches were everywhere in her remote and refrigerator. Resident #3 said she went to another room and came back to this one. The Surveyor did not see roaches in Resident #3's bedroom and bathroom at this time. Resident #4 yelled no when surveyor asked if she had seen roaches in the room recently.During an interview and observation on 01/21/26 at 11:05 a.m., Resident #1 and Resident #2 were roommates and were interviewed together. Resident #1 said, see those little black flies. The surveyor saw gnats around Resident #1's bed. Resident #1 said, it was hard to sleep at night because of the flies around his head all the time. Resident #1 said, he told them [nursing staff] about the[ gnats]and they [Maintenance Director] would come and fix it, The surveyor observed that Resident #1 yelled when he talked and could be heard in the hallway. The Surveyor asked Resident #2 if the flies bother him, and Resident #2 said no.During an interview on 01/21/26 at 11:15 a.m., Resident #5 said that she saw the little black flies in her room, but they do not bother her because they do not bite.During an interview on 01/21/26 at 11:27 a.m., the Dietary Manager said that she had not seen gnats and roaches in the kitchen. The Dietary Manager said she was told by other staff that Resident #3 had a problem with Residents Affected - Few Page 1 of 2 675906 675906 01/22/2026 Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roaches. The Dietary Manager said any sightings of pest were reported to the Maintenance Director.During an interview on 01/21/26 at 12:00 p.m., the Maintenance Director said Resident #3's refrigerator was full of roaches in late December or early January and had to be placed outside. The Maintenance Director said, Resident #3 and Resident #4 were moved out of the room temporarily so that housekeeping could deep clean the room. The Maintenance Director stated he provided treatment and pest control provided treatment to the room immediately. The Maintenance Director said the facility replaced the refrigerator. The Maintenance Director said he had reports of gnats throughout the facility and he provided treatments.During an interview on 01/22/26 at 8:20 a.m., the DON said Resident #3's family and leadership staff had talked about the refrigerator and roach concern around January. The DON said the family, resident #3 and facility agreed that if the roaches continue to be an issue the refrigerator would be removed. The DON said staff does check and clean out the refrigerator. Surveyor asked Resident #3 could surveyor observed the inside of her refrigerator. Surveyor did not observe roaches at the time of visit.During an over the phone interview on 01/22/26 at 8:35 a.m., the housekeeping supervisor said he had to deep clean Resident #1 and Resident #2 room because of the gnats. Both Residents were moved to another room. Prior to that Resident #3's room had to be deep cleaned and the two residents in that room were temporarily moved for about a week and then were moved back into their room. The housekeeping supervisor was not sure when Resident #3 and Resident #4 were moved.During an observation on 01/22/26 at 9:00 a.m., the Maintenance Director and surveyor did a walk-through of Resident #3's room and found the recommended instructions to seal the toilet and sink pest control form had not been completed. The Maintenance Director said he was working on a log to keep updated pest control concerns and treatments. The surveyor observed a blank log at this time. The Maintenance Director had pest control phone number and provided it to surveyor.Attempted to call pest control on 01/22/26 at 9:30 a.m. and left a message with the representative.During an interview on 01/22/26 at 9:36 am, CNA A said Resident #3 and Resident #4 were moved to another room so that they could clean the room for roaches. CNA A said Resident #3 and Resident#4 were in a different room for about a week. CNA A said Resident#1 and Resident #2 were moved because of the gnats. CNA A said staff had to clean the room when the residents leave out to help prevent the bugs. CNA A said housekeeping was cleaning the room. CNA A said she was not sure of any other residents that had Gnats and roaches in their room.During an interview on 01/22/26 at 9:43 a.m., Housekeeper B and Housekeeper C said they had to move Resident #1 and Resident #2 to another room to clean the room for the gnats on 01/22/26. Housekeeper B and Housekeeper C had seen roaches in Resident #3's room before and does not recall seeing any and the last week.During an interview on 01/22/26 at 9:50 a.m., the DON said she did not know why Resident #1 and Resident #2 had changed rooms. The DON stated pest control issues are reported to the nurses usually by residents. The DON stated Maintenance Director, Housekeeping supervisor and the Admin are made aware of the pest sightings.Requested policy on physical environment on 01/22/26 at 9:32 am to the DON by email.Record review of pest prevention service report, dated 09/26/25, reflected: caulking/sealing/screening required/seals around toilets and sinks in rooms [Resident#3 and Resident#4 room} need to be sealed to prevent future American roach activity.Record review of pest prevention service report, dated,9/26/25, 9/29/25, 10/01/25, 10/16/25, 10/17/25, 11/10/25, 11/12/25, 11/21/25,12/03/25, 12/25, 12/22/25, 12/24/25 and 1/9/26 reflected customer responsibility included bathroom recommendations: seal openings to prevent pest access. Interior/Exterior doors recommendations included replace worn weather striping to prevent pests.Surveyor did not receive physical/homelike environment or pest control policy before exit. 675906 Page 2 of 2