Park Village Healthcare and Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately notify the resident's representative when there was a significant change in the physical status and consult with the resident physician for one of three residents (Resident #2) reviewed for notification of change in condition.<BR/>LVN failed to notify Resident #2's resident representative of the significant change of condition of pain, notify the physician, and request for x-ray of the right knee on 10/08/23. <BR/>This failure could place residents at risk for a delay in treatment and not receiving proper care due to failure to notify resident representative.<BR/>Findings included:<BR/>Review of Resident #2's face sheet dated 10/10/23 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, hypertension, difficulty in walking and age related physical debility.<BR/>Review of Resident #2's care plan undated reflected Resident #2 had Condyle (A condyle is the round prominence at the end of a bone) fracture of lower end of right femur. Goal: Return to prior level of function after healing and rehabilitation. Intervention: Anticipate the needs of resident and call light within reach. Modify environment as needed to meet current needs. Non-slip surface for bath/shower, bed in lowest position with bed locked; floors even free from spills and clutter, adequate glare free light, monitor for level of pain.<BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 9:00 AM completed by LVN E reflected Late Entry Signs and symptoms noted of condition change: other change of condition noted: right knee pain. Notifications to care clinician: nurse practitioner 10/09/23 9:11 AM. Name of family member or resident representative notified: Family member 10/09/23 1:45 PM.<BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 9:09 AM completed by LVN E reflected: Resident complaint of right knee and leg pain, Nurse Practitioner notified await instructions. <BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 1:29 PM completed by LVN E reflected orders received x-ray to tibia/fibula (two large bones located in the lower leg) and knee per nurse practitioner.<BR/>Review of Resident #2 nurse progress notes dated 10/09/23 at 5:33 PM completed by LVN F reflected: X-ray exams/test pending. Bedrest encouraged Resident resist supper meal but accepted chilled water, a health shake, and a cup of ice cream.<BR/>Review of Resident #2 x-ray dated 10/09/23 revealed comminuted fracture of distal femur 10/10/23 The bones are osteopenic. Severe Tri compartment degenerative changes are present at the knee. <BR/>Review of hospital records dated 10/10/23 revealed there is severe Tri compartment degenerative joint disease. fracture of distal femur, <BR/>Observation and interview on 10/18/23 at 10:43 AM revealed Resident #2 was sitting up in bed resting, Resident #2 was unable to communicate what happened to right leg. Resident was with a leg brace and foot elevated on pillow. <BR/>Observation and interview on 10/19/23 at 8:40 AM revealed Resident #2 was sitting up in the television room with a right leg brace and right leg elevated with pillow eating a snack. Observation of left knee appeared to be swollen. Resident #2's appearance was well groomed, and she did not have signs of pain. Resident #2 was unable to communicate what happened to right leg. <BR/>Interview on 10/19/23 at 10:33 AM with Resident #2's family member revealed they came to visit Resident #2, and as they entered the unit a nurse grabbed and hugged me. The family member stated the nurse told her she was having an x-ray ordered for Resident #2 due to Resident #2 having a possible fracture of her leg. The family member stated that was how they were informed about the possible injury. The family member stated she immediately began to ask questions about what had happened to Resident #2. She stated the LVN apologized because she thought the family member knew and that it was the reason for the visit. The family member stated she never received updated information pending the results from the x-ray, but was later called and told an ambulance was called to transfer the resident to the hospital. The family member stated she called for two days to speak with someone regarding the injury, but it was as if nobody was talking about it because it was under investigation. The family member stated Resident #2 moved around really good in her wheelchair, so she was surprised to hear about a possible fracture once she arrived at the facility. The family member stated she finally was able to speak with the DON and expressed it would have been nice to have been notified about the situation prior to arriving to the facility. She added that the LVN called her to apologize for not contacting her about the resident's change of condition. <BR/>Interview on 10/19/23 at 1:19 PM with LVN E revealed she entered the facility with her aides alerting her to Resident #2 with pain at her right knee. LVN E stated at that point when she did an assessment, she felt like the right knee was just a bit more swollen than usual. LVN E stated with that she contacted that Nurse Practitioner to request for x-ray to the tibia/fibula and the knee to rule out any findings. LVN E stated she then alerted the DON and began with treatment and care for Resident #2. LVN E stated she did forget to contact family member, and realized it once she saw her enter the facility. LVN E stated The DON addressed it with her and she again contacted family member to apologize. LVN E stated she was just so concerned about ensuring Resident #2 was getting proper care that it slipped her mind. LVN E stated she was responsible for contacting the DON, Physician and family member when there was a change of condition in resident status. LVN E stated not notifying family member could create a delay in care and not keeping them aware of resident conditions. <BR/>Interview on 10/19/23 at 3:06 PM with The DON revealed she was alerted to Resident #2's change of condition by LVN E the morning of 10/09/23. The DON stated Resident #2's family member did come to visit that day; however, she was not aware the family member was not notified of the request for x-ray for Resident #2. The DON stated it was the responsibility of the nurse to contact the physician and resident representatives, so they are aware of any changes in resident conditions. The DON stated not doing so could create concerns for treatment and proper care for residents. <BR/>Review of facility's Change of Condition Reporting policy, revised May 2021, reflected:<BR/>It is the policy of the facility that all changes in resident condition will be communicated to the physician. <BR/>Acute Medical Change<BR/>1. <BR/>Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a require for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician.<BR/>2. <BR/>If unable to contact attending physician or alternate physician timely, notify Medical Director for follow-up to change in resident condition. <BR/>3. <BR/>The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. <BR/>4. <BR/>All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by Resident #60 for 1 resident (Resident #6) of 24 residents reviewed for abuse and neglect.<BR/>On 01/25/25, Resident # 60 swung at Resident #6 and hit Resident # 6's right eye. Resident # 6 sustained bruising under the right eye.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by Resident #60 for 1 resident (Resident #6) of 24 residents reviewed for abuse and neglect.<BR/>On 01/25/25, Resident # 60 swung at Resident #6 and hit Resident # 6's right eye.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any other altercation between the two residents.<BR/>Interview on 03/18/25 at 1:38 PM with CNA A, she stated Resident #6 was sitting on her wheelchair in front of the nursing station, when Resident #60 who was standing next to her swung at her and hit her right eye. CNA A stated she separate the two residents immediately. CNA A denied any other altercation between the two residents.<BR/>In interview on 03/18/25 at 1:40 PM, Resident #6 was unable to respond to interview questions. <BR/>In interview on 03/18/25 at 1:42 PM, Resident #60 stated did not remember the incident, and denied ever hitting another resident. <BR/>Interview with the DON and Administrator on 03/18/25 at 1:58 PM revealed, both checked the incident document and stated after they investigated the incident, they did not report it because there was no identifiable intent from one resident to injure the other resident. The DON stated both residents still socialized with each other, and when both residents were interviewed the next day of the incident none of them remembered the incident. The DON and Administrator both stated the risk to residents could be continuous of harm. The Administrator further stated that he was the abuse coordinator for the facility and according to the facility policy/Provider letter Abuse is a willful infliction of injury.<BR/>Review of the facility's Abuse: Prevention of and Prohibition Against, dated 2017, reflected:<BR/>Policy<BR/>It is the policy of this facility that ear resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment <BR/>Abuse is a a will infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm . Instances of abuse of all residents, irrespective of any mental or physical condition causing physical; harm .<BR/>D Prevention .<BR/>2) The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by . <BR/>Identifying, assessing and are planning for appropriate interventions and monitoring of resident with needs and behaviors which might lead to conflict . such as, Physically aggressive behavior, such as hitting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately report an alleged act of abuse to the State Survey Agency, for 2 residents (Resident #6 and 60) of 24 residents reviewed for abuse and neglect.<BR/>The facility failed to immediately report an allegation of physical abuse.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any other altercation between the two residents.<BR/>Interview on 03/18/25 at 1:38 PM with CNA A, she stated Resident #6 was sitting on her wheelchair in front of the nursing station, when Resident #60 who was standing next to her swung at her and hit her right eye. CNA A stated she separate the two residents immediately. CNA A denied any other altercation between the two residents.<BR/>In interview on 03/18/25 at 1:40 PM, Resident #6 was unable to respond to interview questions. <BR/>In interview on 03/18/25 at 1:42 PM, Resident #60 stated did not remember the incident, and denied ever hitting another resident. <BR/>Interview with the DON and Administrator on 03/18/25 at 1:58 PM revealed, both checked the incident document and stated after they investigated the incident, they did not report it because there was no identifiable intent from one resident to injure the other resident. The DON stated both residents still socialized with each other, and when both residents were interviewed the next day of the incident none of them remembered the incident. The DON and Administrator both stated the risk to residents could be continuous of harm. The Administrator further stated that he was the abuse coordinator for the facility and according to the facility policy/Provider letter Abuse is a willful infliction of injury.<BR/>Review of the facility's Abuse: Prevention of and Prohibition Against, dated 2017, reflected:<BR/>Investigations<BR/>1. <BR/>All identified events are reported to the Administrator immediately.<BR/>H. Reporting/Response<BR/>2. All allegations of abuse, neglect .will be reported outside the facility and to the appropriate state or federal agencies in the applicable timeframes, as per this policy and applicable regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 of 18 residents (Resident #1, Resident #2) reviewed for abuse and neglect.The facility failed to thoroughly investigate inappropriate sexual behavior between Resident #1 and Resident #2. Resident #1 was observed in the dining room by CNA-A massaging the breast of Resident #2.An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 7:12 PM. While the IJ was removed on 11/15/25, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings included: Record review of Resident #2's face sheet dated 11/15/25 reflected she was a [AGE] year-old female admitted into the facility 09/22/25 with a diagnosis of senile degeneration of brain (a general term for a decline in memory, thinking, and other cognitive abilities associated with aging). Record review of Resident #2's care plan dated 9/22/25 reflected ADL self-care performance deficit impaired mobility/cognition. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions were to converse with resident while providing care, explain all procedures before starting, promote dignity by ensuring privacy, staff will provide appropriate level of physical assistance with ADL's, encourage them to participate to the fullest extent possible. Record review of Resident #2's initial assessment MDS dated [DATE] reflected a BIMS score of 01 (Severe Cognitively Impairment).Record review of Resident #1's face sheet dated 11/15/25 reflected he was a [AGE] year-old male admitted into the facility 07/14/25 with a diagnoses of brain compression (a serious condition caused by increased pressure within the skull that pushes the brain against its rigid covering), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #1's care plan dated 9/3/25 reflected a focus of elopement risk and significantly intrudes on the privacy or activities, the goal was to maintain safety and would not leave the facility. Interventions/tasks were to distract resident from wandering by activities, food, conversation, television, document wandering behavior, identify pattern of wandering determine if aimless or escapist, is resident looking for something or did the wondering indicate he needed more exercise. Focus was a potential to demonstrate physical and verbal aggressive behaviors/manic episodes. Goal was to demonstrate effective coping skills and would not harm self or others. Interventions/tasks were to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort and body position, pain. Communication provides physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff members when agitated. When he becomes agitated, guide away from source of distress, engages calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's quarterly MDS dated [DATE] reflected he had a BIMS score of 09 (Moderately Cognitively Impaired).On 11/13/25 the State Surveyor observed the video dated 11/05/25, on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was brought back to the hallway across from the nurses station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.Record review of undated written statement of CNA-A reflected, This morning I witness [Resident #1] coming out of the dining room with a pull-up in his hand. I ask my co-worker where did he get it, he headed back to the dining room and shut the door that's when I went to check to see why he shut the door, as I enter the room both residents were standing by the table [Resident #1] in front of her massaging her chest with his hands holding (She had the top shirt on) her tank top. I told him to stop I patted the pt. realized her brief was off, grabbed her and started walking her out to notify my nurse and pt telling me he has her and I replied: I got her. [sic]Record review of the facility undated investigation reflected, We, [Administrator and DON, interviewed CNA-A 11/5/25 after reading her statement to get clarity on the incident between [Resident #2] and [Resident #1]. Upon speaking with her, her story was inconsistent with what was initially written as she stated she initially assumed that [Resident #1] was touching [Resident #2], by the way he was standing next to her, but was unsure if she could see that [Resident #1] was touching [Resident #2] or not as she did not observe it herself. She state that she saw [Resident #1] come out of the dining room with a brief in hand, she followed him back into the dining room and saw [Resident #1] standing next to [Resident #2], then walked out of the dining room and back to her room and notified the nurse of [Resident #1] carrying dirty brief to trash. [sic]In a face-to-face interview with the DON on 11/13/25 at 1:37 PM, she stated that she became aware of the alleged abuse when it was reported by LVN-B. She stated that LVN-B had conducted the assessment on Resident #2. She stated that she and the Administrator had interviewed CAN-A and CAN-A did not verbally provide the same information she had written in her statement. She stated CAN-A was asked about the discrepancy, but she did not remember the response. She stated based on the discrepancy she and the Administrator determined that nothing had happened between Resident #1 and Resident #2. She stated that Resident #1 had been sent to hospital for psych evaluation, but they sent him back with no new instructions. She stated that staff had documented it on 11/4/25 and during the early shift on 11/5/25 that Resident #1 had been going into other residents rooms. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CAN-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated the resident did not exhibit any distress at the time of examination. In a face-to-face interview with the Administrator on 11/14/25 at 10:10 AM, he stated he stated that he was notified by LVN-B that CNA-A had walked into the dining room and found Resident #1 and Resident #2 in the dining room alone. He stated he conducted a soft investigation, he stated there was no difference between a soft investigation and a regular investigation. He stated that he would do the same thing for both investigations skin assessments, safe surveys, and in-services. He stated that the investigation depended on the situation. He stated in this soft investigation he did not identify anything that was reportable. The Administrator was asked, Was Resident #1 asked to help staff with ADL care? The Administrator denied that Resident #1 was asked to help with other residents ADL care. The Administrator was asked, If nothing happed between Resident #1 and Resident #2, how did Resident #2 end up without a brief, Resident #1 with a dirty brief to put in the trash, and they were the only two people in the room? He stated he could not assume that anything had happened between the residents because there were no witnesses. The Administrator stated the residents were at risk of the facility not creating an environment for resident safety. In a telephone interview on 11/21/25 at 10:35 AM with the NP, he stated he had not been told that there was a potential sexual abuse between Resident #1 and Resident #2. He stated he had first heard there was a significant event regarding Resident #1 when he was notified that the State was in the building. He stated the staff had informed him that Resident #1 had been going in and out of other residents rooms. He stated that Resident #1 had been very restless and was constantly going into rooms wiping down things. He stated the staff informed him that Resident #1 was not responding to direction, and he was trying to help a male resident back to bed. He denied he was ever informed of Resident #1 attempting to assist a female resident. He stated Resident #1 assisting residents placed the residents at risk of trips or falls. A. Record review of facility Abuse and Neglect Policy revised 10.2022 reflected, Investigation 1. All identified events are reported to the Administrator immediately.2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below).3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Upon receiving a report or allegation of a potential violation of this policy involving the taking, keeping, using, or distributing photos or video recordings, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicates resident privacy or security as protected by the Health Insurance Portability and Accountability Act ( HIPAA). Any such actual or potential violation will be managed as per the Facility's HIPAA policies and procedures.5. The investigation will include the following: An interview with the person(s) reporting the incident; An interview with the resident(s); Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; A review of the resident's medical record; An interview with staff members (on all shifts) who may have information regarding the alleged incident; Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; An interview with staff members (on all shifts) having contact with the accused employee; and A review of all circumstances surrounding the incident. 6. To the extent there is evidence that could be used in a criminal investigation, staff will immediately notify the Administrator or his/her designee. Staff are not to tamper with or destroy any such evidence at any time. 7. At the conclusion of the investigation, the Facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation has occurred.8. The investigation, and the results of the investigation, will be documented. 9. All phases of the investigation will be kept confidential in accordance with the Facility's policies governing the confidentiality of medical records and privilege of quality assurance/ quality improvement programs. B. Protection 1. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: Respond immediately to protect the alleged victim and integrity of the investigation; Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increase supervision of the alleged victim and residents; Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protect the involved persons from retaliation; and Provide emotional support and counseling to the resident during and after the investigation, as needed. 2. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor and intervene as necessary to maximize resident health and safety.An IJ was identified on 11/14/25 and the IJ template was provided to the facility on [DATE] at 7:12 PM. The following Plan of Removal was submitted by the facility and was accepted on 11/15/2025 at 12:00 PM and indicated the following: The IJ Template was given on 11/14/23 at [7:05 PM]. The facility failed to protect Resident #2 from being sexually abused by Resident #1. The facility failed to provide supervision to prevent abuse.1. The facility place resident #1on 1:1 supervision. 2. The Medical Director was notified of IJs on 11/14/25 at [7:15 PM].3. Administrator suspended on 11/14/25 pending the outcome of the investigation. 4. The facility's policies on abuse and neglect prevention and reporting were reviewed by the Clinical Resource, Cluster Partners, and Cluster Administrator. There were no concerns and facility will continue with current policy. 5. Education/in-servicing was initiated on 11/14/25 with all staff on abuse and neglect to prevent abuse to residents in the facility. Education/in-servicing to be completed by the DON/ADON/Clinical Resource/Cluster DONs. Education/in-servicing on abuse and neglect included identification, prevention, reporting and what could happen should the staff member fail to follow facility policy including potential injury to a resident. Staff were instructed on examples of resident abuse/neglect and to report all allegations of abuse and neglect to the Abuse Coordinator. Knowledge check forms are completed with all staff on abuse and neglect training that was received. Education was given in person or via phone in written form and verbally to accommodate different learning styles of the staff for abuse/neglect. This education/in-servicing was given using developed policy and procedures based on best practice. With this education/in-servicing, staff will have definitions of the purposes and procedures and will decrease the likelihood of resident abuse or neglect occurrences. 6. All staff to receive education prior to working their next shift. PRN staff received the mandatory training notice and will receive education prior to their next shift.7. This education/in-servicing and the knowledge check forms will be completed with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. 8. An ad hoc QA meeting regarding items in the IJ template was completed on 11/14/25. Attendees will include the Medical Director, Clinical Resource, DON, ADON, Cluster Administrator, and will include the plan of removal items and interventions.9. The DON, ADON, Cluster DONs or Clinical Resource will complete knowledge checks with 10 staff weekly on abuse and neglect. These forms will be completed with staff randomly, sampling from each shift, weekend and weekday staff, and PRN staff. Any concerns with staff competency will be addressed immediately through re-education and/or staff counseling. 10. The Administrator and DON will investigate and report all allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11. Summary of IJ, corrective actions and allegations of abuse/neglect to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. [Acting Administrator] LNFA Monitoring of the Plan of Removal from 11/15/25 included the following:The facility provided a binder with the following documentation to be reviewed, reviewed facility notification to MD at [7:15 PM], observed facility Administrator was no longer in the facility, an acting Administrator continued to meet with surveyor, record review of in-service training and education dated 11/14/25 and 11/15/25 completed by the Cluster nurses (nurses from sister facilities and regional staff. Record review of LVN, RN, ADON change in condition in-service dated 11/14/25 and 11/15/25 for all three shifts. Record review of ad hoc meeting notes dated 11/14/25 Attendees included the Medical Director by phone, Clinical Resource, DON, ADON, Administrator. Record revied of undated knowledge checks used to assess the knowledge of nursing staff. Record review of in-service dated 11/14/25 for Administrator and DON to investigate and report any allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11/15/2025 at 12:32pm Resident #1 observation-He was in his room laying in his bed watching a women's soccer game on TV. He spoke to the surveyor and smiled. He stated that he was doing fine. Surveyor spoke to CNA-D who stated this hall is for men only. She stated that Resident #1 had been out of his room to smoke a cigarette, watch TV and had spoken to some of the men. She stated that Resident #1 had been in a good mood and there had not been any incidents since he had been on one-to-one supervision.Interviews with CNA-A, LVN-B, LVN-C, CNA-D, CNA-E, CNA-F, LVN-G, CNA-H, CNA-I, CNA-J, LVN-K, LVN-L, CNA-M, LVN-N, CNA-O, CNA-P, Staffing Coordinator, and ADON on 11/15/25 from 12:48 PM - 2:55 PM and interviews with LVN-Q, LVN-R, CNA-S, and LVN-T on 11/15/25 from 5:30 PM - 6:25 PM revealed, they had been in-serviced/educated on who the abuse coordinator was at the facility, how and who to report abuse to if they witnessed or suspected abuse. All staff stated they received re-education of inappropriate touching between residents and who it should be reported to and the time frame should be immediate. They stated residents who exhibit aggressive or inappropriate behaviors should be placed on 1:1 supervision immediately, notify the nurse management and administrator immediately. Interviews with LVN's revealed they knew they should call the police, send the resident to the ER for examination for inappropriate touching and abuse. LVN's interviewed also stated they had been re-educated on how to determine a change in condition and that the medical provider and family should be notified. They stated a change in condition would be weight, cognition, infection or new medications and that abuse/neglect would be considered a change in condition. The Administrator was informed that the Immediate Jeopardy was removed on 11/15/2025 at 3:35 PM. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by Resident #60 for 1 resident (Resident #6) of 24 residents reviewed for abuse and neglect.<BR/>On 01/25/25, Resident # 60 swung at Resident #6 and hit Resident # 6's right eye. Resident # 6 sustained bruising under the right eye.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by Resident #60 for 1 resident (Resident #6) of 24 residents reviewed for abuse and neglect.<BR/>On 01/25/25, Resident # 60 swung at Resident #6 and hit Resident # 6's right eye.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any other altercation between the two residents.<BR/>Interview on 03/18/25 at 1:38 PM with CNA A, she stated Resident #6 was sitting on her wheelchair in front of the nursing station, when Resident #60 who was standing next to her swung at her and hit her right eye. CNA A stated she separate the two residents immediately. CNA A denied any other altercation between the two residents.<BR/>In interview on 03/18/25 at 1:40 PM, Resident #6 was unable to respond to interview questions. <BR/>In interview on 03/18/25 at 1:42 PM, Resident #60 stated did not remember the incident, and denied ever hitting another resident. <BR/>Interview with the DON and Administrator on 03/18/25 at 1:58 PM revealed, both checked the incident document and stated after they investigated the incident, they did not report it because there was no identifiable intent from one resident to injure the other resident. The DON stated both residents still socialized with each other, and when both residents were interviewed the next day of the incident none of them remembered the incident. The DON and Administrator both stated the risk to residents could be continuous of harm. The Administrator further stated that he was the abuse coordinator for the facility and according to the facility policy/Provider letter Abuse is a willful infliction of injury.<BR/>Review of the facility's Abuse: Prevention of and Prohibition Against, dated 2017, reflected:<BR/>Policy<BR/>It is the policy of this facility that ear resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment <BR/>Abuse is a a will infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm . Instances of abuse of all residents, irrespective of any mental or physical condition causing physical; harm .<BR/>D Prevention .<BR/>2) The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by . <BR/>Identifying, assessing and are planning for appropriate interventions and monitoring of resident with needs and behaviors which might lead to conflict . such as, Physically aggressive behavior, such as hitting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 5 residents reviewed for infection control<BR/>LVN A failed to wear appropriate PPE when providing suprapubic catheter care for Resident #2 who supposed to be on EBP ( Enhanced Barrier Precautions).<BR/>This failure placed the residents at risk of exposure to possible infectious agents.<BR/>Findings included:<BR/>Record review of Resident #2's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, neurogenic bladder, mild intellectual disabilities, and needs for assistance with personal care. Resident#2 has a BIMS score of 12/15 indicating moderate cognitive impairment. Her Functional Status reflected she was dependent on staff for toileting hygiene including suprapubic catheter exit site care. <BR/>Record review of Resident #2's care plan, dated 10/19/24, reflected she has Indwelling Suprapubic Catheter: R/t Neurogenic Bladder Secondary to QUADRAPLEGIC (paralysis of all four limbs) CP (Cerebral Palsy). <BR/>Record review of Resident #2's physician orders reflected an order dated 06/27/24:Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wound, Indwelling medical device, infection and/or MDRO (Multi drug resistant organism) status.<BR/>Observation on 01/16/25 at 08:47 AM LVN A prepared to provide care to Resident #2's suprapubic catheter . LVN A washed hands and donned gloves and provided care without donning a gown. There was no signage and no supplies outside or inside of the Resident#2's room for EBP.<BR/>Interview on 01/16/25 at 09:14 AM LVN A stated Resident #2 has an indwelling medical device and there supposed to be a signage and required PPE supplies in front of Resident #2 room, indicating she was on EBP, and that staff were required to wear a gown and gloves when providing care for the resident. LVN A stated she just did not wear required PPE when she went to provide suprapubic exit site care for Resident#2. LVN A stated she had been working in the facility for few months and had in service on EBP during orientation. <BR/>Interview on 01/16/25 at 09:30 AM the DON stated all residents with wounds, catheters, feeding tubes, etc. are placed in EBP to minimize the risk of spreading infections between residents. EBP required the use of a gown and gloves for all high contact care of the resident. She stated the risk of not adhering to the appropriate PPE requirements was spreading infections to other residents.<BR/>Interview on 01/16/25 at 12:06 PM the administrator stated there should be signage in front of the Resident#2 room, and the supplies. He stated staff should don and doff proper PPE for high resident contact care, including gown, and gloves. He stated the last in service on EBP was done in November 2024. <BR/>Record review of LVN A's skills verification checklist dated 11/04/24 reflected she was competent in Peri-care-Foley catheter tubing care. <BR/>Review of the facility's policy IPCP Standard and Transmission-Based Precaution, Revised March 2023, reflected: 3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with (MDROs).

**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 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE].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 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE]. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. These failures could affect residents by placing them at risk of allergic reaction, decline in quality of life and death. Findings included: Record review of Resident#1's face sheet revealed, she was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Dementia (decline in cognitive function that affects daily living) in other diseases classified elsewhere, unspecified other severity, with mood disturbance (mental health conditions that primarily affect emotional states), unspecified Dementia, unspecified severity, without behavioral, other disturbance, psychotic disturbance (a condition in which one is unable to distinguish what is and is not real), mood disturbance, and anxiety, erosive (Osteo) arthritis (destruction of joint cartilage and bone erosion), other muscle weakness (Generalized), other unspecified lack of coordination, other personal history of Transient Ischemic attack ( caused by a brief blockage of blood flow to the brain) and cerebral and other infarction without residual deficits (blood flow to a part of the brain is obstructed, leading to tissue death due to lack of oxygen). Record review of Resident#1's MDS, dated [DATE] revealed her BIMS score was undetermined. Resident#1's functional limitation in range of motion reflected impairment on one side, coded for lower extremity (hip, knee, ankle, foot). Resident#1's functional abilities for mobility were undetermined. Record review of Resident#1's care plan, undated revealed, she was at risk for communication problem related to Dementia, at risk for impaired cognitive function/dementia or impaired thought processes r/t long term memory loss, Poor nutrition, short term memory loss, Dementia, and impaired decision making. Resident#1 had bowel/bladder incontinence r/t Alzheimer's, Confusion, Dementia, and impaired Mobility. Record review of Resident#1 EMS report, dated 07/20/25 reflected, Dispatched to nursing home for medical emergency. Upon arrival then [Resident#1] one was found in her wheelchair eyes completely swollen shut and family around her. Family reported that patient was found in her bed, by the family, covered in ants. The [Resident#1]had visible ant bites on her neck, face and eyes. The patient had Alzheimer's and was not able to communicate or provide any information. [Resident#1] was transferred to stretcher by EMS via picking patient up from the wheelchair and placing her on the stretcher. En route to hospital vital perform SPO2, BGL, lung sounds were clear, airway patent. [Resident#1], IV established and right hand 50 milligram of Diphenhydramine given via IV, 2 ants found on patient during transport. Vitals remain stable throughout transportation. Patient transported to [local hospital] for further observation and treatment.Record review of Resident#1's hospital records, dated 07/22/25 reflected, Resident#1 was admitted on [DATE] at 11:28 AM. Per EMS, several small ants were actively crawling around patient. Patient had noted bites around her entire body including her face and neck. Patient had noted eyelid swelling. EMS administered IV Benadryl at 15 mg. Patient's face swollen and red with some insect bites likely allergic reaction from insect bites, will start IV steroids, hydrocortisone and Benadryl cream.Visit diagnosed Insect bite, unspecified site, initial encounter (primary), Urinary tract infection without hematuria, site unspecified Dehydration and Unsatisfactory living conditions. Patient's [family member] also requested new placement to a different facility, case management assisted with placement. [Resident#1] was accepted at another SNF/NF and would be discharged on 07/23/25. Record review of the weekend MOD progress note dated 07/20/25 reflected, Writer was alerted by CNA of rash/swollen eyes. Upon entry to room, no ants present in room, on resident or bed/linen. Resident was removed from area and assessed. Linen had already been removed, bed cleaned, and resident was already showered. Scattered rash like areas noted to body and redness along with bilateral swollen eyes during assessment. Writer notified {medical doctor} made aware of clinical situation and new orders given. Family notified of orders and ER transport. Hydrocortisone cream applied to entire body and PRN pain med and Benadryl administered. EMT present and transferred resident to {local hospital} with family en route. Family provided with Administrator's contact info for any concerns. Record review of the Admin interview with CNA A reflected [CNA A] regarding the incident that took place Sunday 7/20/2025 morning. [CNA A] stated she had been in the room of the affected resident about an hour prior at 8:30 and had checked and changed resident for incontinence. Room was clean, no signs of ants in or around bed or on resident at that time. No signs of clutter in the room or open food to draw pests into the room. Record review of the PCC service Inspection Report dated 4/11/25 reflected, on 05/28/25 the following rooms where treated 106-109 and 405-408 for ants and general pest. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the PCC service Inspection Report dated 07/21/25 reflected the facility was treated for ants on 07/21/25 treated room [ROOM NUMBER] for ants and general pest. On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. Record review of Resident#1 shower sheet, dated 07/20/25 reflected Resident#1 had a scattered rash on chest signed by the weekend MOD and CNA A. Record review of in-service training report dated 07/20/25, titled pest control/homelike environment /abuse prohibition conducted by ED in person and via phone reflected: Summary of in-service reflected: Our residents have the right to a safe, clean comfortable and home like environment. We must be diligent in our processes to ensure this for them. -Rooms need to be clean and free of odors. If you observe issues with cleanliness or odors, you must report it to housekeeping immediately and find the source. Facility needs to be free of pest. If you observe issues with pest control, you must report it to maintenance immediately via MS and notify ED or Maintenance-Facility must monitor food in resident rooms and ensure there aren't items drawing pest attention. If you observe issues, you must report it or correct if able.-Maintenance will adjust interventions as appropriate and as the seasons change. Including checking and treating for ants regularly.-Report to admin and DON if ants observed in residents' room, notify nurse immediately-Head to toe skin assessment to be completed by the nurse on both residents in the room.remove any ants-Remove resident and roommate from the room-check adjacent room for ants, room to be treated for ants,-Resident unable to return to room until treatment and deep cleaning completed During an observation on 07/22/25 at 8:30 am to 9:15 am revealed, the common area, dining area and rm# 301, 302, 303, 304, 305,306,307,308, 309, 310, 311 and 312 were free of ants. In an interview on 07/22/25 at 8:43 am CNA B stated residents in the unit did not eat in their room. CNA B stated snacks were kept in a white container and were given out and staff cleaned up right after. CNA B stated the facility had issues in the past with bugs and they let the MD know. CNA B stated she had not seen ants in Resident#1 room before 07/20/25. CNA B was in serviced over the phone about pest control, resident abuse, homelike environment, and Resident#1 was transported to hospital on [DATE]. In an interview on 07/22/25 at 9:28 am the HKS stated they cleaned and disinfected common areas and resident's rooms daily. HKS stated when notified of a pest sighting, the HKS would first let the MD know. The HKS stated everything would be taken out of the resident's room and washed. The HKS stated Resident#1 room was deep cleaned and then deep cleaned again the following day. The HKS stated she viewed a small number of active and unactive ants in Resident#1 room. In an interview on 07/22/25 at 10:05 am, the MD stated it was reported to him on 07/20/25 that a Resident#1 was bitten by ants. The MD came to the facility and immediately sprayed the Resident#1 room and exterior. The MD stated pest control came out 07/20/25 and 07/21/25 and treated the interior and exterior of the facility. The MD stated the facility had minor problems in the past with residents who had spilled food in their rooms and ants followed the trail. The MD stated staff were supposed to report in MS any pest sighting. MD stated PCC technician came out twice a month to treat the facility. The MD stated the last pest control inspection was on 06/20/25. In an interview on 07/22/25 at 10:20 am the HSW stated Resident #1would be discharged to another SNF/NF. The HSW stated Resident#1's planned discharge was on 07/23/25. In an interview on 07/23/25 at 10:28 am, the HN stated that Resident#1 did not talk and was not ambulatory. The HN stated Resident#1 slept most of the day and a family member had been at her side. The HN stated Resident#1 was in the hospital for an allergic reaction to ant bites from a nursing home. Interview and observation at the local hospital on [DATE] at 10:33 am revealed Resident #1 had bites on her eyelids, face and neck. The Family member stated she visited Resident#1 on the morning of 07/20/25. Resident#1's legs were covered with a blanket and when she moved the blanket ants were crawling on her legs. The Family member stated Resident#1's eyes were swollen shut and there were ants crawling on the wall. The family member stated she went and got CNA A who assisted with Resident#1.Attempted to call LVN I on 07/22/25 at 2:24 pm and did not receive a return call before exit.In an interview on 07/22/25 at 2:30 pm weekend MOD stated LVN I called her about Resident#1 had an allergic reaction to ant bites. The weekend MOD informed the DON about the ant bites. The weekend MOD stated she did a head-to-toe assessment and documented in Resident#1 progress notes the findings. The weekend MOD stated she remember the resident having a rash on her chest and her eyes were swollen. The weekend MOD stated Resident#1 hair was wet and she did not find any ants on her. In an interview on 07/22/25 at 3:36 pm CNA A stated at 8:15 am on 07/20/25 she went into Resident#1's room to provide incontinent care and turned to feed Resident#1 and she would not eat. CNA A stated she did not see any ants in Resident#1's room at that time. CNA A stated the family member came and got her around 10 something. CNA A stated Resident#1's eyes were swollen. CNA A stated she notified LVN I and she called the MD by calling his number. CNA A stated she was in-serviced on 07/20/25 to notified LVN I so they could do a head-to-toe assessment on the resident and roommate. CNA stated Resident#1 was given a shower. CNA A stated no ants were found on the roommate side of the room. CNA A stated nearby rooms should be checked for ants and staff must make sure all food was cleaned up.In an interview on 07/22/25 at 3:40 pm CNA C stated she was not there when the incident happened with Resident#1. CNA C was in-serviced on 07/21/25 on homelike environment, pest control and resident abuse. CNA C stated she had not seen any ants. CNA C stated any sighting of pest should be reported to the MD and tell the nurse so she could do a head-to-toe assessment. Interviews on 07/22/25 from 3:45 pm to 4:10 pm revealed LVN D, CNA E, LVN F, CNA G and LVN H stated if pests were seen, first remove the residents from the room, then the MD and Admin were called, the nurse did a head-to-toe assessment, adjacent rooms were checked for pests, they removed residents' belongings, and the HK deep cleaned the rooms. In an interview on 07/22/25 at 4:12 pm the HK stated if they noticed pests to first notify the MD and then bag residents' items and complete laundry. The HK stated the room was deep cleaned twice and adjacent rooms were checked. In an interview on 07/22/25 at 10:02 am the PCC technician stated the company treated the facility twice a month. PCC stated one exterior treatment would be enough to take care of the ants. PCC technician stated he came in on 07/20/25 and 07/22/25 and treated the interior and exterior of the facility for ants. The PCC technician stated no ants were found in the rooms. The PCC technician stated a lot of things could have led to an ant problem such as the weather. The PCC technician stated little showers and heavy rain caused everything on the ground to move around and food being left out could cause ants. In an interview on 07/22/25 at 4:15 pm the DON and Admin stated the Facility immediately cleared Resident #1, and her bed of ants. Resident #1 was showered and affected areas treated, housekeeping immediately deep cleaned the room, and pest control was called immediately to come and treat the room as well as adjacent rooms. Residents on the hall were checked head to toe for skin assessments, and no other signs of ants or bites were sighted. The DON stated Resident#1 roommate had a head-to-toe assessment and no bites were found on her or in her personal belongings. The DON stated Resident#1 roommate was transferred to 200 hall. Admin stated Pest control treated the exterior of the facility as well as the ant hills on the property. All staff were in-serviced on pest control, safe homelike environment, and abuse prohibition. The MD did exterior rounds of the facility and checked for entrance sights and hills and provided exterior treatment. The PCC Technician came back out the next day for a follow up treatment. Dept heads continue to round twice a day to check for signs of pests. Staff are to notify maintenance via MS and group message as well as the Admin immediately. The DON and Admin stated any pest sighted in the resident rooms will require resident to have a head-to-toe assessment immediately and room deep cleaned. During an observation on 07/22/25 at 4:45 pm the surveyor did an exterior walk through of the facility and ant hills were not noticed at that time of visit. Observed a lot of greenery and shrubbery around the facility. During an observation on 07/22/25 at 5:00 pm, resident rm# 106-109, 206, 211 and 405-408 were checked for ants. The surveyor did not observed pest at the time of visit. During an observation and interview on 07/23/25 at 11:30 am the MD and surveyor did an exterior walk through of the facility. The MD stated ant hills were treated and then knocked down the following day. The MD identified spots where ants had been knocked down and no active ants were observed at the time of the visit. Record review of the PCC service Inspection Report dated 07/21/25 reflected, On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. On 07/21/25 treated room [ROOM NUMBER] for ants and general pest Record review of facility policy titled, safe/comfortable/homelike environment, revised 01/22 revealed: Residents are provided with a safe, clean, comfortable and homelike environment. Record review of a pest contract revealed the agreement was effective October 1, 2021, and reflected .8. Service Provider's Schedule and Availability, service provider shall be reasonably available to the Facility and shall spend sufficient time at the facility premises to fulfill service provider's duties hereunder. Record review of facility policy titled, physical Environment, revised 05/2020 reflected: POLICY:It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.Responsibilities:Facility staff will:1. Report any pest sightings and file a report using the pest observation log.2. Document problems found during inspection and the remedial actions taken.3. Advise staff on preventive measure, unsanitary conditions, etc.4. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment.Pest Identification:The following guidelines for pest identification:1. When pests are sighted, determine why the infestation is occurring and advise department on preventive measures.2. Use pesticides only after all other channels of control are exhausted.3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls.4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information:a. Type of problemb. Locationc. Person reporting and time reported.Pest Prevention:The following are guidelines for pest prevention:1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc.2. Keep grounds free of trash and brush.3. Keep the dumpster area clean.4. Food stored in resident rooms will be in covered containers.5. Clean up food spills.6. Screen foundation areas with mesh.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's kitchen, reviewed for kitchen sanitation. <BR/>The facility failed to ensure liquid Kool Aid stored in the facility's walk-in refrigerator was covered, labelled and dated.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses. <BR/>Findings included:<BR/>Observation on 01/06/2024 from 9:14 AM in the facility's kitchen revealed:<BR/>1. One jar pink liquid Kool Aid in the walk-in refrigerator was not covered, labelled, and dated.<BR/>2. One jar yellow liquid Kool Aid in the walk-in refrigerator was not labelled and dated.<BR/>An interview with the Dietary Manager on 02/06/2024 at 11:39 AM, she stated her expectation of the kitchen staff was to keep the liquid Kool Aid in the refrigerator to be covered, labelled and dated. The liquid Kool Aid which was not covered was considered unsanitary, bugs could fall into the drink, and it had the potential to cross contaminate and cause sickness to the residents. The Dietary Manager stated not labeling and dating the drink could cause confusion about the drink, sickness to the residents since it was difficult to determine when the liquid Kool Aid was kept in the refrigerator. The Dietary Manager stated the cook was responsible to keep the liquid Kool Aid covered, labelled and dated. <BR/>An interview with the [NAME] on 02/08/2024 at 01:45 PM, she stated she realized that morning that the pink liquid Kool Aid jar in the walk in refrigerator was not covered and dated, and a yellow liquid Kool Aid jar was not labelled or dated. The [NAME] stated she did not work the previous night and so she was going to cover it as soon as she saw it in the morning, put label and date on the other one but the state surveyor came to the kitchen before she could do it. The [NAME] stated all the food items in the refrigerator should be covered, labelled and dated. She stated uncovered food items could cause food contamination and make residents sick. Not labelled and dated food items were health risk since it was difficult to determine when it was made. The [NAME] stated all the staff working in the kitchen were responsible to ensure all food items were covered and dated .<BR/>Record review of the facility policy, dated August 2007, reflected It is the policy of this facility that the food storage area shall be maintained in a clean, safe, and sanitary manner. Review revealed the policy did not reflect covering, labelling and dating of stored open food items.<BR/>Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.<BR/>Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. These services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four resident rooms (resident #327, #73, #16 and #11) of 24 resident rooms reviewed for clean and sanitary environment.<BR/>1. Resident #327's room had two nails on the floor, a plastic cup and the floor was dirty.<BR/>2. Resident #73's room had a hole behind the door at the entrance to the room.<BR/>3. Resident #16's room had broken blinds, a stain on the wall by the bathroom, and the toilet was running causing the pipes to make a loud whining noise. <BR/>4. Resident #11's room had broken blinds and a hole behind the door at the entrance to the room. <BR/>These failures could affect all residents, staff, and the public by placing them at risk of not having a clean, sanitary, and comfortable environment. <BR/>Findings included: <BR/>1. Observation of Resident #372's room on 2/6/24 at 9:58 a.m. showed two iron nails on the floor, a plastic cup on the floor and the floor was dirty. <BR/>Interview with Resident #327 revealed the rooms were not cleaned frequently by housekeeping staff. She had been in the facility 3 weeks and the room was swept once. Resident #327 said the window blinds were changed last week and the nails were from that day.<BR/>2. Observation of Resident #73's room on 2/6/24 10:22 a.m. showed there was a 5 by 1.5 inch hole in wall behind the entrance door. <BR/>Interview with Housekeeper F on 02/6/24 at 10:23 a.m. revealed she just noticed the hole today and said Maintenance had fixed a hole in the wall in same area previously from door hitting the wall when opened.<BR/>3. Observation of Resident #16's room on 2/6/24 11:20 a.m. showed broken blinds with strips bent and broken in the middle of the blinds. Also, there were marks running down the wall on the wall outside the bathroom door which was an orange-brown color liquid. There was a &frac12; by &frac12; square of drywall missing from the wall directly to the left when you enter the room. Furthermore, the toilet was heard to be running on three different occasions. Each time the toilet stopped running, the pipes in the bathroom made a loud whining noise for about 10 seconds. <BR/>Interview with Resident #16 said the marks on the wall were from a drink that exploded a long time ago. Resident #16 said the issues in the room were fine and she did not want to bother anyone. Resident #16 said she knows there are other people there who need more help than her and she did not want to bother anyone. <BR/>4. Observation of Resident #11's room on 2/6/24 11:57 a.m. showed the window blinds were broken on both sides of the blinds with strips bent in different directions. <BR/>Interview with Resident #11 said the blinds are always messed up. She said they never fix them when she has told them. <BR/>Interview with Maintenance Director on 2/8/24 at 11:05 a.m. stated he had not known about the issues in the Residents rooms. He said he would get new blinds in the rooms today. He looked at the toilet in resident #16's room and said it was a short chain and he would get it fixed. He is over housekeeping and said he would get someone to clean the wall. The Maintenance Director thought the piece of drywall missing from the wall in Resident #16's room was from a glove box dispenser that used to be there. He said he would get it fixed. The Maintenance Director said he would have fixed the items had he been told. <BR/>Interview with the Maintenance Director on 2/8/24 at 3:10 p.m. showed he had fixed the toilet in Resident #16's room which stopped the loud whining noise. Also, the blinds were also replaced in Resident #16's room. The Maintenance Director said he would have to purchase a new blind for Resident #11's room as it is a larger blind than the other rooms. He showed where he had fixed the holes in the walls in Resident #11 and #73's rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to file grievances anonymously for 1 (Resident #1) of 3 residents reviewed for grievances. <BR/>1. The facility failed to ensure Resident #1 had access to file a grievance anonymously. <BR/>The facility's failure could place the residents at risk for concerns not being reported and addressed.<BR/>Findings included:<BR/>Record review of Resident #1's MDS admission assessment, dated 02/19/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 12. Her cognitive status was moderately impaired. Her diagnoses included stroke and diabetes. <BR/>Record review of the Facility Grievances for April 2025 and May 2025 reflected there were four grievances completed for Resident #1, but none of them were filed anonymously. <BR/>An interview on 05/28/25 at 11:00 AM with Resident #1 revealed she had a personal notebook that she wrote her complaints in. She said she would have a nurse make a copy of the document and she would take it to the SW or the DON and she felt like they did not want to hear from her. Resident #1 said her concerns on the paper were not addressed and she did not know where the grievance forms were. Resident #1 said she did not know if a grievance was ever filed for her complaints. She said she wanted to file a grievance anonymously but did not know how. <BR/>An interview on 05/28/25 at 12:30 PM with the SW revealed she thought Resident #1 had provided her a copy of her complaints one time, but she could not remember for sure. She said she thought she filled out a grievance for the issues for Resident #1. The SW said she thought the paper with the resident's complaints might have been put with the grievance form, but she could not remember. The SW said a resident could file a grievance by getting a form from the receptionist and the office. The SW said she did not know if residents had access to the forms if there was not a staff at the receptionist desk. The SW said after a grievance form was filled out then it was given to her.<BR/>An observation on 05/28/25 at 12:40 PM revealed there were blank grievance forms at the receptionist desk, but you could only obtain a grievance form from the receptionist.<BR/>An interview on 05/28/25 at 1:00 PM with LVN A revealed Resident #1 had a personal notebook and would ask her to make copies of it. LVN A said she gave the originals and copies back to the resident. LVN A said Resident #1 did not voice any complaints to her. <BR/>An interview on 05/28/25 at 2:15 PM with the DON revealed Resident #1 barely talked to her. The DON said Resident #1 thought the DON was sarcastic and nagging to her. The DON said Resident #1 did not give any complaints to her. <BR/>A follow-up interview on 05/28/25 at 3:50 PM with the SW revealed she was the grievance official. She said there was not a way for a resident to file a grievance anonymously, but that a resident could report concerns to her. The SW also said that any staff member could take a grievance and fill it out for the resident.<BR/>An interview on 05/28/25 at 4:15 PM with the Administrator revealed the facility was in the process of posting grievance forms on the wall so that residents could grab the grievance form and file it anonymously. The Administrator said residents who were bed bound would have to get a form from a staff member. The Administrator said residents who could not file anonymous grievances were at risk for not being able to safely express their concerns. <BR/>Record review of the facility policy, Grievances, revised December 2023, reflected:<BR/>It is the policy of this facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the resident may have .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #1) of one resident reviewed for catheter care.<BR/>The facility failed to ensure Resident #1's urine catheter drainage bag kept off the floor when Resident#1 was lying in bed.<BR/>This failure could place residents at risk for urinary tract infections.<BR/>Findings included:<BR/>A record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male with a BIMS score 00 of 15, indicating severe cognitive impairment. Resident #1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses including, neurogenic bladder ( urinary bladder dysfunction cause by nervous system conditions), multiple sclerosis, and hemiplegia or hemiparesis (Hemiplegia: paralysis of one side of the body). The review further reflected the resident had an indwelling suprapubic catheter r/t neurogenic bladder and was totally dependent on staff for the ADL's (activity of daily living).<BR/>A record review of Resident #1's Comprehensive Care Plan dated 11/27/24 reflected Focus: Has Indwelling Suprapubic Catheter r/t Neurogenic bladder. Goal: Will remain free from catheter-related trauma through the review date. Intervention: Catheter: Position catheter bag and tubing below the level of the bladder and away from entrance room door. Secure catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal. <BR/>Review of Resident #1's Physician Orders Report dated 12/11/24 reflected, Suprapubic catheter care every shift. Monitor s/p insertion site for s/s of skin breakdown, pain/discomfort ., catheter pulling causing tension.<BR/>Observation on 01/15/25 at 10:32 AM revealed Resident#1 lying in bed, with the bed to the lowest position, and the foley catheter drainage bag hanging to the side of the bed and sitting on the floor. LVN A entered Resident#1 room noticed the foley catheter drainage bag on the floor and position Resident#1 bed to higher position to prevent the drainage bag from touching the floor. <BR/>Interview on 01/15/25 at 10:33 AM, with LVN A revealed, she stated the urinary drainage bag was to be always kept hanging at the side of the bed bellow the resident bladder, and off the floor. LVN A stated Residnt#1 was a fall risk and the staff had to keep the bed at the lowest position. LVN A stated the risk to Resident#1 development of infection. <BR/>Interview on 01/15/25 at 12:14 PM with the DON, she stated the foley catheter drainage bag should be to gravity, hoked to the bed frame to drain properly, and not touching the floor. She stated it could cause irritation, and development of infection to the resident.<BR/>Interview on 01/16/25 at 12:06 PM with the administrator, he stated the catheter was to be maintained below the level of the resident bladder, and off the floor. He stated the risk to resident development of infection. The administrator further stated the facility will figure out way to keep residents at fall risk bed at lowest position will preventing the foley catheter drainage bag from touching the floor.<BR/>The facility's policy titled, Infection Control Policy/Procedure. Section: Resident Care. Subject: Catheter Care, Foley, revised July 2022, reflected, . 1. May secure the tubing with securement device PRN to prevent migration of catheter/friction/tension. 2. Keep tubing below level of bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 5 residents reviewed for infection control<BR/>LVN A failed to wear appropriate PPE when providing suprapubic catheter care for Resident #2 who supposed to be on EBP ( Enhanced Barrier Precautions).<BR/>This failure placed the residents at risk of exposure to possible infectious agents.<BR/>Findings included:<BR/>Record review of Resident #2's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, neurogenic bladder, mild intellectual disabilities, and needs for assistance with personal care. Resident#2 has a BIMS score of 12/15 indicating moderate cognitive impairment. Her Functional Status reflected she was dependent on staff for toileting hygiene including suprapubic catheter exit site care. <BR/>Record review of Resident #2's care plan, dated 10/19/24, reflected she has Indwelling Suprapubic Catheter: R/t Neurogenic Bladder Secondary to QUADRAPLEGIC (paralysis of all four limbs) CP (Cerebral Palsy). <BR/>Record review of Resident #2's physician orders reflected an order dated 06/27/24:Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wound, Indwelling medical device, infection and/or MDRO (Multi drug resistant organism) status.<BR/>Observation on 01/16/25 at 08:47 AM LVN A prepared to provide care to Resident #2's suprapubic catheter . LVN A washed hands and donned gloves and provided care without donning a gown. There was no signage and no supplies outside or inside of the Resident#2's room for EBP.<BR/>Interview on 01/16/25 at 09:14 AM LVN A stated Resident #2 has an indwelling medical device and there supposed to be a signage and required PPE supplies in front of Resident #2 room, indicating she was on EBP, and that staff were required to wear a gown and gloves when providing care for the resident. LVN A stated she just did not wear required PPE when she went to provide suprapubic exit site care for Resident#2. LVN A stated she had been working in the facility for few months and had in service on EBP during orientation. <BR/>Interview on 01/16/25 at 09:30 AM the DON stated all residents with wounds, catheters, feeding tubes, etc. are placed in EBP to minimize the risk of spreading infections between residents. EBP required the use of a gown and gloves for all high contact care of the resident. She stated the risk of not adhering to the appropriate PPE requirements was spreading infections to other residents.<BR/>Interview on 01/16/25 at 12:06 PM the administrator stated there should be signage in front of the Resident#2 room, and the supplies. He stated staff should don and doff proper PPE for high resident contact care, including gown, and gloves. He stated the last in service on EBP was done in November 2024. <BR/>Record review of LVN A's skills verification checklist dated 11/04/24 reflected she was competent in Peri-care-Foley catheter tubing care. <BR/>Review of the facility's policy IPCP Standard and Transmission-Based Precaution, Revised March 2023, reflected: 3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with (MDROs).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing and administering, of medications for 2 (Nursing Medication cart hall 100 North and nursing medication cart 300 hall) of 3 medication carts reviewed for pharmacy services. <BR/>The facility failed to ensure prompt identification of potential diversion of controlled medications when CMA B did not report a damaged blister pack of Clobazam 20 mg (controlled medication) and LVN D C did not report a damaged blister pack of Tylenol with Codeine#4 oral tablet 300-60 mg (controlled medication).<BR/>This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. <BR/>Findings included:<BR/>Record review of Resident #31's Quarterly MDS assessment, dated 01/12/25, reflected he was a [AGE] year-old male with admission date of 08/30/24. Resident #31's BIMS score was 12/15 which indicated moderate cognition. His diagnoses included diabetes mellitus (elevated blood sugar), dementia (diseases that affect memory, thinking, and the ability to perform daily activities), Alzheimer disease (is a brain disorder that causes memory loss, thinking problems, behavior changes, and brain cell death), hypertension (elevated blood pressure), and aphasia (Aphasia a language disorder that affects a person's ability to communicate).<BR/>Record review of Resident #31's Physician order summary report dated March 2025, reflected . Clobazam 20 mg tablet Give 1 tablet by mouth two times a day . with a start date 03/06/25.<BR/>An observation on 03/19/25 at 12:15 PM revealed the blister pack for Resident #31 Clobazam 20 mg (controlled medication) had 1 blister pack pill area seal broken and the pill still in the blister. <BR/>Review of the controlled medication count sheet for Resident #31 Clobazam 20 mg reflected that the count was accurate when compared to the medications in the drawer. <BR/>In an interview on 03/19/25 at 12:15 PM CMA B stated she was unaware when the blister pack seal became broken. She stated that the seals are easily torn when they are handled every shift to be counted. She stated the medication was supposed to be discarded if opened to prevent potential diversion of controlled medications. <BR/>Record review of Resident #53's Quarterly MDS assessment, dated 02/23/25, reflected she was a [AGE] year-old female initially admitted to facility on 03/28/23, and readmitted on [DATE]. Resident #53's BIMS score of 8/15 which indicated moderate cognition. Her diagnoses included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and arthritis (a broad term for conditions affecting joints, tissues around joints, and other connective tissues, causing pain, stiffness, and reduced movement). <BR/>Record review of Resident#53's Physician order summary report dated March 2025 reflected . Tylenol with Codeine #4 oral tablet 300-60 mg Give 1 Tablet by mouth every 8 hours as needed for pain . with a start date 05/07/24.<BR/>An observation on 03/19/25 1:50 PM revealed the blister pack for Resident #53 blister pack of Tylenol with Codeine#4 oral tablet 300-60 mg had 1 blister pack pill area seal broken and the pill still in the blister. <BR/>Review of the controlled medication count sheet for Resident #53 Tylenol with Codeine#4 oral tablet 300-60 mg reflected that the count was accurate when compared to the medications in the drawer.<BR/>In an interview on 03/19/25 1:55 PM LVN D stated she was unaware when the blister pack seal became broken. She stated she didn't see it this morning when she counted with the night shift nurse. She stated the medication was supposed to be discarded if opened to prevent medication error that can harm the resident. <BR/>In an interview on 03/19/25 at 2:25 PM, the DON revealed she expected if a blister pack medication seal is broken; the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk to residents would be giving the wrong and ineffective medication. DON stated charge nurses were responsible to check, every day, the carts for medications with broken seals during the count with the relieving nurses. <BR/>Review of the facility's Storage of Medications policy, Revised April 2007, indicated . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Residents #36) reviewed for dental services.<BR/>The facility failed to provide timely dental services for Resident #36 when he started having tooth pain on 02/11/25. <BR/>This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.<BR/>Findings included: <BR/>Record review of Resident #36's Quarterly MDS dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]with the diagnoses of stroke, cognitive communication deficit, and unspecified pain. His BIMS score was a 13 (intact cognition). <BR/>Record review of Resident #36's care plan revealed a focus area communication problem due to expressive aphasia and slurring. Interventions included encouraging resident to continue to state his thoughts if he was having difficulty, assist with finding words as needed/appropriate, and monitor/document for physical/nonverbal indicators of discomfort or distress and follow up as needed .<BR/>In an interview on 03/18/25 at 12:58 PM with Resident #36 revealed he stated he had tooth pain for about a month that came and went and pointed to his bottom right jaw. He stated he had received pain medication for the tooth pain. He stated he would like to see the dentist and was not sure if he had an appointment. <BR/>Record review of Resident #36's physician orders reflected an order with the start date of 11/22/24 for monitoring of pain using the pain scale from 0 (no pain) to 10 (severe pain) every shift. <BR/>Record review of Resident #36's physician orders reflected an order with the start date of 11/22/24 for Acetaminophen tablet, 325 mg, give 2 tablets by mouth every 4 hours as needed for mild pain/headache. <BR/>Record review of Resident #36's physician orders reflected an order with the start date of 2/11/25 for Tramadol 50 mg- give one tablet by mouth every 6 hours as needed for Pain. <BR/>Record review of Resident #36's e-MAR for February 2025 reflected he was administered Tramadol 50mg on 02/20/25 at 4:31 PM, 02/21/25 at 2:55 PM and 10:15 PM, and 02/22/25 at 5:45 PM, and on 02/27/25 at 4:45 PM. <BR/>Record review of Resident #36's e-MAR for 03/01/25-03/22/25 reflected he was administered Tramadol 50 mg on 03/18/25 and it was effective. Resident #36 had no pain except for on 03/18/25 for the month of March. <BR/>Record review of Resident #36's e-MAR progress note, written by LVN I and dated 02/11/25 at 12:10 PM, reflected Acetaminophen Tablet 325 mg was administered .resident having a toothache pain 6/10 on scale . and it was effective. <BR/>Record review of Resident #36's e-MAR progress note, written by LVN I and dated 02/11/25 at 5:45 PM, reflected the nurse practitioner ordered a dental referral and the social worker was made aware and the resident had a new order for the pain medication Tramadol 50mg every 6 hours for pain as needed. <BR/>Record review of Resident #36's e-MAR progress note, written by LVN I and dated 02/18/25 at 9:34 PM, reflected Acetaminophen Tablet 325 mg was administered .toothache to lower right jaw, dental referral in place and was effective. <BR/>Record review of Resident #36's e-MAR progress note, written by RN AD and dated 02/20/25 at 4:31 PM, reflected Tramadol 50 mg was administered to the resident for complaints of tooth pain and was effective upon follow up. <BR/>Record review of Resident #36's e-MAR progress note, written by LVN I and dated 02/21/25 at 2:55 PM, reflected Tramadol 50 mg was administered to the resident due to toothache to right lower side of jaw rated 5/10 on pain scale and was effective upon follow up. <BR/>Record review of Resident #36's e-MAR progress note, written by LVN Q and dated 02/22/25 at 10:15 PM, reflected Tramadol 50 mg was administered to the resident due for pain and was effective upon follow up. <BR/>Record review of Resident #36's e-MAR progress note, written by LVN I and dated 02/26/25 at 9:59 AM, reflected resident had a toothache to the lower right jaw. <BR/>Record review of Resident #36's e-MAR progress note, written by RN AD and dated 02/27/25 at 4:45 PM, reflected Tramadol 50 mg was administered to the resident for toothache and was effective upon follow up. <BR/>Record review of Resident 36's e-MAR progress note, written by RN AD and dated 03/18/25 at 4:45 PM, reflected Resident #36 was administered Tramadol 50 mg for pain and it was effective. <BR/>Record review of Resident #36's social services progress note, written by the Social Worker, dated 03/19/25 at 4:01 PM, reflected the resident stated he was not having tooth pain at that time and a dental visit was scheduled for Friday, 03/21/25. <BR/>Record review of Resident #36's nurse's progress note, written by LVN I and dated 03/21/25 at 2:20 PM, reflected he had complaints of tooth pain and pain medication was administered with effective results and he was seen by dental services.<BR/>Record review of dental referral, dated faxed on 03/14/25, by the Social Worker, reflected Resident #36 had signed the authorization on 03/13/25. <BR/>Record review of email, subject line: [Resident #36] dental dated 03/19/25 from the Social Worker to dental services revealed the fax was missed by dental services. Further review revealed Resident #36 was seen by dental services on 3/21/25. Resident #36 was a new patient and had a chart review, x-rays, and photos by the dental hygienist and would see the physician in a week. <BR/>In an interview on 03/19/25 at 3:15 PM with RN AD revealed Resident #36 occasionally had tooth pain and leg pain. She stated the nurse practitioner had been notified and a new order was given for Tramadol 50 mg as needed for the pain. She stated the social worker was working on a dental referral for the resident. <BR/>In an interview on 03/19/25 at 3:24 PM with LVN I revealed she had notified the nurse practitioner that Resident #36 had tooth pain and a new order was given of Tramadol 50 mg. She stated she knew the resident had a dental referral because the social worker handled the referrals and she talked to her on the phone about the resident's tooth pain. <BR/>In an interview on 03/22/25 at 1:20 PM with the Social Worker revealed she was responsible for dental referrals and if a resident had dental concerns such as pain the nurse would typically tell her. She stated she did not recall anyone informing her of Resident #36's the tooth pain in February 2025 and would have immediately sent a dental referral if she had known. She stated nurses, residents, or their representative usually informed her of any referrals needed and she would coordinate the consents and paperwork. She stated she talked to Resident #36 on 03/19/25 and asked if he had pain with his mouth, which he denied, and she asked him if it was okay to have dental come see him. She stated Resident #36 agreed, signed the consents and dental services saw him on 03/21/25. She stated this was not a timely referral, it typically took 2-3 days for the non-emergency referrals. She stated it was important to ensure residents received timely referrals to ensure they received their needed services.<BR/>In an interview on 3/23/25 8:41 AM with Administrator revealed dental referrals are the social worker's responsibility. He stated if a resident had dental pain the nurse notified the social worker and the social worker coordinated the referral. He stated depending on situation a resident would be seen by dental services within days and not longer than a week. He stated Resident #36 referral should have been completed sooner. He stated it was important for residents to have timely referrals to ensure pain is managed and to receive needed dental services.<BR/>Record review of the facility's referral policy titled Outside Referrals, revised July 2013, reflected: .the facility will make necessary arrangements for services to be furnished to the resident by a person or agency outside the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (Resident #57) of 6 residents reviewed for resident call system <BR/>The facility failed to ensure the call light in resident room [ROOM NUMBER] used by Resident #57 for dialysis treatment went to a centralized staff work area. <BR/>This failure placed resident at risk of a delay in receiving assistance from facility staff and being unable to obtain assistance in the event of an emergency.<BR/>Findings included:<BR/>Review of Resident #57's MDS assessment dated [DATE] reflected Resident #57 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of acute osteomyelitis (bone infection) of left ankle/foot, end stage renal disease, diabetes, stroke, hemiplegia and hemiparesis (weakness and paralysis affecting one side). MDS assessment reflected Resident #57 required substantial/maximal assistance to dependent with ADLs. Resident #57 had a BIMS of 12 indicating he was moderately cognitively impaired. Resident #57 was on dialysis services. <BR/>Review of Resident #57's comprehensive care plan last updated on 12/05/23 reflected Resident #57 had renal insufficiency r/t to ESRD (End Stage Renal Disease). Interventions included assist resident with ADLs and ambulation as needed. Resident #57's care plan reflected Resident #57 was at risk for falls related to left sided hemiplegia as result of CVA . Interventions included Be sure the call light is within reach and encourage to use it to call for assistance as needed and Room assignment close to the nurses station.<BR/>Observation on 02/07/24 at 11:55 AM revealed doors were closed to 200 hall. At 11:57 AM revealed Resident #57 was lying in bed in resident room [ROOM NUMBER] for dialysis treatment with no other occupied resident rooms on 200 hall for dialysis. <BR/>Observation on 02/07/24 at 11:59 AM revealed Resident #57 lying in the bed close to the door entrance, awake, alert, dialysis access in the right upper extremity. Dialysis nurse in the process of cannulating resident dialysis access and drawing blood. Dialysis nurse was wearing full PPE : gown, mask, face shield, and glove.<BR/>Surveyor asked the resident to push the call light at 1:00 PM. Observation revealed Resident #57 pushed the call button and it went to the 200 hall nursing station. <BR/>Observation on 02/07/24 at 1:00 PM with Contract Dialysis Nurse revealed she was in process of disconnecting Resident #57 from the dialysis machine. Interview with Dialysis nurse revealed she was having technical issue with the dialysis machine, returned resident blood, and waiting for a dialysis technician from the dialysis company to come and check the machine. Contract Dialysis Nurse stated she had been coming to facility providing dialysis treatments in resident room [ROOM NUMBER] to Resident #57 since December 2023. She stated if she needed assistance from facility staff when Resident #57 was receiving dialysis she would use the call button to alert facility staff for assistance. <BR/>Observation on 02/07/24 at 1:03 PM revealed Maintenance Director came and checked on the room and turned the call light off for Resident #57 . <BR/>Interview on 02/07/24 with LVN D at 1:10 PM revealed she was unaware of any resident call lights going off on 200 hall at the 400 hall nurse's station she only was aware of resident call lights on 400 hall. <BR/>Interview on 02/07/24 with LVN E at 1:12 PM revealed she was unaware of any resident call lights going off on 200 hall at the 300 hall nurse's station. She stated she was only aware of resident call lights on 300 hall . <BR/>Interview on 02/07/2024 at 2:40 PM with the DON revealed she was aware Resident #57 was receiving dialysis treatments in room [ROOM NUMBER]. When asked if the hall was monitored by facility staff, she stated there was no nursing staff, but the Maintenance Director and Staffing Coordinator had offices on the 200 hall. When asked what the dialysis employee would do in the event of emergency and needed facility staff, she stated they could yell down the hall. When asked if the dialysis employee could be heard yelling down the hall, she stated they would use the nurse call light if no one heard them. When asked what the resident would do in the event of an emergency and needed facility staff, she stated he would do the same thing, yell or use the nurse call light. When asked where the call light signal was relayed to, she stated the 200 nurses' station and thought it went to central nurse call system located in the reception area in which the receptionist would alert staff if the call light was not answered in a couple of minutes.<BR/>Follow-up interview on 02/07/2024 at 3:05 PM with the DON revealed she had only been at the facility for two months and did not know the facility did not have a central nurse call system. She stated a resident call light on the 200 hall would only provide an audible and visible signal to the 200 hall. The DON stated not having facility staff available at the nurse station could place Resident #57 at risk for delay in assistance and risk of causing mental distress and physical injuries to Resident #57 if the hall is not monitored at the nurses' station by facility staff. <BR/>Interview on 02/07/2024 at 3:25 PM with the Executive Director revealed he was aware Resident #57 was receiving dialysis treatments in room [ROOM NUMBER]. He stated dialysis treatments were originally done on the 100 hall but they had to convert the room back for a new resident, so dialysis treatment was moved to the 200 hall. He stated they had been using room [ROOM NUMBER] for about two months. He acknowledged the risk of delay in Resident #57 getting assistance using his call light while receiving dialysis if facility staff were not on 200 hall. <BR/>Interview on 02/07/24 at 4:05 PM with the Maintenance Director revealed his office was located behind the 200 hall nurse station but he was not usually in his office.<BR/>Review of facility's policy Call Light/Bell revised 05/2020 reflected the policy of this facility to provide the resident a means of communication with nursing staff .Procedures: 1. Answer the light/bell within a reasonable time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by Resident #60 for 1 resident (Resident #6) of 24 residents reviewed for abuse and neglect.<BR/>On 01/25/25, Resident # 60 swung at Resident #6 and hit Resident # 6's right eye. Resident # 6 sustained bruising under the right eye.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by Resident #60 for 1 resident (Resident #6) of 24 residents reviewed for abuse and neglect.<BR/>On 01/25/25, Resident # 60 swung at Resident #6 and hit Resident # 6's right eye.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any other altercation between the two residents.<BR/>Interview on 03/18/25 at 1:38 PM with CNA A, she stated Resident #6 was sitting on her wheelchair in front of the nursing station, when Resident #60 who was standing next to her swung at her and hit her right eye. CNA A stated she separate the two residents immediately. CNA A denied any other altercation between the two residents.<BR/>In interview on 03/18/25 at 1:40 PM, Resident #6 was unable to respond to interview questions. <BR/>In interview on 03/18/25 at 1:42 PM, Resident #60 stated did not remember the incident, and denied ever hitting another resident. <BR/>Interview with the DON and Administrator on 03/18/25 at 1:58 PM revealed, both checked the incident document and stated after they investigated the incident, they did not report it because there was no identifiable intent from one resident to injure the other resident. The DON stated both residents still socialized with each other, and when both residents were interviewed the next day of the incident none of them remembered the incident. The DON and Administrator both stated the risk to residents could be continuous of harm. The Administrator further stated that he was the abuse coordinator for the facility and according to the facility policy/Provider letter Abuse is a willful infliction of injury.<BR/>Review of the facility's Abuse: Prevention of and Prohibition Against, dated 2017, reflected:<BR/>Policy<BR/>It is the policy of this facility that ear resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment <BR/>Abuse is a a will infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm . Instances of abuse of all residents, irrespective of any mental or physical condition causing physical; harm .<BR/>D Prevention .<BR/>2) The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by . <BR/>Identifying, assessing and are planning for appropriate interventions and monitoring of resident with needs and behaviors which might lead to conflict . such as, Physically aggressive behavior, such as hitting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately report an alleged act of abuse to the State Survey Agency, for 2 residents (Resident #6 and 60) of 24 residents reviewed for abuse and neglect.<BR/>The facility failed to immediately report an allegation of physical abuse.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any other altercation between the two residents.<BR/>Interview on 03/18/25 at 1:38 PM with CNA A, she stated Resident #6 was sitting on her wheelchair in front of the nursing station, when Resident #60 who was standing next to her swung at her and hit her right eye. CNA A stated she separate the two residents immediately. CNA A denied any other altercation between the two residents.<BR/>In interview on 03/18/25 at 1:40 PM, Resident #6 was unable to respond to interview questions. <BR/>In interview on 03/18/25 at 1:42 PM, Resident #60 stated did not remember the incident, and denied ever hitting another resident. <BR/>Interview with the DON and Administrator on 03/18/25 at 1:58 PM revealed, both checked the incident document and stated after they investigated the incident, they did not report it because there was no identifiable intent from one resident to injure the other resident. The DON stated both residents still socialized with each other, and when both residents were interviewed the next day of the incident none of them remembered the incident. The DON and Administrator both stated the risk to residents could be continuous of harm. The Administrator further stated that he was the abuse coordinator for the facility and according to the facility policy/Provider letter Abuse is a willful infliction of injury.<BR/>Review of the facility's Abuse: Prevention of and Prohibition Against, dated 2017, reflected:<BR/>Investigations<BR/>1. <BR/>All identified events are reported to the Administrator immediately.<BR/>H. Reporting/Response<BR/>2. All allegations of abuse, neglect .will be reported outside the facility and to the appropriate state or federal agencies in the applicable timeframes, as per this policy and applicable regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #327) of 5 residents reviewed for ADLs. <BR/>The facility failed to ensure Resident #327 had her fingernails cleaned and trimmed and was provided incontinent care for more than 4 hours on 2/7/24. <BR/>This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>Review of Resident #327's admission MDS assessment dated [DATE] reflected Resident #327 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included hypertension (high blood pressure), peripheral vascular disease (circulation disorder caused by narrowing in a blood vessel), septicemia (blood poisoning by bacteria), and hyperlipidemia (high blood lipid levels). Resident #327 had a BIMS of 14 which indicated Resident #327 was cognitively intact. Resident #327 was always incontinent of bowel and bladder and required assistance with toilet use and personal hygiene.<BR/>Review of Resident #327's Comprehensive Care Plan, revised 2/2/24, reflected the following: Focus: Has bowel/bladder incontinence r/t Confusion, and Impaired Mobility. Goal: Will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Incontinent: Check as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes.<BR/>Review of Resident #327's Comprehensive Care Plan, revised 2/2/24, reflected the following: Focus: ADL Self Care Performance Deficit r/t impaired mobility, wounds with infection Goal: Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene with assistance through the review date. Interventions: Requires Skin inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse.<BR/>An observation and interview on 02/06/24 at 09:58 AM revealed Resident #327 was lying in her bed. The nails on both hands were approximately 0.75 centimeter in length extending from the tip of her fingers and had black area underneath the nails. Resident #327 stated she liked to trim her own nails and had asked for a nail trimmer last week from the nurse and wasn't provide with one. She also stated during her three weeks stay at the facility, nursing staff had not cleaned or offered nail trimmer to cut her nails. <BR/>Interview with CNA A on 2/6/24 at 11:11AM revealed that most ADL such as hair trimming, nail clipping care were completed during shower times. She revealed that she does not work on the Resident # 327s hall often and was not familiar with resident's care. CNA A stated that fingernail clipping should be done weekly but also as needed and CNAs provided nail care unless the resident had diagnosis of diabetes ( elevated blood glucose). <BR/>Interview with CNA B on 2/6/24 at 11:16 AM revealed that she usually worked the night shift but was asked to work on the Morning 6AM - 2 PM shift on 2/6/24. She revealed that that nail care was provided by CNAs on the morning or afternoon shift and CNAs were responsible for providing it.<BR/>Interview with LVN D on 2/6/24 at 11:32 AM revealed that there were no specific days for nailcare. LVN D stated that for all residents with diabetes, nails were trimmed by Nurses. She also stated Resident #327 did not want her fingernails trimmed last week and had asked for nail trimmer. LVN D stated that Resident #327s fingernails were dirty and attested they were not cleaned since resident admit on 1/19/24. LVN D stated she would clean Resident #327's nails right then. <BR/>An interview with Resident #327 on 2/7/24 at 9:13 AM revealed she had not been provided incontinent care since 5 AM on 2/7/24. She reported that she was soaking wet and had asked LVN D around 8 AM on 2/7/24 that she needed to be changed. <BR/>An observation by survey team nurse surveyor on 2/7/24 at 9:20 AM revealed Resident #327 brief was soaked in urine and linen between her legs was soaked in urine too. No foul smell.<BR/>Interview with CNA C on 2/7/24 at 9:19 AM revealed that her shift started at 6 AM on 2/7/24 . She had not had a chance to go to Resident #327's room to provide incontinent care since she was busy with showering the other residents on the hall and taking them to dining room for breakfast. She stated she went to Resident #327's room to give her a breakfast tray around 8:30 AM but did not physically check on her to see if she needed incontinent care. She revealed she knew to round on all residents every two hours and check for incontinence as needed. <BR/>Interview with LVN D on 2/7/24 at 9:28 AM revealed she thought the CNAs must have checked and changed her when their shift began at 6AM . She also said that Resident #327 had informed her that she needed to be changed around 8AM when she provided medicines to Resident #327. She revealed she had told CNA C about it but did not follow-up on it. She stated she was the assigned Charge Nurses on the floor, and she was responsible to ensure residents are provided ADL care. <BR/>Observation on 2/7/24 at 9:33 AM revealed DON was present on the Resident #327s Hall and proceeded to provide incontinent care to Resident #327.<BR/>Interview with the DON on 2/7/24 9:48 AM revealed that her expectation was Nursing staff provided incontinent care to all residents in a timely manner. She expected CNAs and Charge Nurses to round every 2 hours and check on all incontinent residents. The DON stated that Resident #327 brief diaper and sheets were soaking wet when she went to the room to change her, and Resident #327 should have been changed earlier. The DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. She also stated that Charge nurses were primarily responsible for ADL. The DON stated residents having long and dirty fingernails could be an infection control issue as well as residents being wet for too long may led to skin infections in peri area. The DON stated she was responsible to do routine rounds for monitoring.<BR/>Interview with the ADON on 2/8/24 at 10:20 AM revealed that she had started working at the facility about a month ago. She stated that her expectation was that CNA and Nurses round on each resident every 2 hours and provide incontinent care to residents as needed and in a timely manner. The ADON revealed that her expectation regarding nail care was that resident nails should be checked, and nail care completed weekly and on as needed basis. The ADON stated that she rounds on residents frequently to ensure resident's ADL needs are met. The ADON stated that not providing incontinent care in a timely manner or residents not been provided nailcare , both can lead to infection control issues and diminished quality of life. <BR/>Record review of the facility's policy titled Care of Nails, review date January 2022, reflected .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis . Nail care will be provided between scheduled occasions as the need arises . <BR/>Record review of the facility's policy titled ADL, services to carry out , revised date July 2020 reflected If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming and personal oral hygiene will be provided by qualified staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 5 residents reviewed for infection control<BR/>LVN A failed to wear appropriate PPE when providing suprapubic catheter care for Resident #2 who supposed to be on EBP ( Enhanced Barrier Precautions).<BR/>This failure placed the residents at risk of exposure to possible infectious agents.<BR/>Findings included:<BR/>Record review of Resident #2's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, neurogenic bladder, mild intellectual disabilities, and needs for assistance with personal care. Resident#2 has a BIMS score of 12/15 indicating moderate cognitive impairment. Her Functional Status reflected she was dependent on staff for toileting hygiene including suprapubic catheter exit site care. <BR/>Record review of Resident #2's care plan, dated 10/19/24, reflected she has Indwelling Suprapubic Catheter: R/t Neurogenic Bladder Secondary to QUADRAPLEGIC (paralysis of all four limbs) CP (Cerebral Palsy). <BR/>Record review of Resident #2's physician orders reflected an order dated 06/27/24:Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wound, Indwelling medical device, infection and/or MDRO (Multi drug resistant organism) status.<BR/>Observation on 01/16/25 at 08:47 AM LVN A prepared to provide care to Resident #2's suprapubic catheter . LVN A washed hands and donned gloves and provided care without donning a gown. There was no signage and no supplies outside or inside of the Resident#2's room for EBP.<BR/>Interview on 01/16/25 at 09:14 AM LVN A stated Resident #2 has an indwelling medical device and there supposed to be a signage and required PPE supplies in front of Resident #2 room, indicating she was on EBP, and that staff were required to wear a gown and gloves when providing care for the resident. LVN A stated she just did not wear required PPE when she went to provide suprapubic exit site care for Resident#2. LVN A stated she had been working in the facility for few months and had in service on EBP during orientation. <BR/>Interview on 01/16/25 at 09:30 AM the DON stated all residents with wounds, catheters, feeding tubes, etc. are placed in EBP to minimize the risk of spreading infections between residents. EBP required the use of a gown and gloves for all high contact care of the resident. She stated the risk of not adhering to the appropriate PPE requirements was spreading infections to other residents.<BR/>Interview on 01/16/25 at 12:06 PM the administrator stated there should be signage in front of the Resident#2 room, and the supplies. He stated staff should don and doff proper PPE for high resident contact care, including gown, and gloves. He stated the last in service on EBP was done in November 2024. <BR/>Record review of LVN A's skills verification checklist dated 11/04/24 reflected she was competent in Peri-care-Foley catheter tubing care. <BR/>Review of the facility's policy IPCP Standard and Transmission-Based Precaution, Revised March 2023, reflected: 3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with (MDROs).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for five (Residents #1, #2, #3, #4 #5) of 12 residents reviewed for incident accidents. <BR/>The Nursing staff failed to ensure black ants were not in Residents #1, #2, #3, #4 and #5's rooms and beds. <BR/>These failures could place residents at risk of being bitten by ants causing skin irritation, skin infection and pain resulting in decreased health and psychosocial well-being. <BR/>Findings included:<BR/>1) Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to express ideas and wants, able to see in adequate light without corrective lenses. He had a staff assisted BIMS score of 01 (Modified independence cognition) and upper and lower one-sided weakness. He used a wheelchair and was diagnosed with anemia (low iron), renal insufficiency (kidney failure), Diabetes Mellitus, Cerebral Vascular Accident (Stroke), Hemiplegia (Partial paralysis), Malnutrition, Anxiety, depression, and pressure ulcer. <BR/>Record review of Resident #1's Nurse Progress Note dated 08/04/24 at 10:12 pm by LVN A revealed, Note Text: This Nurse was called to resident's room and noted a minimal amount of ants on the floor. Resident was transferred to his wheelchair, this Nurse sprayed the areas, disinfected the bed, and asked resident if he wanted a shower, resident stated I quote No I will get a bed bath when my bed is ready. After reassessing the resident's room this Nurse noted no more ants in the area at the time. Will continue with plan of care.<BR/>Interview on 08/28/24 at 12:26 pm, Resident #1 stated a couple of weeks ago, while he was in bed, he had little black ants all over him but none bit him. He stated they sprayed and cleaned his room and he had not seen any ants since then. He stated they were little black ants, more than 20 ants all over his body and the staff were aware. He stated afterwards no one assessed him but they did shower him and stated he had not had any itchiness since then. He stated Maintenance sprayed his room again two days ago. <BR/>Interview on 08/29/24 at 2:25 pm, FM Q stated about two weeks ago Resident #1 complained about black ants in his room and that they were all over him and it was reported to the nurse. He stated he did not get a call from the nurses about the ants on him either. He stated there were no issue with ants since then.<BR/>2) Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with the ability to express ideas and wants and see in adequate light and without corrective lenses. She had a staff assisted BIMS score of 01 (Modified independence cognition) with no upper or lower weakness and used a motorized scooter. Resident #2 was diagnosed with Heart Failure, Hypertension(high blood pressure), Diabetes Mellites (high blood sugar), Aphasia (speech loss), Cerebrovascular Accident, Multiple Sclerosis (nerve damage), Malnutrition and Anxiety and Depression. <BR/>Record review of Resident #2's Nurse Progress Notes from 08/20/24 and thereafter, did not reveal any Progress Notes from anyone, including LVN A about ants being found in her room and outcome of her skin assessment and notifications to other department heads.<BR/>Interview on 08/27/24 at 12:08 pm, Resident #2 stated two weeks ago she was bitten by little black ants, they were in the corner of her room. Maintenance came and sprayed her room, but no one assessed her after she told LVN A she was bitten by ants. She stated there was around 25 black ants behind two boxes in the corner of her room but had not seen any ants since then.<BR/>3) Record review of Resident #3's admission MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to make self-understood, able to see in adequate light with corrective lenses. His BIMS Score was 12 (Moderate cognitive impairment), upper impairment of both sides, used a cane/crutch and walker. He was diagnosed with Cancer, atrial fibrillation,(irregular heart rate) heart failure, gastroesophageal reflux, renal insufficiency (Kidney failure), urinary tract infection and hyperlipidemia (high fat lipids). <BR/>Record review of Resident #3's Nurse Progress Notes from 08/09/24 to 08/29/24 revealed no documentation of ants in his room and steps done to address, prevent and notify department heads. <BR/>Interview on 08/30/24 at 11:30 am, Visitor S stated a week and a half ago she saw four or five small black ants on Resident #3's bed and two or three on the floor and Resident #3 was sitting in his wheelchair. She stated she told RN H who assessed him and added she had not seen any ants since then.<BR/>4) Record review of Resident #4's admission MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with an ability to express ideas and wants and see in adequate light with corrective lenses. His staff assisted BIMS score of 01 (Modified independence cognition) and with upper and lower impairment and no use of device. He was diagnosed with hypertension (high blood pressure), renal insufficiency (kidney failure), pneumonia, Diabetes mellitus (high blood sugar), hyperkalemia (high potassium), cerebrovascular accident (stroke), hemiplegia (partial paralysis), and dependence on renal dialysis. <BR/>Record review of Resident #4's Nurse Progress Note dated 08/22/24 at 4:11 pm, by RN H revealed, Note Text: Residents FM P showed writer several white pustules to right elbow. Resident denies any itching or c/o. NP U notified. Orders noted: Lotrisone Ointment BID X2 weeks and Bactrim DS 1 TAB po BID X 8 days. Skin infection. FM P and resident notified of orders.<BR/>Interview and observation on 08/29/24 at 10:40 am, Resident #4 stated last week he saw little black ants coming from his AC unit, his brown chair across from his bed and on his bed sheets. He stated he did not feel any bites initially and was showered and his nurse did not assess him; and he moved to another room while his room was cleaned and sprayed. He lifted his right arm and said he had some bites on his arm but they went away because he was given skin cream and antibiotics and his skin cleared up. He stated he had not seen any ants since then. <BR/>Interview on 08/29/24 at 12:14 pm, FM P stated around Wednesday (08/21/24) at 6:00 pm or 7:00 pm she saw little black ants moving around underneath Resident #4's bed. She stated they were coming from Resident #4's AC unit at the end of his bed but she did not see any on him but Resident #4 said there were ants on him. She stated she reported it to the nurse at the nurses station and ask the nurse to go to check him out and the nurse said she would take care of it. She stated the nurse called housekeeping and said she would notate it in his record. She stated she returned the next day and she did not see any more black ants. She stated she had not spoken to the DON and Administrator because she notified the nurse.<BR/>5) Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] and rarely/never understood the ability to express ideas and wants with highly impaired vision. His staff assisted BIMS score was 03 (severely impaired cognition) with upper and lower impairments of both sides and used a wheelchair. He used a catheter with was diagnosed with anemia (low iron), hypertension (high blood pressure), neurogenic bladder (bladder dysfunction), hemiplegia (partial paralysis), Multiple sclerosis (nerve damage), seizure disorder and malnutrition. <BR/>Record review of Resident #5's Nurse Progress Note dated 08/25/24 at 1:03 pm by Agency LVN E revealed, Note Text: Resident remains in stable condition. Resting easy and comfortable in bed. As this nurse was administering medications to pt and noted 3 ants. This nurse assessed pt from head to toe. No bites and redness noted to skin. Pt denies any pain or itchiness. This nurse proceeded promptly with CNA to get pt out bed and into wheelchair. As pt was up in wheelchair, this nurse examined bed mattress, and no ants noted. CNA disinfected mattress with cleaning solution. This noted notified responsible party FM R and weekend RN manager. Weekend RN Manager stated that she would have housekeeping to do a deep clean to room. And responsible party the FM R was appeased that I called and informed her of the current situation and pt was promptly up in wheelchair. FM R went on a rant. Per FM R she knew this very thing was going to happen because housekeeping poorly cleans Resident #5's rooms. <BR/>Record review of Resident #5's Nurse Progress Notes on 08/26/24 did not reveal any documentation about LVN A seeing ants in his room on 08/26/24 at 7:30 am, and no documentation of what was done and notifications to department heads. <BR/>Interview on 8/29/24 at 3:56 pm, FM R stated last Sunday 08/25/24 she received a call from Agency LVN E saying they had to get Resident #5 out of bed because ants were on it. She stated LVN A said he was assessed and not bitten and they said he was okay. She stated last Monday 08/26/24, LVN A called her early that morning around 7:00 am or 9:00 am saying he had ants on his bed. She stated being told he was showered and they just wanted her to be aware and said she had never noticed any ants in his room. She stated she was very diligent about Resident #5's care, because he was nonverbal and could not speak for himself. She stated she checked Resident #5 this week and did not notice any ants or ant bites and rashes on him. <BR/>Interview on 08/27/24 at 2:25 pm, the Administrator stated he was not aware Resident #2 had ants in her room and was bitten by them. He stated he would get maintenance to address and talk to DON about it. <BR/>Interview on 08/27/28 at 3:03pm, LVN A stated she had not seen or had any reports of ants in the residents' rooms. She stated she was not aware of ants being reported in Resident #2's room. <BR/>Interview on 08/27/24 at 6:23 pm, the DON stated she heard about some ants in Resident #2's room about a week ago and was not sure why there were no skin assessments for Residents #1, #2, #3, #4, #5. She stated maintenance inspected and sprayed Resident #2's room and she was assessed and she had no bitemarks. She stated she heard about ants in Resident #1's room last week and added the issue with ants had been going on since last week. She stated pest control came out last week and today (08/27/24) and said she had not seen any ants at this facility and not aware of any residents being bitten by any. <BR/>Interview on 08/29/24 on at 12:35 pm, Agency LVN E stated last weekend, she worked the 6:00 am - 2:00 pm shift. She stated on Sunday 08/25/24 around 7:00 am, she went to Resident #5 to administer his medications through his g-tube and noticed three black baby ants on top of his bed and draw sheet he was laying on. She stated she assessed Resident #5 and he did not have any bite marks or red marks and no signs and symptoms of pain. She stated the CNA's came in to get him out of bed and took his sheets and draw sheet out of the room and showered him and he was assessed again with no bite marks seen. She stated Resident #5 stayed in his wheelchair while his room was cleaned and sanitized and sprayed and she did not see any ants after that. She stated she notified his FM R she said 'okay and that she was not surprised because the housekeeping was not that good. She stated she notified RN Supervisor F about it as well and did not call Resident #5's doctor because she did a thorough assessment and he had no signs or symptoms of distress or bite marks. She stated she did not directly see ants on him but they were on the edge of his draw sheet at the end of his bed. She stated she did a head-to-toe skin assessment but did not complete an actual skin assessment because RN Supervisor F told her she could just document it in the nurses note. She stated that was her first time seeing something like that and said if she saw any redness of red marks, she would have definitely notified Resident #5's doctor. She stated Resident #5 was up at the nurses' station most of the day and he did not have any itchiness or signs or symptoms of bitemarks. She stated she did not know she needed to notify the DON because no one told he to. <BR/>Interview on 08/29/24 at 2:32 pm, RN H stated she was not aware of any ants in Resident #4's room but he had a rash on his right elbow, it was some little white pustules on it. She stated there was no mention from Resident #4 and FM P about him having ant bites or ants in his room. She stated she called his doctor and an order for Lotrisone cream and oral antibiotic was started, and stated she did a head-to-toe skin assess and looked at everything. She stated his elbow rash was localized in one spot and did not look like ant bites she said she did not do an incident report because it was localized to the elbow. She stated she documented it in the nurses' notes. She stated his elbow was much better now and had no white pustules (little white bumps) and did not appear inflamed. She stated she was not aware of any reports of ants in Resident #3's room and had not seen any ants in his room. She stated if a resident were to get bitten by ants could cause them to get a skin infection, have an allergic infection or inflammation. She stated ant bites could get systemic really quickly. <BR/>Interview on 08/29/24 2:54 pm, LVN A stated there was some issues with some ants this past Monday 08/26/24 around 7:30 am, Resident #5 was in his room and there was one or two black little sugar ants on his blanket at the foot area. She stated she did not see any ants on him or rashes but she assessed and showered him with no evidence of ant bites. She stated he was up in his chair while housekeeping and maintenance went and cleaned and sprayed his room. She stated she notified the doctor when he came to the facility that same day and he asked were there any bitemarks and she said no. She stated she had not seen any ants since then and added if residents were bitten, they could end up scratching them and could open up a sore. She stated she was not sure why she did not do an incident report or complete a skin assessment form but did assess him. She stated she saw two little black ants on his bed and Resident #5 was showered and a shower sheet was done. She stated she reported the ant sighting to the DON, Administrator and housekeeping and maintenance cleaned and sprayed the room. She stated she did not document the ant incident in Resident #5's nurse progress notes because she got busy that morning but notified the oncoming nurse about it. <BR/>Interview on 08/29/4 at 5:26 pm, the DOR stated on 08/20/24 Resident #2 had a lot of little black specks crawling (approximately 10 ants) around some crumbs on the floor. He stated he reported in their electronic maintenance system and to LVN A to do a skin assessment. He stated he saw LVN A go down to Resident #2's room.<BR/>Interview on 08/29/24 at 5:53 pm, the DON stated she heard about ants on Resident #5's bed sheet from LVN A earlier in the week, 08/26/24. She stated LVN A took Resident #5 out the bed and said there was no incident report completed because there was no skin alterations. She stated LVN A said she got the Maintenance Director to spray treat the room and it was cleaned. She stated not being aware of any ant reports for Residents #3 and #4 and was not aware ants were found in Resident #5's room Sunday 08/25/24. She stated hearing about Residents #1 and #2 having ants in their rooms last week, but Resident #1 ate a lot of food that got on the floor. <BR/>Interview on 08/29/24 at 6:51 pm, the Administrator stated he was not aware of ant sightings in Residents #1, #3, #4 and #5's rooms. He stated the only ant sighting he was aware of was in Resident #2's room last week 08/20/24. He stated he would talk to the DON about checking these residents out. He stated he spoke to Resident #1 daily and he never reported ants in him room or on him. <BR/>Interview on 08/30/34 at 2:49 pm, ADON B stated they had a few residents with ant sightings like Residents #1 and #5 within the past 30 days. She stated she did the head-to-toe assessment of Resident #1 on 08/04/24 around 10:30 am. She said she did his assessment on paper and did not document it in the EMR because she thought LVN A did and said she notified the DON and his charge nurse. She stated on 08/04/24 she was about to do his wound care and she saw about 15 black ants on the floor and a few of the ants were on his bed. She stated at night Resident #1 liked to eat snacks in bed and could not say if the ants got to him but he did not appear to have any ant bites. She stated she was not sure if LVN A did an incident report because he did not have an injury. She stated she did not complete a nurses note after she saw the ants and believed LVN A did it. She stated she heard Resident #5 had ants in his room once and was not aware of ants in his room the second time. She stated if a resident had ants in their rooms they needed to be showered immediately and put in another room then assessed by the nurse and monitored for 72 hours. She stated it should be reported to maintenance to treat and pest control to come out. She stated she was not aware of ants in Residents #3 and #4's rooms and added if the staff did not know how to report in their electronic maintenance system, they needed to let someone know to assist them. She stated the nurses needed to notify the family and Doctor, DON, ADON and following up 72 hours to check the resident's skin and do an incident report. She stated communication was lacking because all the staff did not know what steps to take. <BR/>Interview on 08/30/34 at 4:20 pm, the Administrator they were going to start keeping a better track of the ant sightings by going over the pest sighting log sheets and reviewing skin assessments and ensuring documentation was in place and incident reports. He stated he wanted to ensure the staff knew what to do if they saw ants including if ants were seen in a resident's bed, a skin assessment should be done even if there was no skin alteration, and for the skin assessment to be done daily for a few days afterwards. He stated the Housekeeping Director was responsible for ensuring the cleanliness of the facility. He stated himself and the DON were responsible for ensuring the documentation was accurate. He stated himself and the DON were responsible for ensuring the incident reporting was done. He stated his expectation was for maintenance to check for ants and for everyone to notify maintenance and himself and the DON, if they have any ant sightings, to ensure all steps were done.<BR/>Interview on 08/30/34 at 4:40 pm, the DON stated she started trainings with the nursing department on if ants were seen or reported they needed to notify the Charge Nurses, Nursing Management, Maintenance, family and after assessment notify the resident's Doctor. She stated the Charge Nurse needed to do a resident's skin assessment, shower resident, change the mattress, deep clean. She stated an incident report was only done if the resident had an alteration of their skin, falls, case by case, abuse, medication errors. She stated for ant bite sightings she expected the CNAs to document the resident's skin on a shower sheet and for the charge nurses to do a skin assessment and document their findings in the nurse progress note. She stated for the agency nurses they needed to have better guidelines for management to be notified for ant sightings also. She stated for medical records every nurse was in charge of their own documentation and ultimately, she and nurse management were responsible for ensuring documentation was complete and accurate. She stated Residents #1, #2, #3, #4, and #5 skin assessments were completed on 08/30/24 and they did not have an signs or symptoms of ant bites.<BR/>The facility's Incident policy was requested on 08/27/24 at 11:21 am, 08/30/24 at 8:59 am, 08/30/24 at 3:12 pm and the Administrator stated they did not have an incident/accident policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that were accurately documented and must contain a record of the resident's assessment for five residents (Residents #1, #2, #3 #4 and #5) of 12 residents reviewed for Medical Records. <BR/>The Nursing staff failed to ensure incident reports, skin assessments and Nurse progress notes were completed after reports of black ants were found in the rooms and beds of Residents #1, #2, #3, #4 and #5. <BR/>These failures could affect all residents by placing them at risk of not being properly monitored and treated if documentation were not completed, accurate or missing which could result in decline in their health and psycho-social well-being. <BR/>Findings included:<BR/>1)Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to express ideas and wants, able to see in adequate light without corrective lenses. He had a staff assisted BIMS score of 01 (Modified independence cognition) and upper and lower one-sided weakness. He used a wheelchair and was diagnosed with anemia (low iron), renal insufficiency (kidney failure), Diabetes Mellitus, Cerebral Vascular Accident (Stroke), Hemiplegia (Partial paralysis), Malnutrition, Anxiety, depression, and pressure ulcer. <BR/>Record review of Resident #1's Nurse Progress Note dated 08/04/24 at 10:12 pm by LVN A revealed, Note Text: This Nurse was called to resident's room and noted a minimal amount of ants on the floor. Resident was transferred to his wheelchair, this Nurse sprayed the areas, disinfected the bed, and asked resident if he wanted a shower, resident stated I quote No I will get a bed bath when my bed is ready. After reassessing the resident's room this Nurse noted no more ants in the area at the time. Will continue with plan of care.<BR/>Record review of Resident #1's EMR did not reveal she had any Incident/accident reports involving ants from 06/27/24/- 08/27/24.<BR/>Record Review of Resident #1's Skin Assessments did not reveal any skin assessments for ants were completed after ants were found in his room and bed on 08/04/24.<BR/>Interview on 08/28/24 at 12:26 pm, Resident #1 stated a couple of weeks ago, while he was in bed, he had little black ants all over him but none bit him. He stated they sprayed and cleaned his room and he had not seen any more ants since then. He stated they were little black ants, more than 20 ants all over his body and the staff were aware. He stated afterwards no one assessed him but they did shower him and stated he had not had any itchiness since then. He stated Maintenance sprayed his room again two days ago.<BR/>Interview on 08/29/24 at 2:25 pm, FM Q stated about two weeks ago Resident #1 complained about black ants in his room and that they were all over him and it was reported to the nurse. He stated he did not get a call from the nurses about the ants on him either. He stated there were no issue with ants since then.<BR/>2) Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with the ability to express ideas and wants and see in adequate light and without corrective lenses. She had a staff assisted BIMS score of 01 (Modified independence cognition) with no upper or lower weakness and used a motorized scooter. Resident #2 was diagnosed with Heart Failure, Hypertension (high blood pressure), Diabetes Mellites (high blood sugar), Aphasia (speech loss), Cerebrovascular Accident, Multiple Sclerosis (nerve damage), Malnutrition and Anxiety and Depression. <BR/>Record review of Resident #2's Nurse Progress Notes from 08/20/24 and thereafter, did not reveal any Progress Notes from anyone, including LVN A about ants being found in her room and outcome of her skin assessment and notifications to other department heads.<BR/> Record review of Resident #2's EMR did not reveal she had any Incident/accident reports involving ants from 06/27/24/- 08/27/24.<BR/>Record review of Resident #2's Skin Assessment after it was reported ants were in her room on 08/20/24. <BR/>Interview on 08/27/24 at 12:08 pm, Resident #2 stated two weeks ago she was bitten by little black ants, they were in the corner of her room. Maintenance came and sprayed her room, but no one assessed her after she told LVN A she was bitten by ants. She stated there was around 25 black ants behind two boxes in the corner of her room but had not seen any ants since then.<BR/>3) Record review of Resident #3's admission MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to make self-understood, able to see in adequate light with corrective lenses. His BIMS Score was 12 (Moderate cognitive impairment), upper impairment of both sides, used a cane/crutch and walker. He was diagnosed with Cancer, atrial fibrillation, heart failure, gastroesophageal reflux, renal insufficiency, urinary tract infection, hyperlipidemia. <BR/>Record review of Resident #3's Nurse Progress Notes from 08/09/24 to 08/29/24 revealed no reports of ants in his room and steps done to address, prevent and notify department heads since he admitted . <BR/>Record review of Resident #3's EMR did not reveal she had any Incident/accident reports involving ants from 06/27/24/- 08/27/24.<BR/>Record review of Resident #3's Skin Assessments were not completed for ant bites in his EMR from 08/01/24 to 08/28/24. <BR/>Interview on 08/30/24 at 11:30 am, Visitor S stated a week and a half ago she saw four or five small black ants were on Resident #3's bed and two or three on the floor. She stated telling RN H who came in to assess Resident #3. She stated Resident #3 was sitting in his chair and since then she had not seen any ants.<BR/>4) Record review of Resident #4's admission MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with an ability to express ideas and wants and see in adequate light with corrective lenses. His staff assisted BIMS score of 01 (Modified independence cognition) and with upper and lower impairment and no use of device. He was diagnosed with hypertension (high blood pressure), renal insufficiency (kidney failure), pneumonia, Diabetes mellitus (high blood sugar), hyperkalemia (high potassium), cerebrovascular accident (stroke), hemiplegia (partial paralysis), and dependence on renal dialysis. <BR/>Record review of Resident #4's Nurse Progress Note dated 08/22/24 at 4:11 pm, by RN H revealed, Note Text: Residents FM P showed writer several white pustules to right elbow. Resident denies any itching or c/o. NP U notified. Orders noted: Lotrisone Ointment BID X2 weeks and Bactrim DS 1 TAB po BID X 8 days. Skin infection. FM P and resident notified of orders.<BR/>Interview and observation on 08/29/24 at 10:40 am, Resident #4 stated last week he saw little black ants coming from his AC unit, his brown chair across from his bed and on his bed sheets. He stated he did not feel any bites initially and was showered and his nurse did not assess him; and he moved to another room while his room was cleaned and sprayed. He lifted his right arm and said he had some bites on his arm but they went away because he was given skin cream and antibiotics and his skin cleared it up. He stated he had not seen any ants since then. <BR/>Interview on 08/29/24 at 12:14 pm, FM P stated last Wednesday (08/21/24) around 6:00 pm or 7:00 pm she saw little black ants moving around underneath Resident #4's bed. She stated they were coming from Resident #4's AC unit at the end of his bed but she did not see any on him but Resident #4 said there were ants on him. She stated she reported it to the nurse at the nurses station and ask the nurse to go to check him out and the nurse said she would take care of it. She stated the nurse called housekeeping and said she would notate it in his record. She stated she returned the next day and she did not see any more black ants. She stated she had not spoken to the DON and Administrator because she notified the nurse.<BR/>Record review of Resident #4's EMR did not reveal he had any Incident/accident reports involving ants from 06/27/24 to 08/27/24. <BR/>Record review of Resident #4's Skin assessment dated [DATE] did not reveal a skin assessment was completed and in his EMR. <BR/>5) Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] and rarely/never understood the ability to express ideas and wants with highly impaired vision. His staff assisted BIMS score was 03 (severely impaired cognition) with upper and lower impairments of both sides and used a wheelchair. He used a catheter with was diagnosed with anemia, hypertension, neurogenic bladder (bladder dysfunction), hemiplegia (partial paralysis), Multiple sclerosis (nerve damage), seizure disorder and malnutrition. <BR/>Record review of Resident #5's Nurse Progress Note dated 08/25/24 at 1:03 pm by Agency LVN E revealed, Note Text: Resident remains in stable condition. Resting easy and comfortable in bed. As this nurse was administering medications to pt and noted 3 ants. This nurse assessed pt from head to toe. No bites and redness noted to skin. Pt denies any pain or itchiness. This nurse proceeded promptly with can to get pt out bed and into wheelchair. As pt was up in wheelchair, this nurse examined bed mattress, and no ants were noted. CNA disinfected mattress with cleaning solution. This noted notified responsible party FM R and weekend RN manager. Weekend RN Manager stated that she would have housekeeping to do a deep clean to room. And responsible party the FM R was appeased that I called and informed her of the current situation and pt was promptly up in wheelchair. FM R went on a rant. Per FM R she knew this very thing was going to happen because housekeeping poorly cleans Resident #5's rooms. <BR/>Record review of Resident #5's Nurse Progress Notes on 08/26/24 did not reveal any documentation by LVN A seeing ants in his room at 7:30 am. <BR/>Interview on 8/29/24 at 3:56 pm, FM R stated last Sunday 08/25/24 she received a call from Agency LVN E saying they had to get Resident #5 out of bed because ants were on it. She stated LVN A said he was assessed and not bitten and they said he was okay. She stated last Monday 08/26/24, LVN A called her early that morning around 7:00 am or 9:00 am saying he had ants on his bed. She stated being told he was showered and they just wanted her to be aware and said she had never noticed any ants in his room. She stated she was very diligent about Resident #5's care, because he was nonverbal and could not speak for himself. She stated she checked Resident #5 this week and did not notice any ants or ant bites and rashes on him.<BR/>Record review of Resident #5's Nurse Progress Notes from 08/26/24 did not reveal any documentation about LVN A seeing ants in his room on 08/26/24 at 7:30 am. <BR/>Record review of Resident #5's EMR did not reveal he had any Incident/accident reports involving ants from 06/27/24 to 08/27/24<BR/>Record review of Resident #5's Skin assessment dated [DATE] did not reveal a skin assessment for ants was completed and in his EMR.<BR/>Record review of Resident #5's Skin assessment dated [DATE] did not reveal a skin assessment for ants was completed and in his EMR.<BR/>Interview on 08/27/28 at 3:03pm, LVN A stated she had not seen or had any reports of ants in the resident's rooms. She stated she was not aware of ants being reported in Resident #2's room. <BR/>Interview on 08/27/24 at 6:23 pm, the DON stated she heard about some ants in Resident #2's room about a week ago. She stated she heard about ants were in Resident #1's room last week and added the issue with ants had been going on since last week. <BR/>Interview on 08/28/24 at 1:12 pm, CNA C stated the morning of 08/12/24, a couple of weeks ago, she saw ants in Resident #1's room. She stated she saw five black sugar ants on the floor in Resident #1's room and pulled his covers back and checked him out and did not seen any ants on him or his bed. She stated she reported seeing the ants to an agency nurse and Maintenance spray treated Resident #1's room.<BR/>Interview on 08/29/24 on at 12:35 pm, Agency LVN E stated last weekend, she worked the 6:00 am - 2:00 pm shift. She stated on Sunday 08/25/24 around 7:00 am, she went to Resident #5 to administer his medications through his g-tube and noticed three black baby ants on top of his bed and draw sheet he was laying on. She stated she assessed Resident #5 and he did not have any bite marks or red marks and no signs and symptoms of pain. She stated she did not directly see ants on him but they were on the edge of his draw sheet at the end of his bed. She stated she did a Head-to-toe skin assessment but did not complete an actual skin assessment because RN Supervisor F told her she could just document it in the nurses note. She stated this was her first time seeing something like that and said if she saw any redness of red marks, she would have definitely notified Resident #5's Doctor. <BR/>Interview on 08/29/24 at 1:38 pm, CNA F stated she worked the 6:00 am to 2:00 pm shift and saw ants a week or 2 weeks ago in Resident #1's room around 11:30 am. She stated she saw a trail of ants on the floor by the side of the wall of his AC unit and reported it to his nurse and the Maintenance Director. She stated there was a trail, a lot of little black ants on the floor and they were going toward Resident #1's bed. She stated she was not sure if the nurse checked him.<BR/>Interview on 08/29/24 at 2:32 pm, RN H stated she was not aware of any ants in Resident #4's room but he had a rash on his right elbow, it was some little white pustules on it. She stated there was no mention from Resident #4 and FM P about him having ant bites or ants in his room. She stated she called his Doctor and an order for Lotrisone cream and oral antibiotic was started, and stated she did a head-to-toe skin assess and look at everything. She stated his elbow rash was localized in one spot and did not look like ant bites and said she did not do an incident report because it was localized to the elbow. She stated she documented it in the nurses notes. She stated his elbow was much better now and had no white pustules (little white bumps) and did not appear inflamed. She stated she was not aware of any reports of ants in Resident #3's room and had not seen any ants in his room. She stated if a resident were to get bitten by ants could cause them to get a skin infection, have an allergic infection or inflammation. She stated ant bites could get systemic really quickly. <BR/>Interview on 08/29/24 2:54 pm, LVN A stated there was some issues with some ants this past Monday 08/26/24 around 7:30 am, Resident #5 was in his room and there was one or two black little sugar ants on his blanket at the foot area. She stated she did not see any ants on him or rashes but she assessed and showered him with no evidence of ants. She stated he was up in his chair while housekeeping and maintenance went and cleaned and sprayed his room. She stated she notified Doctor M when he came to the facility that same day and he asked were there any bitemarks and she said no. She stated she had not seen any ants since then and added if residents were bitten, they could end up scratching them and could open up a sore. She stated she was not sure why she did not do an incident report or complete a skin assessment form but did assess him. She stated she saw two little black ants on his bed and Resident #5 was showered and a shower sheet was done. She stated she did not document the ant incident in Resident #5's nurse progress notes because she got busy that morning but notified the oncoming nurse about it. She stated not doing an incident report or progress note about ants being in resident's rooms could cause the incident to reoccur. <BR/>Interview on 08/29/24 at 3:22 pm, LVN I stated if he saw ants on a resident or it was reported to him, he would do an incident report, notify their doctor, RP, and Administrator. <BR/>Interview on 08/29/4 at 5:26 pm, the DOR stated on 08/20/24 Resident #2 had a lot of little black specks crawling (approximately 10 ants) around some crumbs on the floor. He stated he reported to LVN A to do a skin assessment. He stated he saw LVN A go down to Resident #2's room and was not sure if an incident report done. <BR/>Interview on 08/29/24 at 5:53 pm, the DON stated she heard about ants on Resident #5's bed sheet from LVN A earlier this week 08/26/24. She stated LVN A took Resident #5 out the bed and said there was no skin report completed because there was no skin alterations. She stated not being aware of any ant reports for Residents #3 and #4 and was not aware ants were found in Resident #5's room Sunday 08/25/24. She stated hearing about Resident #1 and #2 having ants in his room last week. She stated there would not be an incident report completed for these ant sightings unless there was an actual injury and she did not feel the Doctor needed to be notified about the ant sightings. She stated if there was no negative outcome, just a nursing judgement was needed for them to continue to monitor them. She stated Doctor M was aware of the ant issue at the facility but was not sure if the Medical Director Doctor N knew about the ant problem. <BR/>Interview on 08/30/24 at 10:56 am, CNA D stated she had not seen any ants and all she could do was report ant sightings to the Electronic Maintenance System. She stated she did not look at the floor to look for any ants because she was too busy taking care of Resident #3. She stated Visitor S said he had ants in his room but she did not see them and did not go into Resident #3's room because it was a busy day. She stated she did not report the ant sighting to the nurse because Visitor S did. She stated she saw Visitor S report the ant sighting to RN H and then saw RN H went to Resident #3's room. She stated she did not shower Resident #3. <BR/>Interview on 08/30/34 at 2:03 pm, the Medical Records Director stated she did not have any skin assessments for Residents #1, #2, #3, #4, #5 and was not aware of any issues with missing documentation such as incident/accident reports, skin assessments or nurse progress notes. <BR/>Interview on 08/30/34 at 2:49 pm, ADON B stated she did the head-to-toe assessment of Resident #1 on 08/04/24 around 10:30 am. She said she did his assessment on paper and did not document it in the EMR and said she notified the DON his charge nurse. She stated on 08/04/24 she was about to do his wound care and she saw about 15 blacks the ants on the floor and a few of the ants were on his bed. She stated she was not sure if LVN A did an incident report because he did not have an injury. She stated she did not complete a nurses note after she saw the ants and believed LVN A did it. She stated if a resident had ants in their room they needed to be assessed by the nurse and monitored for 72 hours. She stated the nurses needed to notify the Family and Doctor, DON, ADON and following up 72 hours to check the resident skin and do an incident report.<BR/>Interview on 08/30/34 at 4:20 pm, the Administrator stated they were going to start reviewing skin assessments and ensuring documentation was in place and incident reports. He stated he would be doing monthly trainings on documentation. He stated he wanted to ensure the nurses documentation was accurate, He stated he wanted to correctly train and have postings up for agency staff to know who to call for various topics. He stated he wanted to ensure the staff knew what to do if they saw ants including if ants were seen in a resident's bed, a skin assessment should be done even if there was no skin alteration, and for the skin assessment to be done daily for a few days afterwards. He stated himself and the DON were responsible for ensuring the documentation was accurate. He stated himself and the DON were responsible for ensure the incident reporting was done. <BR/>Interview on 08/30/34 at 4:40 pm, the DON stated she started trainings with the nursing department if ants were seen or reported they needed to notify the Charge Nurses, Nursing Management, Maintenance, family and after skin assessment notify the resident's Doctor. She stated the Charge Nurse needed to do a resident's skin assessment. She stated an Incident Report was only done if the resident had an alteration of their skin, falls, case by case, abuse, medication errors. She stated for ant bite sightings she expected the CNA's to document the resident's skin on a shower sheet and for the Charge Nurses to do a skin assessment and document their findings in the nurse progress note. She stated for the agency nurses they needed to have better guidelines for management to be notified for ant sightings also. She stated for Medical Records every nurse was in charge of their own documentation and ultimately, she and nurse management were responsible for ensuring documentation was complete and accurate. She stated Residents #1, #2, #3, #4, #5 skin assessments were completed on 08/30/24 and they did not have an signs or symptoms of ant bites.<BR/>The facility's Incident policy was requested on 08/27/24 at 11:21 am, 08/30/24 at 8:59 am, 08/30/24 at 3:12 pm and the Administrator stated they did not have an incident/accident policy. <BR/>Record Review of the facility's Documentation and Charting Policy and Procedures dated 10/2021 revealed, POLICY: It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 3.The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. 4. Nursing service personnel with a record of the physical and mental status of the resident. 5. Assistant in the development of a Plan of Care for each resident. 6. The elements of quality medical nursing care. 7. A legal record that protects the resident, physician, nurse, and the facility. 8. A source of all resident charges. PROCEDURES . 10. Follow-up-Notes: Documentation relating to follow-up notes should include. A. A summary of the resident's condition, until the resident is stable. B. Documentation that the resident's condition has stabilized. C. Signature and title of person recording the data. <BR/>

**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 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE].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 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE]. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. These failures could affect residents by placing them at risk of allergic reaction, decline in quality of life and death. Findings included: Record review of Resident#1's face sheet revealed, she was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Dementia (decline in cognitive function that affects daily living) in other diseases classified elsewhere, unspecified other severity, with mood disturbance (mental health conditions that primarily affect emotional states), unspecified Dementia, unspecified severity, without behavioral, other disturbance, psychotic disturbance (a condition in which one is unable to distinguish what is and is not real), mood disturbance, and anxiety, erosive (Osteo) arthritis (destruction of joint cartilage and bone erosion), other muscle weakness (Generalized), other unspecified lack of coordination, other personal history of Transient Ischemic attack ( caused by a brief blockage of blood flow to the brain) and cerebral and other infarction without residual deficits (blood flow to a part of the brain is obstructed, leading to tissue death due to lack of oxygen). Record review of Resident#1's MDS, dated [DATE] revealed her BIMS score was undetermined. Resident#1's functional limitation in range of motion reflected impairment on one side, coded for lower extremity (hip, knee, ankle, foot). Resident#1's functional abilities for mobility were undetermined. Record review of Resident#1's care plan, undated revealed, she was at risk for communication problem related to Dementia, at risk for impaired cognitive function/dementia or impaired thought processes r/t long term memory loss, Poor nutrition, short term memory loss, Dementia, and impaired decision making. Resident#1 had bowel/bladder incontinence r/t Alzheimer's, Confusion, Dementia, and impaired Mobility. Record review of Resident#1 EMS report, dated 07/20/25 reflected, Dispatched to nursing home for medical emergency. Upon arrival then [Resident#1] one was found in her wheelchair eyes completely swollen shut and family around her. Family reported that patient was found in her bed, by the family, covered in ants. The [Resident#1]had visible ant bites on her neck, face and eyes. The patient had Alzheimer's and was not able to communicate or provide any information. [Resident#1] was transferred to stretcher by EMS via picking patient up from the wheelchair and placing her on the stretcher. En route to hospital vital perform SPO2, BGL, lung sounds were clear, airway patent. [Resident#1], IV established and right hand 50 milligram of Diphenhydramine given via IV, 2 ants found on patient during transport. Vitals remain stable throughout transportation. Patient transported to [local hospital] for further observation and treatment.Record review of Resident#1's hospital records, dated 07/22/25 reflected, Resident#1 was admitted on [DATE] at 11:28 AM. Per EMS, several small ants were actively crawling around patient. Patient had noted bites around her entire body including her face and neck. Patient had noted eyelid swelling. EMS administered IV Benadryl at 15 mg. Patient's face swollen and red with some insect bites likely allergic reaction from insect bites, will start IV steroids, hydrocortisone and Benadryl cream.Visit diagnosed Insect bite, unspecified site, initial encounter (primary), Urinary tract infection without hematuria, site unspecified Dehydration and Unsatisfactory living conditions. Patient's [family member] also requested new placement to a different facility, case management assisted with placement. [Resident#1] was accepted at another SNF/NF and would be discharged on 07/23/25. Record review of the weekend MOD progress note dated 07/20/25 reflected, Writer was alerted by CNA of rash/swollen eyes. Upon entry to room, no ants present in room, on resident or bed/linen. Resident was removed from area and assessed. Linen had already been removed, bed cleaned, and resident was already showered. Scattered rash like areas noted to body and redness along with bilateral swollen eyes during assessment. Writer notified {medical doctor} made aware of clinical situation and new orders given. Family notified of orders and ER transport. Hydrocortisone cream applied to entire body and PRN pain med and Benadryl administered. EMT present and transferred resident to {local hospital} with family en route. Family provided with Administrator's contact info for any concerns. Record review of the Admin interview with CNA A reflected [CNA A] regarding the incident that took place Sunday 7/20/2025 morning. [CNA A] stated she had been in the room of the affected resident about an hour prior at 8:30 and had checked and changed resident for incontinence. Room was clean, no signs of ants in or around bed or on resident at that time. No signs of clutter in the room or open food to draw pests into the room. Record review of the PCC service Inspection Report dated 4/11/25 reflected, on 05/28/25 the following rooms where treated 106-109 and 405-408 for ants and general pest. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the PCC service Inspection Report dated 07/21/25 reflected the facility was treated for ants on 07/21/25 treated room [ROOM NUMBER] for ants and general pest. On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. Record review of Resident#1 shower sheet, dated 07/20/25 reflected Resident#1 had a scattered rash on chest signed by the weekend MOD and CNA A. Record review of in-service training report dated 07/20/25, titled pest control/homelike environment /abuse prohibition conducted by ED in person and via phone reflected: Summary of in-service reflected: Our residents have the right to a safe, clean comfortable and home like environment. We must be diligent in our processes to ensure this for them. -Rooms need to be clean and free of odors. If you observe issues with cleanliness or odors, you must report it to housekeeping immediately and find the source. Facility needs to be free of pest. If you observe issues with pest control, you must report it to maintenance immediately via MS and notify ED or Maintenance-Facility must monitor food in resident rooms and ensure there aren't items drawing pest attention. If you observe issues, you must report it or correct if able.-Maintenance will adjust interventions as appropriate and as the seasons change. Including checking and treating for ants regularly.-Report to admin and DON if ants observed in residents' room, notify nurse immediately-Head to toe skin assessment to be completed by the nurse on both residents in the room.remove any ants-Remove resident and roommate from the room-check adjacent room for ants, room to be treated for ants,-Resident unable to return to room until treatment and deep cleaning completed During an observation on 07/22/25 at 8:30 am to 9:15 am revealed, the common area, dining area and rm# 301, 302, 303, 304, 305,306,307,308, 309, 310, 311 and 312 were free of ants. In an interview on 07/22/25 at 8:43 am CNA B stated residents in the unit did not eat in their room. CNA B stated snacks were kept in a white container and were given out and staff cleaned up right after. CNA B stated the facility had issues in the past with bugs and they let the MD know. CNA B stated she had not seen ants in Resident#1 room before 07/20/25. CNA B was in serviced over the phone about pest control, resident abuse, homelike environment, and Resident#1 was transported to hospital on [DATE]. In an interview on 07/22/25 at 9:28 am the HKS stated they cleaned and disinfected common areas and resident's rooms daily. HKS stated when notified of a pest sighting, the HKS would first let the MD know. The HKS stated everything would be taken out of the resident's room and washed. The HKS stated Resident#1 room was deep cleaned and then deep cleaned again the following day. The HKS stated she viewed a small number of active and unactive ants in Resident#1 room. In an interview on 07/22/25 at 10:05 am, the MD stated it was reported to him on 07/20/25 that a Resident#1 was bitten by ants. The MD came to the facility and immediately sprayed the Resident#1 room and exterior. The MD stated pest control came out 07/20/25 and 07/21/25 and treated the interior and exterior of the facility. The MD stated the facility had minor problems in the past with residents who had spilled food in their rooms and ants followed the trail. The MD stated staff were supposed to report in MS any pest sighting. MD stated PCC technician came out twice a month to treat the facility. The MD stated the last pest control inspection was on 06/20/25. In an interview on 07/22/25 at 10:20 am the HSW stated Resident #1would be discharged to another SNF/NF. The HSW stated Resident#1's planned discharge was on 07/23/25. In an interview on 07/23/25 at 10:28 am, the HN stated that Resident#1 did not talk and was not ambulatory. The HN stated Resident#1 slept most of the day and a family member had been at her side. The HN stated Resident#1 was in the hospital for an allergic reaction to ant bites from a nursing home. Interview and observation at the local hospital on [DATE] at 10:33 am revealed Resident #1 had bites on her eyelids, face and neck. The Family member stated she visited Resident#1 on the morning of 07/20/25. Resident#1's legs were covered with a blanket and when she moved the blanket ants were crawling on her legs. The Family member stated Resident#1's eyes were swollen shut and there were ants crawling on the wall. The family member stated she went and got CNA A who assisted with Resident#1.Attempted to call LVN I on 07/22/25 at 2:24 pm and did not receive a return call before exit.In an interview on 07/22/25 at 2:30 pm weekend MOD stated LVN I called her about Resident#1 had an allergic reaction to ant bites. The weekend MOD informed the DON about the ant bites. The weekend MOD stated she did a head-to-toe assessment and documented in Resident#1 progress notes the findings. The weekend MOD stated she remember the resident having a rash on her chest and her eyes were swollen. The weekend MOD stated Resident#1 hair was wet and she did not find any ants on her. In an interview on 07/22/25 at 3:36 pm CNA A stated at 8:15 am on 07/20/25 she went into Resident#1's room to provide incontinent care and turned to feed Resident#1 and she would not eat. CNA A stated she did not see any ants in Resident#1's room at that time. CNA A stated the family member came and got her around 10 something. CNA A stated Resident#1's eyes were swollen. CNA A stated she notified LVN I and she called the MD by calling his number. CNA A stated she was in-serviced on 07/20/25 to notified LVN I so they could do a head-to-toe assessment on the resident and roommate. CNA stated Resident#1 was given a shower. CNA A stated no ants were found on the roommate side of the room. CNA A stated nearby rooms should be checked for ants and staff must make sure all food was cleaned up.In an interview on 07/22/25 at 3:40 pm CNA C stated she was not there when the incident happened with Resident#1. CNA C was in-serviced on 07/21/25 on homelike environment, pest control and resident abuse. CNA C stated she had not seen any ants. CNA C stated any sighting of pest should be reported to the MD and tell the nurse so she could do a head-to-toe assessment. Interviews on 07/22/25 from 3:45 pm to 4:10 pm revealed LVN D, CNA E, LVN F, CNA G and LVN H stated if pests were seen, first remove the residents from the room, then the MD and Admin were called, the nurse did a head-to-toe assessment, adjacent rooms were checked for pests, they removed residents' belongings, and the HK deep cleaned the rooms. In an interview on 07/22/25 at 4:12 pm the HK stated if they noticed pests to first notify the MD and then bag residents' items and complete laundry. The HK stated the room was deep cleaned twice and adjacent rooms were checked. In an interview on 07/22/25 at 10:02 am the PCC technician stated the company treated the facility twice a month. PCC stated one exterior treatment would be enough to take care of the ants. PCC technician stated he came in on 07/20/25 and 07/22/25 and treated the interior and exterior of the facility for ants. The PCC technician stated no ants were found in the rooms. The PCC technician stated a lot of things could have led to an ant problem such as the weather. The PCC technician stated little showers and heavy rain caused everything on the ground to move around and food being left out could cause ants. In an interview on 07/22/25 at 4:15 pm the DON and Admin stated the Facility immediately cleared Resident #1, and her bed of ants. Resident #1 was showered and affected areas treated, housekeeping immediately deep cleaned the room, and pest control was called immediately to come and treat the room as well as adjacent rooms. Residents on the hall were checked head to toe for skin assessments, and no other signs of ants or bites were sighted. The DON stated Resident#1 roommate had a head-to-toe assessment and no bites were found on her or in her personal belongings. The DON stated Resident#1 roommate was transferred to 200 hall. Admin stated Pest control treated the exterior of the facility as well as the ant hills on the property. All staff were in-serviced on pest control, safe homelike environment, and abuse prohibition. The MD did exterior rounds of the facility and checked for entrance sights and hills and provided exterior treatment. The PCC Technician came back out the next day for a follow up treatment. Dept heads continue to round twice a day to check for signs of pests. Staff are to notify maintenance via MS and group message as well as the Admin immediately. The DON and Admin stated any pest sighted in the resident rooms will require resident to have a head-to-toe assessment immediately and room deep cleaned. During an observation on 07/22/25 at 4:45 pm the surveyor did an exterior walk through of the facility and ant hills were not noticed at that time of visit. Observed a lot of greenery and shrubbery around the facility. During an observation on 07/22/25 at 5:00 pm, resident rm# 106-109, 206, 211 and 405-408 were checked for ants. The surveyor did not observed pest at the time of visit. During an observation and interview on 07/23/25 at 11:30 am the MD and surveyor did an exterior walk through of the facility. The MD stated ant hills were treated and then knocked down the following day. The MD identified spots where ants had been knocked down and no active ants were observed at the time of the visit. Record review of the PCC service Inspection Report dated 07/21/25 reflected, On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. On 07/21/25 treated room [ROOM NUMBER] for ants and general pest Record review of facility policy titled, safe/comfortable/homelike environment, revised 01/22 revealed: Residents are provided with a safe, clean, comfortable and homelike environment. Record review of a pest contract revealed the agreement was effective October 1, 2021, and reflected .8. Service Provider's Schedule and Availability, service provider shall be reasonably available to the Facility and shall spend sufficient time at the facility premises to fulfill service provider's duties hereunder. Record review of facility policy titled, physical Environment, revised 05/2020 reflected: POLICY:It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.Responsibilities:Facility staff will:1. Report any pest sightings and file a report using the pest observation log.2. Document problems found during inspection and the remedial actions taken.3. Advise staff on preventive measure, unsanitary conditions, etc.4. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment.Pest Identification:The following guidelines for pest identification:1. When pests are sighted, determine why the infestation is occurring and advise department on preventive measures.2. Use pesticides only after all other channels of control are exhausted.3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls.4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information:a. Type of problemb. Locationc. Person reporting and time reported.Pest Prevention:The following are guidelines for pest prevention:1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc.2. Keep grounds free of trash and brush.3. Keep the dumpster area clean.4. Food stored in resident rooms will be in covered containers.5. Clean up food spills.6. Screen foundation areas with mesh.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing and administering, of medications for 2 (Nursing Medication cart hall 100 North and nursing medication cart 300 hall) of 3 medication carts reviewed for pharmacy services. <BR/>The facility failed to ensure prompt identification of potential diversion of controlled medications when CMA B did not report a damaged blister pack of Clobazam 20 mg (controlled medication) and LVN D C did not report a damaged blister pack of Tylenol with Codeine#4 oral tablet 300-60 mg (controlled medication).<BR/>This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. <BR/>Findings included:<BR/>Record review of Resident #31's Quarterly MDS assessment, dated 01/12/25, reflected he was a [AGE] year-old male with admission date of 08/30/24. Resident #31's BIMS score was 12/15 which indicated moderate cognition. His diagnoses included diabetes mellitus (elevated blood sugar), dementia (diseases that affect memory, thinking, and the ability to perform daily activities), Alzheimer disease (is a brain disorder that causes memory loss, thinking problems, behavior changes, and brain cell death), hypertension (elevated blood pressure), and aphasia (Aphasia a language disorder that affects a person's ability to communicate).<BR/>Record review of Resident #31's Physician order summary report dated March 2025, reflected . Clobazam 20 mg tablet Give 1 tablet by mouth two times a day . with a start date 03/06/25.<BR/>An observation on 03/19/25 at 12:15 PM revealed the blister pack for Resident #31 Clobazam 20 mg (controlled medication) had 1 blister pack pill area seal broken and the pill still in the blister. <BR/>Review of the controlled medication count sheet for Resident #31 Clobazam 20 mg reflected that the count was accurate when compared to the medications in the drawer. <BR/>In an interview on 03/19/25 at 12:15 PM CMA B stated she was unaware when the blister pack seal became broken. She stated that the seals are easily torn when they are handled every shift to be counted. She stated the medication was supposed to be discarded if opened to prevent potential diversion of controlled medications. <BR/>Record review of Resident #53's Quarterly MDS assessment, dated 02/23/25, reflected she was a [AGE] year-old female initially admitted to facility on 03/28/23, and readmitted on [DATE]. Resident #53's BIMS score of 8/15 which indicated moderate cognition. Her diagnoses included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and arthritis (a broad term for conditions affecting joints, tissues around joints, and other connective tissues, causing pain, stiffness, and reduced movement). <BR/>Record review of Resident#53's Physician order summary report dated March 2025 reflected . Tylenol with Codeine #4 oral tablet 300-60 mg Give 1 Tablet by mouth every 8 hours as needed for pain . with a start date 05/07/24.<BR/>An observation on 03/19/25 1:50 PM revealed the blister pack for Resident #53 blister pack of Tylenol with Codeine#4 oral tablet 300-60 mg had 1 blister pack pill area seal broken and the pill still in the blister. <BR/>Review of the controlled medication count sheet for Resident #53 Tylenol with Codeine#4 oral tablet 300-60 mg reflected that the count was accurate when compared to the medications in the drawer.<BR/>In an interview on 03/19/25 1:55 PM LVN D stated she was unaware when the blister pack seal became broken. She stated she didn't see it this morning when she counted with the night shift nurse. She stated the medication was supposed to be discarded if opened to prevent medication error that can harm the resident. <BR/>In an interview on 03/19/25 at 2:25 PM, the DON revealed she expected if a blister pack medication seal is broken; the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk to residents would be giving the wrong and ineffective medication. DON stated charge nurses were responsible to check, every day, the carts for medications with broken seals during the count with the relieving nurses. <BR/>Review of the facility's Storage of Medications policy, Revised April 2007, indicated . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 5 residents reviewed for infection control<BR/>LVN A failed to wear appropriate PPE when providing suprapubic catheter care for Resident #2 who supposed to be on EBP ( Enhanced Barrier Precautions).<BR/>This failure placed the residents at risk of exposure to possible infectious agents.<BR/>Findings included:<BR/>Record review of Resident #2's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, neurogenic bladder, mild intellectual disabilities, and needs for assistance with personal care. Resident#2 has a BIMS score of 12/15 indicating moderate cognitive impairment. Her Functional Status reflected she was dependent on staff for toileting hygiene including suprapubic catheter exit site care. <BR/>Record review of Resident #2's care plan, dated 10/19/24, reflected she has Indwelling Suprapubic Catheter: R/t Neurogenic Bladder Secondary to QUADRAPLEGIC (paralysis of all four limbs) CP (Cerebral Palsy). <BR/>Record review of Resident #2's physician orders reflected an order dated 06/27/24:Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wound, Indwelling medical device, infection and/or MDRO (Multi drug resistant organism) status.<BR/>Observation on 01/16/25 at 08:47 AM LVN A prepared to provide care to Resident #2's suprapubic catheter . LVN A washed hands and donned gloves and provided care without donning a gown. There was no signage and no supplies outside or inside of the Resident#2's room for EBP.<BR/>Interview on 01/16/25 at 09:14 AM LVN A stated Resident #2 has an indwelling medical device and there supposed to be a signage and required PPE supplies in front of Resident #2 room, indicating she was on EBP, and that staff were required to wear a gown and gloves when providing care for the resident. LVN A stated she just did not wear required PPE when she went to provide suprapubic exit site care for Resident#2. LVN A stated she had been working in the facility for few months and had in service on EBP during orientation. <BR/>Interview on 01/16/25 at 09:30 AM the DON stated all residents with wounds, catheters, feeding tubes, etc. are placed in EBP to minimize the risk of spreading infections between residents. EBP required the use of a gown and gloves for all high contact care of the resident. She stated the risk of not adhering to the appropriate PPE requirements was spreading infections to other residents.<BR/>Interview on 01/16/25 at 12:06 PM the administrator stated there should be signage in front of the Resident#2 room, and the supplies. He stated staff should don and doff proper PPE for high resident contact care, including gown, and gloves. He stated the last in service on EBP was done in November 2024. <BR/>Record review of LVN A's skills verification checklist dated 11/04/24 reflected she was competent in Peri-care-Foley catheter tubing care. <BR/>Review of the facility's policy IPCP Standard and Transmission-Based Precaution, Revised March 2023, reflected: 3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with (MDROs).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor the resident right to choose his or her attending physician for 1 of 5 residents (Resident #1) reviewed for resident rights.<BR/>The facility did not honor Resident #1's right to choose his primary care physician as his attending physician.<BR/>This deficient practice could place residents at risk of decreased quality care and treatment due to their lack of free choice for their attending physician care while in the facility.<BR/>Findings included:<BR/>Record review of Resident #1's admission Record, revealed a [AGE] year-old male, who admitted to the facility on [DATE] from a short-term (acute) hospital with the following diagnoses: Acute on Chronic Systolic CHF (history of relatively stable HF, with a new diagnosis or active symptoms); CKD, Stage 3 (kidneys have mild to moderate damage); and T2DM.<BR/>Record review of Resident #1's Comprehensive MDS admission assessment, dated 11/14/23, revealed Resident #1 had a BIMS of 11 which suggested moderately impaired cognition. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 admitted with an indwelling catheter and was frequently incontinent of bowel.<BR/>Record review of printed Appointments and Visits list from Resident #1's health and hospital system personal on-line health resource, dated 11/13/23, reflected the following upcoming visit:<BR/>12/11/23, arrive by 10:45 AM: Established Patient (Primary Care)<BR/>The appointment included contact information (phone number and address) for the primary care physician and other responsible care professionals.<BR/>During an interview on 01/05/24 at 9:48 AM, the DON indicated the LSW recently quit for personal reasons on or about 01/03/24. The DON stated she [the DON] worked at the facility for about two - three weeks and was not employed by the SNF at the time Resident #1 was admitted to the facility. The DON said that she was not familiar with the SNF's specific written policies and procedures but was aware that a resident had the right to choose his or her attending physician. The DON sated that the selected physician had to be licensed to practice, the facility would ensure the physician met requirements and was willing to provide care and treatment of the resident at the SNF.<BR/>Record review of an undated personnel list with phone numbers revealed the LSW was not listed. The NFA and DON indicated they would try to obtain a contact number for the LSW.<BR/>During an interview on 01/05/24 at 12:30 PM, LVN A indicated she was the admitting nurse for Resident #1 on 11/08/23. LVN A stated that she received Resident #1 from an acute hospital and informed Resident #1 would be under the care of the SNF's attending physician. LVN A said that she placed a call to the SNF's attending physician per protocol to notify about a new patient and to verify medications. LVN A said that the call was accepted by the attending physician's NP. LVN A stated that Resident #1's RP was present at the time of admission. LVN A stated that the RP presented a list of upcoming scheduled appointments and LVN A redirected the RP to the LSW who was responsible for coordinating appointments and scheduling transportation.<BR/>During an interview on 01/05/24 at 2:15 PM, the RP stated she returned to the SNF the next day (11/09/23) to sign paperwork with the admission Coordinator. The RP said that she clarified with the admission Coordinator who agreed that she (the RP) should provide the LSW the list of upcoming appointments to arrange transportation. The RP stated that she met with the LSW in his office and handed him the list of upcoming appointments that included the scheduled appointment with Resident #1's PCP on 12/11/23. The RP stated that she was informed by the LSW that Resident #1 could not see the designated PCP (scheduled 12/11/23) due to conflicts with double billing and Resident #1 would be followed by the SNFs attending physician. The RP stated that Resident #1 had been under the care of the designated PCP for a long time and preferred Resident #1 to continue to see the designated PCP for continuity of care. The RP said that the LSW indicated that was not possible and the appointment would be cancelled.<BR/>During an interview on 01/08/24 at 9:15 AM, the admission Coordinator indicated responsibilities included receiving referrals (forwarded to clinical team), making outbound calls to verify insurance, ensure the room was ready, and complete admission paperwork with Resident or RP within 24 - 48 hrs. of admission. The admission Coordinator indicated the paperwork included the consent to treat, resident rights, privacy practice, and admission agreement/acknowledgement. Record review of the admission packet with the admission Coordinator revealed the Resident admission Agreement. The Resident admission Agreement outlined: Consent to routine care and treatment provided by the SNF, provision of facility services, nursing services, ancillary services and supplies, services or supplies of other providers, role of attending physician and medical director, and independent medical practitioners. The admission Coordinator indicated that it was her responsibility to explain the terms of admission in simple words and phrases so that the Resident or RP understood what was told to them and provided an opportunity to ask questions about the agreement before signing. The admission Coordinator stated that one of the terms emphasized during admission is that the Resident/RP had the right to choose an attending physician who will provide medical care during the resident's stay at the facility. The admission Coordinator stated that the RP came in the next day after Resident #1 arrived at the facility to sign the admission paperwork. The admission Coordinator said that the RP presented a list of appointments Resident #1 had coming up and the admission Coordinator stated that she referred the RP to the LSW to coordinate appointments and transportation.<BR/>During an interview on 01/08/24 at 11:38 AM, the NFA provided an updated personnel list and phone numbers for opportunity to contact LSW. The NFA indicated the resident had the right to obtain services of a qualified attending physician of their choice. The NFA said that he was unaware that the LSW cancelled the appointment with the resident's PCP and the RP was misinformed that Resident #1 could not choose his own attending physician.<BR/>Record Review of the facility's Resident Rights and Responsibilities, Notice of policy revised 01/2022 reflected:<BR/>Policy:<BR/>It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as, the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility.<BR/>Procedure:<BR/>Prior to or upon admission, a representative of the admitting office will provide the resident with a written copy of resident rights and a copy of all rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility.<BR/>The resident will be required to sign a statement acknowledging that he/she was informed of his/her rights and responsibilities.<BR/>The facility will inform the resident of his/her rights and responsibilities in a language that is both clear and understandable to the resident.<BR/>Written copies of resident rights and responsibilities are available upon request and may be obtained from the social services department during normal office hours (8:00 a.m.- 5:00 p.m., Monday-Friday (except holidays).<BR/>The resident will be promptly informed, both orally and in writing, of a change in resident rights and when changes occur in facility rules that govern the resident's conduct or responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance for 1 of 3 residents (Resident #1) reviewed for transportation services, in that <BR/>The facility failed to ensure Resident #1 was provided transportation to services from outside entities on 12/07/23 and 12/15/23.<BR/>This failure could result in missed appointments and delayed treatments.<BR/>Findings included:<BR/>Record review of Resident #1's admission Record, revealed a [AGE] year-old male, who admitted to the facility on [DATE] from a short-term (acute) hospital with the following diagnoses: Acute on Chronic Systolic CHF (history of relatively stable HF, with a new diagnosis or active symptoms); CKD, Stage 3 (kidneys have mild to moderate damage); and T2DM.<BR/>Record review of Resident #1's Comprehensive MDS admission assessment, dated 11/14/23, revealed Resident #1 had a BIMS of 11 which suggested moderately impaired cognition. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 admitted with an indwelling catheter and was frequently incontinent of bowel.<BR/>Record review of printed Appointments and Visits list from Resident #1's health and hospital system personal on-line health resource, dated 11/13/23, reflected the following upcoming visits:<BR/>12/07/23, arrive by 10:30 AM: New Patient (Multidisciplinary Surgery Clinic - urology follow-up after hospital discharge on [DATE])<BR/>The appointments included contact information (phone number and address) for the primary care physician and other responsible care professionals.<BR/>Record review of Appointment communication forms uploaded to Resident #1's chart revealed:<BR/>Appointment date: 12/07/23 at 11:00 AM; Doctor: [reflected the scheduled provider's name]<BR/>Facility Name/Address/Phone number: identified name, location, and phone number of scheduled provider.<BR/>Purpose: Appointment [related to urology follow-up appointment scheduled by discharging hospital]<BR/>Signed by LSW and dated 12/05/23.<BR/>Appointment date: 12/15/23 at 3:00 PM; Doctor: [reflected the same scheduled provider's name as 12/07/23]<BR/>Facility Name/Address/Phone number: identified name, location, and phone number of scheduled provider.<BR/>Purpose: follow up [related to urology follow-up appointment scheduled by discharging hospital]<BR/>Signed by LSW and dated 12/06/23.<BR/>A trip number was highlighted that indicated transportation arrangements were made with a transportation provider.<BR/>Record review of Resident #1's progress notes indicated:<BR/>- <BR/>Social Services Note Effective Date: 12/06/23 at 11:51 AM, written by the LSW, reflected, RP stated appointments for [Resident #1] in which one is 12/07/23. contacted [urology follow-up clinic] rescheduled appointment to 12/15/23<BR/>- <BR/>Social Services Note Effective Date: 12/06/23 at 12:41 PM, written by the LSW, reflected, Transportation scheduled for 12/15/23 appointment . Trip ID is 66448.<BR/>During an interview on 01/05/24 at 8:45 AM, the ADON indicated during an IDT care meeting with on 12/21/23, the RP voiced concerns about conflicts with transportation and missed appointments. The ADON stated that the LSW explained that when the RP made appointments, she needed to ensure that the facility was informed timely to add to the transportation list. <BR/>Record review of the IDT Care Plan Review dated 12/21/23 revealed it was signed and dated by the LSW. The Social Services Plan of Care section revealed the transportation concerns voiced by the RP and the LSW response to notify the facility timely.<BR/>During an interview on 01/05/24 at 9:38 AM, the DON stated she was not employed by the SNF at the time Resident #1 was admitted to the facility. The DON stated that she worked at the facility for about two - three weeks. The DON indicated the LSW recently quit for personal reasons on or about 01/03/24. The DON said that she was not familiar with the SNF's specific written policies and procedures but was aware that the facility had a responsibility to assist residents in arranging transportation to and from appointments if necessary. The DON stated during an IDT Care Plan meeting in December, [the DON] supported the RP when the RP indicated she was able to provide transportation services at times. The DON stated the RP said that she would take Resident #1 to cardiology appointments to prevent missed appointments.<BR/>During an interview on 01/05/24 at 11:07 AM, the NFA and DON indicated they would try to obtain a contact number for the LSW.<BR/>During an interview on 01/05/24 at 12:30 PM, LVN A indicated she was the admitting nurse for Resident #1 on 11/08/23. LVN A stated that Resident #1's RP was present at the time of admission. LVN A stated that the RP presented a list of upcoming scheduled appointments and LVN A redirected the RP to the LSW who was responsible for coordinating appointments and scheduling transportation.<BR/>During an interview on 01/05/24 at 2:15 PM, the RP stated she visited Resident #1 on 12/06/23 and approached the LSW in his office to ensure transportation was arranged for Resident #1's appointment on 12/07/23. The RP said that the LSW told [the RP] that transportation was arranged for all the follow up appointments scheduled by the hospital [when Resident #1 discharged and transferred to the SNF]. The RP said that the LSW then stated that he forgot to schedule transportation for the 12/07/23 appointment. The RP said that the LSW asked a staff nurse (The RP could not identify the staff nurse) to come into the office as a witness while the LSW called the [urology follow-up clinic] and rescheduled the (12/07/23) appointment for 12/15/23.<BR/>During an interview on 01/08/24 at 10:24 AM, the Activity Director indicated that she was also the facility transportation van driver. The Activity Director stated that the LSW was responsible for scheduling appointments, arranging transportation, and would notify her at least 2 weeks to a month in advance about upcoming appointments. The Activity Director stated the LSW would hand her an appointment form or place a copy in her assigned mailbox. The Activity Director said that she checked her mailbox daily when she was at work or the first day following the weekend or if she was absent. The Activity Director said that she was approached by the RP one day (could not recall which day exactly) and the RP attempted to provide a list of Resident #1's upcoming appointments. The Activity Director said that she referred the RP to the LSW to ensure transportation was coordinated and scheduled. The Activity Director maintained a planner with appointments that she was assigned to transport residents to appointments in the facility van. The Activity Director presented appointment forms provided to her by the LSW that reflected an appointment form dated for 12/15/23 with a pre-authorized trip number that indicated arrangements with a transportation service was scheduled. The Activity Director said that the appointment scheduled 12/15/23 was rescheduled by the LSW because he did not notify (the Activity Director) about the appointment on 12/07/23. The Activity Director stated that she recalled there was a conflict with the transportation service on 12/15/23 and Resident #1 missed his appointment.<BR/>During an interview on 01/08/24 at 11:38 AM, the NFA provided an updated personnel list and phone numbers that did not reflect a contact number for the LSW. The NFA could not produce related policies about medical transportation but was able to speak to the facility's responsibility to provide a resident transportation to medical services outside the facility. The NFA said that the LSW was responsible for coordinating and scheduling appointments and transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (Resident #57) of 6 residents reviewed for resident call system <BR/>The facility failed to ensure the call light in resident room [ROOM NUMBER] used by Resident #57 for dialysis treatment went to a centralized staff work area. <BR/>This failure placed resident at risk of a delay in receiving assistance from facility staff and being unable to obtain assistance in the event of an emergency.<BR/>Findings included:<BR/>Review of Resident #57's MDS assessment dated [DATE] reflected Resident #57 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of acute osteomyelitis (bone infection) of left ankle/foot, end stage renal disease, diabetes, stroke, hemiplegia and hemiparesis (weakness and paralysis affecting one side). MDS assessment reflected Resident #57 required substantial/maximal assistance to dependent with ADLs. Resident #57 had a BIMS of 12 indicating he was moderately cognitively impaired. Resident #57 was on dialysis services. <BR/>Review of Resident #57's comprehensive care plan last updated on 12/05/23 reflected Resident #57 had renal insufficiency r/t to ESRD (End Stage Renal Disease). Interventions included assist resident with ADLs and ambulation as needed. Resident #57's care plan reflected Resident #57 was at risk for falls related to left sided hemiplegia as result of CVA . Interventions included Be sure the call light is within reach and encourage to use it to call for assistance as needed and Room assignment close to the nurses station.<BR/>Observation on 02/07/24 at 11:55 AM revealed doors were closed to 200 hall. At 11:57 AM revealed Resident #57 was lying in bed in resident room [ROOM NUMBER] for dialysis treatment with no other occupied resident rooms on 200 hall for dialysis. <BR/>Observation on 02/07/24 at 11:59 AM revealed Resident #57 lying in the bed close to the door entrance, awake, alert, dialysis access in the right upper extremity. Dialysis nurse in the process of cannulating resident dialysis access and drawing blood. Dialysis nurse was wearing full PPE : gown, mask, face shield, and glove.<BR/>Surveyor asked the resident to push the call light at 1:00 PM. Observation revealed Resident #57 pushed the call button and it went to the 200 hall nursing station. <BR/>Observation on 02/07/24 at 1:00 PM with Contract Dialysis Nurse revealed she was in process of disconnecting Resident #57 from the dialysis machine. Interview with Dialysis nurse revealed she was having technical issue with the dialysis machine, returned resident blood, and waiting for a dialysis technician from the dialysis company to come and check the machine. Contract Dialysis Nurse stated she had been coming to facility providing dialysis treatments in resident room [ROOM NUMBER] to Resident #57 since December 2023. She stated if she needed assistance from facility staff when Resident #57 was receiving dialysis she would use the call button to alert facility staff for assistance. <BR/>Observation on 02/07/24 at 1:03 PM revealed Maintenance Director came and checked on the room and turned the call light off for Resident #57 . <BR/>Interview on 02/07/24 with LVN D at 1:10 PM revealed she was unaware of any resident call lights going off on 200 hall at the 400 hall nurse's station she only was aware of resident call lights on 400 hall. <BR/>Interview on 02/07/24 with LVN E at 1:12 PM revealed she was unaware of any resident call lights going off on 200 hall at the 300 hall nurse's station. She stated she was only aware of resident call lights on 300 hall . <BR/>Interview on 02/07/2024 at 2:40 PM with the DON revealed she was aware Resident #57 was receiving dialysis treatments in room [ROOM NUMBER]. When asked if the hall was monitored by facility staff, she stated there was no nursing staff, but the Maintenance Director and Staffing Coordinator had offices on the 200 hall. When asked what the dialysis employee would do in the event of emergency and needed facility staff, she stated they could yell down the hall. When asked if the dialysis employee could be heard yelling down the hall, she stated they would use the nurse call light if no one heard them. When asked what the resident would do in the event of an emergency and needed facility staff, she stated he would do the same thing, yell or use the nurse call light. When asked where the call light signal was relayed to, she stated the 200 nurses' station and thought it went to central nurse call system located in the reception area in which the receptionist would alert staff if the call light was not answered in a couple of minutes.<BR/>Follow-up interview on 02/07/2024 at 3:05 PM with the DON revealed she had only been at the facility for two months and did not know the facility did not have a central nurse call system. She stated a resident call light on the 200 hall would only provide an audible and visible signal to the 200 hall. The DON stated not having facility staff available at the nurse station could place Resident #57 at risk for delay in assistance and risk of causing mental distress and physical injuries to Resident #57 if the hall is not monitored at the nurses' station by facility staff. <BR/>Interview on 02/07/2024 at 3:25 PM with the Executive Director revealed he was aware Resident #57 was receiving dialysis treatments in room [ROOM NUMBER]. He stated dialysis treatments were originally done on the 100 hall but they had to convert the room back for a new resident, so dialysis treatment was moved to the 200 hall. He stated they had been using room [ROOM NUMBER] for about two months. He acknowledged the risk of delay in Resident #57 getting assistance using his call light while receiving dialysis if facility staff were not on 200 hall. <BR/>Interview on 02/07/24 at 4:05 PM with the Maintenance Director revealed his office was located behind the 200 hall nurse station but he was not usually in his office.<BR/>Review of facility's policy Call Light/Bell revised 05/2020 reflected the policy of this facility to provide the resident a means of communication with nursing staff .Procedures: 1. Answer the light/bell within a reasonable time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #327) of 5 residents reviewed for ADLs. <BR/>The facility failed to ensure Resident #327 had her fingernails cleaned and trimmed and was provided incontinent care for more than 4 hours on 2/7/24. <BR/>This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>Review of Resident #327's admission MDS assessment dated [DATE] reflected Resident #327 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included hypertension (high blood pressure), peripheral vascular disease (circulation disorder caused by narrowing in a blood vessel), septicemia (blood poisoning by bacteria), and hyperlipidemia (high blood lipid levels). Resident #327 had a BIMS of 14 which indicated Resident #327 was cognitively intact. Resident #327 was always incontinent of bowel and bladder and required assistance with toilet use and personal hygiene.<BR/>Review of Resident #327's Comprehensive Care Plan, revised 2/2/24, reflected the following: Focus: Has bowel/bladder incontinence r/t Confusion, and Impaired Mobility. Goal: Will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Incontinent: Check as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes.<BR/>Review of Resident #327's Comprehensive Care Plan, revised 2/2/24, reflected the following: Focus: ADL Self Care Performance Deficit r/t impaired mobility, wounds with infection Goal: Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene with assistance through the review date. Interventions: Requires Skin inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse.<BR/>An observation and interview on 02/06/24 at 09:58 AM revealed Resident #327 was lying in her bed. The nails on both hands were approximately 0.75 centimeter in length extending from the tip of her fingers and had black area underneath the nails. Resident #327 stated she liked to trim her own nails and had asked for a nail trimmer last week from the nurse and wasn't provide with one. She also stated during her three weeks stay at the facility, nursing staff had not cleaned or offered nail trimmer to cut her nails. <BR/>Interview with CNA A on 2/6/24 at 11:11AM revealed that most ADL such as hair trimming, nail clipping care were completed during shower times. She revealed that she does not work on the Resident # 327s hall often and was not familiar with resident's care. CNA A stated that fingernail clipping should be done weekly but also as needed and CNAs provided nail care unless the resident had diagnosis of diabetes ( elevated blood glucose). <BR/>Interview with CNA B on 2/6/24 at 11:16 AM revealed that she usually worked the night shift but was asked to work on the Morning 6AM - 2 PM shift on 2/6/24. She revealed that that nail care was provided by CNAs on the morning or afternoon shift and CNAs were responsible for providing it.<BR/>Interview with LVN D on 2/6/24 at 11:32 AM revealed that there were no specific days for nailcare. LVN D stated that for all residents with diabetes, nails were trimmed by Nurses. She also stated Resident #327 did not want her fingernails trimmed last week and had asked for nail trimmer. LVN D stated that Resident #327s fingernails were dirty and attested they were not cleaned since resident admit on 1/19/24. LVN D stated she would clean Resident #327's nails right then. <BR/>An interview with Resident #327 on 2/7/24 at 9:13 AM revealed she had not been provided incontinent care since 5 AM on 2/7/24. She reported that she was soaking wet and had asked LVN D around 8 AM on 2/7/24 that she needed to be changed. <BR/>An observation by survey team nurse surveyor on 2/7/24 at 9:20 AM revealed Resident #327 brief was soaked in urine and linen between her legs was soaked in urine too. No foul smell.<BR/>Interview with CNA C on 2/7/24 at 9:19 AM revealed that her shift started at 6 AM on 2/7/24 . She had not had a chance to go to Resident #327's room to provide incontinent care since she was busy with showering the other residents on the hall and taking them to dining room for breakfast. She stated she went to Resident #327's room to give her a breakfast tray around 8:30 AM but did not physically check on her to see if she needed incontinent care. She revealed she knew to round on all residents every two hours and check for incontinence as needed. <BR/>Interview with LVN D on 2/7/24 at 9:28 AM revealed she thought the CNAs must have checked and changed her when their shift began at 6AM . She also said that Resident #327 had informed her that she needed to be changed around 8AM when she provided medicines to Resident #327. She revealed she had told CNA C about it but did not follow-up on it. She stated she was the assigned Charge Nurses on the floor, and she was responsible to ensure residents are provided ADL care. <BR/>Observation on 2/7/24 at 9:33 AM revealed DON was present on the Resident #327s Hall and proceeded to provide incontinent care to Resident #327.<BR/>Interview with the DON on 2/7/24 9:48 AM revealed that her expectation was Nursing staff provided incontinent care to all residents in a timely manner. She expected CNAs and Charge Nurses to round every 2 hours and check on all incontinent residents. The DON stated that Resident #327 brief diaper and sheets were soaking wet when she went to the room to change her, and Resident #327 should have been changed earlier. The DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. She also stated that Charge nurses were primarily responsible for ADL. The DON stated residents having long and dirty fingernails could be an infection control issue as well as residents being wet for too long may led to skin infections in peri area. The DON stated she was responsible to do routine rounds for monitoring.<BR/>Interview with the ADON on 2/8/24 at 10:20 AM revealed that she had started working at the facility about a month ago. She stated that her expectation was that CNA and Nurses round on each resident every 2 hours and provide incontinent care to residents as needed and in a timely manner. The ADON revealed that her expectation regarding nail care was that resident nails should be checked, and nail care completed weekly and on as needed basis. The ADON stated that she rounds on residents frequently to ensure resident's ADL needs are met. The ADON stated that not providing incontinent care in a timely manner or residents not been provided nailcare , both can lead to infection control issues and diminished quality of life. <BR/>Record review of the facility's policy titled Care of Nails, review date January 2022, reflected .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis . Nail care will be provided between scheduled occasions as the need arises . <BR/>Record review of the facility's policy titled ADL, services to carry out , revised date July 2020 reflected If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming and personal oral hygiene will be provided by qualified staff .

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's kitchen, reviewed for kitchen sanitation. <BR/>The facility failed to ensure liquid Kool Aid stored in the facility's walk-in refrigerator was covered, labelled and dated.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses. <BR/>Findings included:<BR/>Observation on 01/06/2024 from 9:14 AM in the facility's kitchen revealed:<BR/>1. One jar pink liquid Kool Aid in the walk-in refrigerator was not covered, labelled, and dated.<BR/>2. One jar yellow liquid Kool Aid in the walk-in refrigerator was not labelled and dated.<BR/>An interview with the Dietary Manager on 02/06/2024 at 11:39 AM, she stated her expectation of the kitchen staff was to keep the liquid Kool Aid in the refrigerator to be covered, labelled and dated. The liquid Kool Aid which was not covered was considered unsanitary, bugs could fall into the drink, and it had the potential to cross contaminate and cause sickness to the residents. The Dietary Manager stated not labeling and dating the drink could cause confusion about the drink, sickness to the residents since it was difficult to determine when the liquid Kool Aid was kept in the refrigerator. The Dietary Manager stated the cook was responsible to keep the liquid Kool Aid covered, labelled and dated. <BR/>An interview with the [NAME] on 02/08/2024 at 01:45 PM, she stated she realized that morning that the pink liquid Kool Aid jar in the walk in refrigerator was not covered and dated, and a yellow liquid Kool Aid jar was not labelled or dated. The [NAME] stated she did not work the previous night and so she was going to cover it as soon as she saw it in the morning, put label and date on the other one but the state surveyor came to the kitchen before she could do it. The [NAME] stated all the food items in the refrigerator should be covered, labelled and dated. She stated uncovered food items could cause food contamination and make residents sick. Not labelled and dated food items were health risk since it was difficult to determine when it was made. The [NAME] stated all the staff working in the kitchen were responsible to ensure all food items were covered and dated .<BR/>Record review of the facility policy, dated August 2007, reflected It is the policy of this facility that the food storage area shall be maintained in a clean, safe, and sanitary manner. Review revealed the policy did not reflect covering, labelling and dating of stored open food items.<BR/>Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.<BR/>Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. These services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four resident rooms (resident #327, #73, #16 and #11) of 24 resident rooms reviewed for clean and sanitary environment.<BR/>1. Resident #327's room had two nails on the floor, a plastic cup and the floor was dirty.<BR/>2. Resident #73's room had a hole behind the door at the entrance to the room.<BR/>3. Resident #16's room had broken blinds, a stain on the wall by the bathroom, and the toilet was running causing the pipes to make a loud whining noise. <BR/>4. Resident #11's room had broken blinds and a hole behind the door at the entrance to the room. <BR/>These failures could affect all residents, staff, and the public by placing them at risk of not having a clean, sanitary, and comfortable environment. <BR/>Findings included: <BR/>1. Observation of Resident #372's room on 2/6/24 at 9:58 a.m. showed two iron nails on the floor, a plastic cup on the floor and the floor was dirty. <BR/>Interview with Resident #327 revealed the rooms were not cleaned frequently by housekeeping staff. She had been in the facility 3 weeks and the room was swept once. Resident #327 said the window blinds were changed last week and the nails were from that day.<BR/>2. Observation of Resident #73's room on 2/6/24 10:22 a.m. showed there was a 5 by 1.5 inch hole in wall behind the entrance door. <BR/>Interview with Housekeeper F on 02/6/24 at 10:23 a.m. revealed she just noticed the hole today and said Maintenance had fixed a hole in the wall in same area previously from door hitting the wall when opened.<BR/>3. Observation of Resident #16's room on 2/6/24 11:20 a.m. showed broken blinds with strips bent and broken in the middle of the blinds. Also, there were marks running down the wall on the wall outside the bathroom door which was an orange-brown color liquid. There was a &frac12; by &frac12; square of drywall missing from the wall directly to the left when you enter the room. Furthermore, the toilet was heard to be running on three different occasions. Each time the toilet stopped running, the pipes in the bathroom made a loud whining noise for about 10 seconds. <BR/>Interview with Resident #16 said the marks on the wall were from a drink that exploded a long time ago. Resident #16 said the issues in the room were fine and she did not want to bother anyone. Resident #16 said she knows there are other people there who need more help than her and she did not want to bother anyone. <BR/>4. Observation of Resident #11's room on 2/6/24 11:57 a.m. showed the window blinds were broken on both sides of the blinds with strips bent in different directions. <BR/>Interview with Resident #11 said the blinds are always messed up. She said they never fix them when she has told them. <BR/>Interview with Maintenance Director on 2/8/24 at 11:05 a.m. stated he had not known about the issues in the Residents rooms. He said he would get new blinds in the rooms today. He looked at the toilet in resident #16's room and said it was a short chain and he would get it fixed. He is over housekeeping and said he would get someone to clean the wall. The Maintenance Director thought the piece of drywall missing from the wall in Resident #16's room was from a glove box dispenser that used to be there. He said he would get it fixed. The Maintenance Director said he would have fixed the items had he been told. <BR/>Interview with the Maintenance Director on 2/8/24 at 3:10 p.m. showed he had fixed the toilet in Resident #16's room which stopped the loud whining noise. Also, the blinds were also replaced in Resident #16's room. The Maintenance Director said he would have to purchase a new blind for Resident #11's room as it is a larger blind than the other rooms. He showed where he had fixed the holes in the walls in Resident #11 and #73's rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident/RP has the right to be informed of, and participate in, his or her treatment for one (Resident #1) of 22 residents reviewed for resident and RP rights.<BR/>Resident #1's RP was not notified when the physician's order for glucose monitoring was entered as once-a-week monitoring the day after Resident #1 admitted to the facility. Prior to admitting to the facility, Resident's glucose was monitored twice daily. Resident #1's RP was not educated on the risks or benefits of testing glucose less frequently to make an informed consent to the change. The resident was hospitalized for 10 days with increased confusion, poor wound healing, hyperglycemia (high blood sugar), and septicemia (bacterial infection of the blood). <BR/>This failure could place residents at risk for delayed interventions in treatment when glucose levels spike or drop due to underlining conditions e.g., sepsis, chronic kidney disease, infections, cancer, and diabetes. <BR/>Findings included:<BR/>Record review of Resident #1's history and physical, dated 06/16/2022 revealed she was admitted to the facility on [DATE] from home. She was an [AGE] year-old female with a medical history of dementia, cognitive communication deficits, BIMS 0, hypertension (high blood pressure), type 2 diabetes, chronic kidneys disease and dysphagia (difficulty swallowing).<BR/>Record Review of physician orders records on 10/25/2023 at 2:00 PM dated 6/16/2022, reflected blood sugar monitoring one time a day in the AM, one a week on Wednesday. The order was entered by the facility's previous ADON and reported orders received by phone.<BR/>In an interview and record review with LVN A and the MD on 10/26/2023 at 11:40 AM, after reviewing the glucose monitoring orders, the MD reported he did not recall initiating the orders as they differed from his usual orders of fasting glucose testing once daily for diabetic patient monitoring. The MD stated unless the resident reported an intolerance for daily testing, he would assess the historical weekly glucose values and hemoglobin A1C results before reducing glucose monitoring days, which would be reduced to testing every other day. The MD stated he had no record of a request for changing glucose testing days for Resident #1. The record review revealed the order was initiated by the facility's past ADON. LVN A stated the previous ADON made this once-a-week glucose monitoring change to all the diabetic residents on oral hyperglycemic medications. <BR/>Review of physician order records on 10/27/2023 at 1:10 PM revealed Resident #1's glucose monitoring orders were entered by the previous ADON and reflected glucose monitoring one time a day in the AM, once a week. There was no record of resident or POA being educated of the risks or benefits of reduced testing or consent to the change.<BR/>On 10/23/2023 at 8:00 PM Resident #1's visiting family reported to nursing staff their observation of a new wound observed on the residents' inner thigh and expressed concern about Resident #1's declining condition. The nurse on duty stated she did not know how wound the occurred and did not seem to care about the symptoms of decline/change of condition. Resident #1's family reported their grievances to the facility Executive Director (ED) and the ED responded, We don't have a medical license and we can't diagnose her with anything. Resident #1's family called 911 out of urgent concern for Resident #1's observed symptoms of increased confusion, weakness, low appetite, and weight loss. EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. After hospital admission, ER labs were positive for sepsis and the retest of blood sugar was 724. Resident #1 was admitted to the hospital for 10 days with increased confusion, hyperglycemia (elevated blood sugar), poor wound healing, and septicemia (bacterial blood infection).<BR/>In an interview on 11/1/2023 at 9:33 AM with Resident #1's RP, he stated he tested Resident #1's glucose daily, twice a day, once in the morning and once in the evening prior to Resident #1 admitting to the facility. Resident #1's RP stated this was the testing regimen discussed with the facility at admission on [DATE]. Resident #1's RP stated he was never contacted by the facility or physician about the change in glucose monitoring testing. Resident #1's RP stated he was not educated on the risks or benefits of testing glucose less frequently to make informed consent to the change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately notify the resident's representative when there was a significant change in the physical status and consult with the resident physician for one of three residents (Resident #2) reviewed for notification of change in condition.<BR/>LVN failed to notify Resident #2's resident representative of the significant change of condition of pain, notify the physician, and request for x-ray of the right knee on 10/08/23. <BR/>This failure could place residents at risk for a delay in treatment and not receiving proper care due to failure to notify resident representative.<BR/>Findings included:<BR/>Review of Resident #2's face sheet dated 10/10/23 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, hypertension, difficulty in walking and age related physical debility.<BR/>Review of Resident #2's care plan undated reflected Resident #2 had Condyle (A condyle is the round prominence at the end of a bone) fracture of lower end of right femur. Goal: Return to prior level of function after healing and rehabilitation. Intervention: Anticipate the needs of resident and call light within reach. Modify environment as needed to meet current needs. Non-slip surface for bath/shower, bed in lowest position with bed locked; floors even free from spills and clutter, adequate glare free light, monitor for level of pain.<BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 9:00 AM completed by LVN E reflected Late Entry Signs and symptoms noted of condition change: other change of condition noted: right knee pain. Notifications to care clinician: nurse practitioner 10/09/23 9:11 AM. Name of family member or resident representative notified: Family member 10/09/23 1:45 PM.<BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 9:09 AM completed by LVN E reflected: Resident complaint of right knee and leg pain, Nurse Practitioner notified await instructions. <BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 1:29 PM completed by LVN E reflected orders received x-ray to tibia/fibula (two large bones located in the lower leg) and knee per nurse practitioner.<BR/>Review of Resident #2 nurse progress notes dated 10/09/23 at 5:33 PM completed by LVN F reflected: X-ray exams/test pending. Bedrest encouraged Resident resist supper meal but accepted chilled water, a health shake, and a cup of ice cream.<BR/>Review of Resident #2 x-ray dated 10/09/23 revealed comminuted fracture of distal femur 10/10/23 The bones are osteopenic. Severe Tri compartment degenerative changes are present at the knee. <BR/>Review of hospital records dated 10/10/23 revealed there is severe Tri compartment degenerative joint disease. fracture of distal femur, <BR/>Observation and interview on 10/18/23 at 10:43 AM revealed Resident #2 was sitting up in bed resting, Resident #2 was unable to communicate what happened to right leg. Resident was with a leg brace and foot elevated on pillow. <BR/>Observation and interview on 10/19/23 at 8:40 AM revealed Resident #2 was sitting up in the television room with a right leg brace and right leg elevated with pillow eating a snack. Observation of left knee appeared to be swollen. Resident #2's appearance was well groomed, and she did not have signs of pain. Resident #2 was unable to communicate what happened to right leg. <BR/>Interview on 10/19/23 at 10:33 AM with Resident #2's family member revealed they came to visit Resident #2, and as they entered the unit a nurse grabbed and hugged me. The family member stated the nurse told her she was having an x-ray ordered for Resident #2 due to Resident #2 having a possible fracture of her leg. The family member stated that was how they were informed about the possible injury. The family member stated she immediately began to ask questions about what had happened to Resident #2. She stated the LVN apologized because she thought the family member knew and that it was the reason for the visit. The family member stated she never received updated information pending the results from the x-ray, but was later called and told an ambulance was called to transfer the resident to the hospital. The family member stated she called for two days to speak with someone regarding the injury, but it was as if nobody was talking about it because it was under investigation. The family member stated Resident #2 moved around really good in her wheelchair, so she was surprised to hear about a possible fracture once she arrived at the facility. The family member stated she finally was able to speak with the DON and expressed it would have been nice to have been notified about the situation prior to arriving to the facility. She added that the LVN called her to apologize for not contacting her about the resident's change of condition. <BR/>Interview on 10/19/23 at 1:19 PM with LVN E revealed she entered the facility with her aides alerting her to Resident #2 with pain at her right knee. LVN E stated at that point when she did an assessment, she felt like the right knee was just a bit more swollen than usual. LVN E stated with that she contacted that Nurse Practitioner to request for x-ray to the tibia/fibula and the knee to rule out any findings. LVN E stated she then alerted the DON and began with treatment and care for Resident #2. LVN E stated she did forget to contact family member, and realized it once she saw her enter the facility. LVN E stated The DON addressed it with her and she again contacted family member to apologize. LVN E stated she was just so concerned about ensuring Resident #2 was getting proper care that it slipped her mind. LVN E stated she was responsible for contacting the DON, Physician and family member when there was a change of condition in resident status. LVN E stated not notifying family member could create a delay in care and not keeping them aware of resident conditions. <BR/>Interview on 10/19/23 at 3:06 PM with The DON revealed she was alerted to Resident #2's change of condition by LVN E the morning of 10/09/23. The DON stated Resident #2's family member did come to visit that day; however, she was not aware the family member was not notified of the request for x-ray for Resident #2. The DON stated it was the responsibility of the nurse to contact the physician and resident representatives, so they are aware of any changes in resident conditions. The DON stated not doing so could create concerns for treatment and proper care for residents. <BR/>Review of facility's Change of Condition Reporting policy, revised May 2021, reflected:<BR/>It is the policy of the facility that all changes in resident condition will be communicated to the physician. <BR/>Acute Medical Change<BR/>1. <BR/>Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a require for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician.<BR/>2. <BR/>If unable to contact attending physician or alternate physician timely, notify Medical Director for follow-up to change in resident condition. <BR/>3. <BR/>The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. <BR/>4. <BR/>All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as based on the comprehensive assessment of the resident; in that:<BR/>The facility failed to promptly identify and intervene for complications of acute hyperglycemia (high blood sugar) for one (Resident #1) of 22 residents reviewed for hyperglycemia related to type 2 diabetes, resulting in the family calling 911 to transport the resident to the hospital. <BR/>This failure could place residents at risk for delayed interventions in treatment when glucose levels spike or drop due to underlining conditions. Moreover, this failure is likely to cause severe injury, serious harm, serious impairment, or death in residents with medical histories positive for sepsis, chronic kidney disease, infections, cancer, and diabetes. <BR/>This failure resulted in the identification of Immediate Jeopardy (IJ) on 10/27/2023 at 5:30 PM. While the immediacy was removed on 10/30/2023 at 8:15 PM, the facility remained out of compliance at scope of isolated and a severity level of actual harm due to the facility's need to monitor the implementation of the plan of removal).<BR/>Findings included: <BR/>Record review of Resident #1's history and physical, dated 6/16/2022, revealed she was admitted to the facility on [DATE] from home. She was an [AGE] year-old female with a medical history of dementia, cognitive communication deficits, BIMS 0, hypertension, type 2 diabetes, chronic kidneys disease and dysphagia.<BR/>Review of Resident #1's care plan, reflected the following: Date revised: 02/07/23, Focus: [Resident #1] has Diabetes Mellitus r/t diabetes mellitus d/t underlying condition with diabetic neuropathy. Goal: Will have no complications related to diabetes through the review date. Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor. Check skin when assisting with ADLS .<BR/>Review of Resident #1's physician orders on 10/25/2023 at 2:00 PM revealed physician order dated 6/16/2022, reflected blood glucose checks one time a day in the AM, one a week on Wednesday. The order was entered by the facility's previous ADON and reported orders received by phone.<BR/>Resident #1's September and October 2023 MAR reflected the resident had blood sugars greater than 200 on the following dates: <BR/>9/24/2023 3:28 PM - BS 258 checked by LVN B (Agency Nurse) <BR/> 9/25/2023 11:35 AM - BS 340 checked by LVN A<BR/>Record review of the MAR dated 09/25/23 Wound care doctor here making rounds, continue wound care, chest x-ray obtained significant findings, right pleural effusion orders sent to doctors' PA await orders. <BR/>10/18/2023 8:56 AM - BS 226 checked by LVN A <BR/>Record review of the MAR revealed that the Blood Glucose was Monitored BS 226.0 - 10/18/2023 08:56 blood glucose level at baseline, well controlled Teachings/Education was not provided regarding Blood Glucose levels.<BR/>Vital Signs do not show any fluctuations from baseline that require intervention(s)<BR/>Record review of hospital records, dated 10/23/23, reflected Resident #1 was transported to the emergency department by EMS for hyperglycemia and a foul-smelling sacral decubitus ulcer (pressure injury). Hospital records reflected Resident #1 had a glucose level of 724. Resident #1 was given IV fluid bolus and started on a broad-spectrum vancomycin (antibiotic) and ceftriaxone (antibiotic). The hospital records reflected Resident #1 was started on an insulin drip for hyperkalemia (high potassium) and hyperglycemia (elevated blood sugar). <BR/>In a telephone interview on 10/25/2023 at 10:10 AM EMT A reported on the evening of 10/23/2023 Resident #1's visiting family called 911 out of concern for Resident #1's present conditions of increased confusion, weakness, low appetite, and weight loss. EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. <BR/>Interview with Resident #1's Family Member on 10/31/23 at 4:00PM revealed on 10/23/2023 at 8:00 PM, Resident #1's visiting family reported to nursing staff their observation of a new wound on the residents' inner thigh and expressed concern about Resident #1's declining condition. Resident #1's family member stated the nurse on duty stated she did not know how the wound occurred and did not seem to care about the symptoms of decline/change of condition. Resident #1's family member stated they reported their concerns to the facility Executive Director (ED) and the ED responded, We don't have a medical license and we can't diagnose her with anything. Resident #1's family member stated they called 911 out of urgent concern for Resident #1's symptoms of increased confusion, weakness, low appetite, and weight loss. They stated that when EMS arrived at the facility to find the resident with a blood sugar greater than 600 on 10/23/2023. The family member stated that the ER labs were positive for sepsis and the retest of blood sugar was 724. Resident #1 was admitted to the hospital for 10 days with increased confusion, hyperglycemia (elevated blood sugar), poor wound healing, and septicemia (bacterial blood infection).<BR/>Interview with Resident #1's family member stated EMS arrived at the facility on 10/23/23 to find the resident with a blood sugar greater than 600. <BR/>In an interview with the Interim DON on 10/25/2023 at 4:20 PM revealed she never met Resident #1 and was not familiar with her medical history because she started working at the facility on the morning of 10/25/2023. The Interim DON stated she expected for nurses to contact the physician anytime a resident's blood sugar was greater than 200 or lower than 70. DON stated the nurses were expected to monitor and notify the physician when blood sugars were too high because they were the ones doing the finger sticks. <BR/>In an interview and record review with LVN A on 10/26/2023 at 11:25 AM, LVN A stated she did not notice any change in condition when caring for Resident #1. After record review of the September - October 2023 glucose labs, LVN A identified the spikes in the blood sugar values. When questioned about what parameters of glucose levels should a nurse notify the doctor, LVN A stated values less than 70 or higher than 200 and insulin dependent residents have sliding scale orders. Record review of nursing notes revealed she reported to the RP a decline in the resident's condition for the last 3 weeks but spikes in glucose levels ranging from 226 to 340 were not reported to the RP or the residents' physician as a change in condition. LVN A stated she was following orders to check the residents' glucose once a week. LVN A could not explain why she did not notify the physician of the abnormal results. LVN A stated, I messed up.<BR/>In an interview and record review with LVN A and MD on 10/26/2023 at 11:40 AM after reviewing Resident #1's glucose monitoring orders, MDS, and Care Plan the MD reported he did not recall initiating the orders as they differed from his usual orders of fasting glucose testing once daily for diabetic patient monitoring. The MD stated, Unless the resident reports an intolerance for daily testing, then I would assess the historical weekly glucose values and hemoglobin A1C results before reducing glucose monitoring days, which would be reduced to testing every other day. The MD stated he had no record of request for changing glucose testing days for Resident #1. Record review of the physician orders revealed the order was initiated by the facility's past ADON. LVN A stated the previous ADON made this once-a-week glucose monitoring change to all the diabetic residents on oral hyperglycemic medications.<BR/>Review of the facility's policy for Significant Change in Condition, Response, revision dated 06/2019 reflected, the nurse shall use his/her clinical judgment and shall contact the physician based on urgency of the situation. <BR/>The facility was notified of the identification of an Immediate Jeopardy on 10/27/23 at 5:30PM. The Administrator was provided the immediate jeopardy template on 10/27/23 at 5:30PM. <BR/>The facility's plan of removal was accepted on 10/28/23 at 9:00AM and included the following:<BR/>Facility's Plan of Removal <BR/>Per the information provided in the IJ Template given on 10/27/23, the facility failed to properly identify and intervene for an acute change in a resident's condition related to type two diabetes, resulting in the family calling 911 to transport the resident to the hospital. <BR/>Immediate Action <BR/>The Medical Director was notified of IJ on 10/27/2023 at 5:50 pm by the Clinical Resource. <BR/>Resident 40010 was transferred to the hospital on [DATE]. Family and Physician were aware of the transfer. She is not returning to the facility per the family. <BR/>Train the trainer in-service was given by the Clinical Market Leader and completed for company Directors of Nursing, ADON and Clinical Resources. Training and knowledge checks for change in condition/notifications, blood glucose monitoring orders and signs/symptoms of hypo/hyperglycemia will be completed with all nursing staff. This training will be completed by 10/27/23. This training will be provided by company Directors of Nursing, ADON and Clinical Resources. <BR/>This training will be completed with all nursing staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. <BR/>Residents requiring oral hypoglycemic medications were reviewed for orders and glucose monitoring. Each of their physicians were contacted and gave orders for daily blood glucose monitoring. Each resident and/or responsible party were notified and consented to the new orders. Orders were placed. Blood sugar thresholds were added to each resident's chart for additional monitoring through [facility electronic medical record's system]<BR/>An ad hoc meeting regarding items in the IJ template was completed on 10/27/2023. Attendees will include the Medical Director, Clinical Resources, Administrator, and ADON and included the plan of removal items and interventions. <BR/>The company Directors of Nursing, ADON or Clinical Resource will verify staff knowledge with 10 nursing staff weekly. <BR/>The Clinical Resource or ADON will verify blood glucose level documentation daily. Diabetic residents receiving oral hypoglycemics will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions, as necessary. Meetings attendees to include but not limited to the Clinical Resource, ADON, and Administrator. The Clinical Resource and Administrator will be responsible for ensuring this meeting is held weekly. <BR/>Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. <BR/>On 10/30/23, the investigator confirmed the facility had implemented their plan of removal sufficiently to remove the Immediate Jeopardy by:<BR/>Monitoring interviews on 10/28/2023 through 10/30/2023 with 8 staff and 3 agency staff across two shifts to include 6AM-2PM, 2PM-10PM (ADON A, CNA A, CNA B, CNA C, LVN C, LVN D, LVN E, DON, and ED) indicated they had been in-serviced on blood sugar parameters and how to identify and report changes of condition. Review of nursing notes revealed the facility notified physicians of the need to change glucose monitoring to daily testing for residents on oral hyperglycemic medications. Physician orders were updated to test diabetic residents' blood sugars daily; it was documented in the nursing notes that residents/POAs were notified and educated about the glucose monitoring risks and benefits. <BR/>Interview with Executive Director on 10/30/2023 6:47 PM revealed that he did not feel comfortable with making clinical decisions for residents, he trusted his clinical staff to manage that. He stated After Change in Condition (CIC) training he feels more comfortable and understands the importance more proactive in addressing changes in a residents' condition. He stated When the incident with the Resident #1 happened, the family was very upset, and I felt they wanted more than we could offer. We were giving the best care we could for their mother, but their expectations need to be more realistic. In retrospect I feel the situation could have been handled differently. If they would have given us the opportunity to investigate the issue. We originally thought the family was upset about the wound on their mother's leg, not her symptoms at the time. That's why we only self-reported abuse. We have now changed our blood sugar monitoring protocols so we can catch changes earlier. We have a lot of agency clinical staff, so it is difficult for the nurses to know every resident's norm.<BR/> While the immediate jeopardy was removed on 10/30/2023 at 8:15 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medications errors for one resident (Resident #1) of 22 residents reviewed for medication accuracy in that: <BR/>The facility failed to hold antibiotic medication (Amoxicillin/Clavulanate) after orders were attached to Resident #1's hospital discharge documents until after 3 doses were administered 10/01/2023 to 10/02/2023. <BR/>The facility failed to ensure Resident #1 was not administered medications that belonged to another resident that was a hospital patient. This failure could place residents at risk of receiving medications not ordered by their physician, which could cause exacerbate kidney disease, diarrhea, and nausea.<BR/>Findings included: <BR/>Record review of hospital notes, MDS, care plan and orders on 10/27/2023 at 9:30 AM for Resident #1 revealed, Resident #1 is an [AGE] year-old female with a medical history of dementia, cognitive communication deficits, hypertension, type 2 diabetes, chronic kidneys disease and dysphagia. <BR/>9/25/2023, Resident #1 was sent to the hospital. An x-ray was performed. The resident was diagnosed with pneumonia, sepsis, and blood sugar 237. Antibiotics were administered for pneumonia and sepsis, breathing treatment, and wound care.<BR/>9/30/2023, Resident #1 was discharged and returned to the facility clear of pneumonia and sepsis when discharged back to the facility with no orders for medications.<BR/>Record review of Resident #1's October 2023 MAR reflected Resident #1 received two doses (one tablet per dose) of Amoxicillin-Pot Clavulanate Oral Tablet (antibiotic) 875-125 MG on 10/01/23 and one dose (one tablet) on 10/02/23.<BR/>In an interview and record review with LVN A and MD on 10/26/2023 at 11:40 AM after reviewing Resident #1's MAR for scheduled for October 2023 it revealed orders for Amoxicillin/Clavulanate to be given 1 tablet by mouth two times a day for cough. Order date 9/30/2023. LVN A stated, Resident #1 doesn't have a cough and her hospital discharge notes stated pneumonia resolved. I do not work weekends, but when I started my shift on Monday, I noticed the MAR showed the Resident #1 was given antibiotics for a cough. I went and double checked the hospital orders and discovered the orders were for another hospital patient. So, I discontinued the order. The MD stated, I do not recall Resident #1 needing antibiotics after her discharge from the hospital, her pneumonia had resolved in the hospital. I will check her discharge records when I get back to the hospital. I am the hospitalist there and I will let you know what I find tomorrow.<BR/>In a telephone interview with Resident #1's physician on 10/27/2023 at 9:00 AM, he stated after reviewing hospital discharge records, Resident #1 was clear of pneumonia and sepsis when discharged back to the facility with no orders for medications. <BR/>In interviews with the ED and Interim DON on 10/30/2023 at 7:50 PM they were not familiar with the policies as this was the ED's second month at the facility and the Interim DON had been at the facility for 5 days (The day of entrance), as the previous ADON and DON quit the day before entrance. Policies were developed during the POR period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately notify the resident's representative when there was a significant change in the physical status and consult with the resident physician for one of three residents (Resident #2) reviewed for notification of change in condition.<BR/>LVN failed to notify Resident #2's resident representative of the significant change of condition of pain, notify the physician, and request for x-ray of the right knee on 10/08/23. <BR/>This failure could place residents at risk for a delay in treatment and not receiving proper care due to failure to notify resident representative.<BR/>Findings included:<BR/>Review of Resident #2's face sheet dated 10/10/23 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, hypertension, difficulty in walking and age related physical debility.<BR/>Review of Resident #2's care plan undated reflected Resident #2 had Condyle (A condyle is the round prominence at the end of a bone) fracture of lower end of right femur. Goal: Return to prior level of function after healing and rehabilitation. Intervention: Anticipate the needs of resident and call light within reach. Modify environment as needed to meet current needs. Non-slip surface for bath/shower, bed in lowest position with bed locked; floors even free from spills and clutter, adequate glare free light, monitor for level of pain.<BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 9:00 AM completed by LVN E reflected Late Entry Signs and symptoms noted of condition change: other change of condition noted: right knee pain. Notifications to care clinician: nurse practitioner 10/09/23 9:11 AM. Name of family member or resident representative notified: Family member 10/09/23 1:45 PM.<BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 9:09 AM completed by LVN E reflected: Resident complaint of right knee and leg pain, Nurse Practitioner notified await instructions. <BR/>Review of Resident #2's nurse progress note dated 10/09/23 at 1:29 PM completed by LVN E reflected orders received x-ray to tibia/fibula (two large bones located in the lower leg) and knee per nurse practitioner.<BR/>Review of Resident #2 nurse progress notes dated 10/09/23 at 5:33 PM completed by LVN F reflected: X-ray exams/test pending. Bedrest encouraged Resident resist supper meal but accepted chilled water, a health shake, and a cup of ice cream.<BR/>Review of Resident #2 x-ray dated 10/09/23 revealed comminuted fracture of distal femur 10/10/23 The bones are osteopenic. Severe Tri compartment degenerative changes are present at the knee. <BR/>Review of hospital records dated 10/10/23 revealed there is severe Tri compartment degenerative joint disease. fracture of distal femur, <BR/>Observation and interview on 10/18/23 at 10:43 AM revealed Resident #2 was sitting up in bed resting, Resident #2 was unable to communicate what happened to right leg. Resident was with a leg brace and foot elevated on pillow. <BR/>Observation and interview on 10/19/23 at 8:40 AM revealed Resident #2 was sitting up in the television room with a right leg brace and right leg elevated with pillow eating a snack. Observation of left knee appeared to be swollen. Resident #2's appearance was well groomed, and she did not have signs of pain. Resident #2 was unable to communicate what happened to right leg. <BR/>Interview on 10/19/23 at 10:33 AM with Resident #2's family member revealed they came to visit Resident #2, and as they entered the unit a nurse grabbed and hugged me. The family member stated the nurse told her she was having an x-ray ordered for Resident #2 due to Resident #2 having a possible fracture of her leg. The family member stated that was how they were informed about the possible injury. The family member stated she immediately began to ask questions about what had happened to Resident #2. She stated the LVN apologized because she thought the family member knew and that it was the reason for the visit. The family member stated she never received updated information pending the results from the x-ray, but was later called and told an ambulance was called to transfer the resident to the hospital. The family member stated she called for two days to speak with someone regarding the injury, but it was as if nobody was talking about it because it was under investigation. The family member stated Resident #2 moved around really good in her wheelchair, so she was surprised to hear about a possible fracture once she arrived at the facility. The family member stated she finally was able to speak with the DON and expressed it would have been nice to have been notified about the situation prior to arriving to the facility. She added that the LVN called her to apologize for not contacting her about the resident's change of condition. <BR/>Interview on 10/19/23 at 1:19 PM with LVN E revealed she entered the facility with her aides alerting her to Resident #2 with pain at her right knee. LVN E stated at that point when she did an assessment, she felt like the right knee was just a bit more swollen than usual. LVN E stated with that she contacted that Nurse Practitioner to request for x-ray to the tibia/fibula and the knee to rule out any findings. LVN E stated she then alerted the DON and began with treatment and care for Resident #2. LVN E stated she did forget to contact family member, and realized it once she saw her enter the facility. LVN E stated The DON addressed it with her and she again contacted family member to apologize. LVN E stated she was just so concerned about ensuring Resident #2 was getting proper care that it slipped her mind. LVN E stated she was responsible for contacting the DON, Physician and family member when there was a change of condition in resident status. LVN E stated not notifying family member could create a delay in care and not keeping them aware of resident conditions. <BR/>Interview on 10/19/23 at 3:06 PM with The DON revealed she was alerted to Resident #2's change of condition by LVN E the morning of 10/09/23. The DON stated Resident #2's family member did come to visit that day; however, she was not aware the family member was not notified of the request for x-ray for Resident #2. The DON stated it was the responsibility of the nurse to contact the physician and resident representatives, so they are aware of any changes in resident conditions. The DON stated not doing so could create concerns for treatment and proper care for residents. <BR/>Review of facility's Change of Condition Reporting policy, revised May 2021, reflected:<BR/>It is the policy of the facility that all changes in resident condition will be communicated to the physician. <BR/>Acute Medical Change<BR/>1. <BR/>Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a require for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician.<BR/>2. <BR/>If unable to contact attending physician or alternate physician timely, notify Medical Director for follow-up to change in resident condition. <BR/>3. <BR/>The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. <BR/>4. <BR/>All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately report an alleged act of abuse to the State Survey Agency, for 2 residents (Resident #6 and 60) of 24 residents reviewed for abuse and neglect.<BR/>The facility failed to immediately report an allegation of physical abuse.<BR/>This failure placed the facility's residents at risk for abuse and neglect.<BR/>Findings included: <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. <BR/>Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#60 has a BIMS score of 05/15 indicating severe cognitive impairment. <BR/>Interview on 03/18/25 at 1:35 PM with LVN C, revealed at first, she did not remember the incident, and after she looked at her notes, she stated yes that day (01/25/25) the residents (Resident#6, Resident#60) had an altercation here in front of the nursing station. She stated CNA A separated them. She stated, she assessed both residents and Resident #6 had a bruise under her right eye, and Resident #60 did not have any bruising . She stated she reported the incident to the MD, ADON, and DON . LVN C denied any other altercation between the two residents.<BR/>Interview on 03/18/25 at 1:38 PM with CNA A, she stated Resident #6 was sitting on her wheelchair in front of the nursing station, when Resident #60 who was standing next to her swung at her and hit her right eye. CNA A stated she separate the two residents immediately. CNA A denied any other altercation between the two residents.<BR/>In interview on 03/18/25 at 1:40 PM, Resident #6 was unable to respond to interview questions. <BR/>In interview on 03/18/25 at 1:42 PM, Resident #60 stated did not remember the incident, and denied ever hitting another resident. <BR/>Interview with the DON and Administrator on 03/18/25 at 1:58 PM revealed, both checked the incident document and stated after they investigated the incident, they did not report it because there was no identifiable intent from one resident to injure the other resident. The DON stated both residents still socialized with each other, and when both residents were interviewed the next day of the incident none of them remembered the incident. The DON and Administrator both stated the risk to residents could be continuous of harm. The Administrator further stated that he was the abuse coordinator for the facility and according to the facility policy/Provider letter Abuse is a willful infliction of injury.<BR/>Review of the facility's Abuse: Prevention of and Prohibition Against, dated 2017, reflected:<BR/>Investigations<BR/>1. <BR/>All identified events are reported to the Administrator immediately.<BR/>H. Reporting/Response<BR/>2. All allegations of abuse, neglect .will be reported outside the facility and to the appropriate state or federal agencies in the applicable timeframes, as per this policy and applicable regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for five (Residents #1, #2, #3, #4 #5) of 12 residents reviewed for incident accidents. <BR/>The Nursing staff failed to ensure black ants were not in Residents #1, #2, #3, #4 and #5's rooms and beds. <BR/>These failures could place residents at risk of being bitten by ants causing skin irritation, skin infection and pain resulting in decreased health and psychosocial well-being. <BR/>Findings included:<BR/>1) Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to express ideas and wants, able to see in adequate light without corrective lenses. He had a staff assisted BIMS score of 01 (Modified independence cognition) and upper and lower one-sided weakness. He used a wheelchair and was diagnosed with anemia (low iron), renal insufficiency (kidney failure), Diabetes Mellitus, Cerebral Vascular Accident (Stroke), Hemiplegia (Partial paralysis), Malnutrition, Anxiety, depression, and pressure ulcer. <BR/>Record review of Resident #1's Nurse Progress Note dated 08/04/24 at 10:12 pm by LVN A revealed, Note Text: This Nurse was called to resident's room and noted a minimal amount of ants on the floor. Resident was transferred to his wheelchair, this Nurse sprayed the areas, disinfected the bed, and asked resident if he wanted a shower, resident stated I quote No I will get a bed bath when my bed is ready. After reassessing the resident's room this Nurse noted no more ants in the area at the time. Will continue with plan of care.<BR/>Interview on 08/28/24 at 12:26 pm, Resident #1 stated a couple of weeks ago, while he was in bed, he had little black ants all over him but none bit him. He stated they sprayed and cleaned his room and he had not seen any ants since then. He stated they were little black ants, more than 20 ants all over his body and the staff were aware. He stated afterwards no one assessed him but they did shower him and stated he had not had any itchiness since then. He stated Maintenance sprayed his room again two days ago. <BR/>Interview on 08/29/24 at 2:25 pm, FM Q stated about two weeks ago Resident #1 complained about black ants in his room and that they were all over him and it was reported to the nurse. He stated he did not get a call from the nurses about the ants on him either. He stated there were no issue with ants since then.<BR/>2) Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with the ability to express ideas and wants and see in adequate light and without corrective lenses. She had a staff assisted BIMS score of 01 (Modified independence cognition) with no upper or lower weakness and used a motorized scooter. Resident #2 was diagnosed with Heart Failure, Hypertension(high blood pressure), Diabetes Mellites (high blood sugar), Aphasia (speech loss), Cerebrovascular Accident, Multiple Sclerosis (nerve damage), Malnutrition and Anxiety and Depression. <BR/>Record review of Resident #2's Nurse Progress Notes from 08/20/24 and thereafter, did not reveal any Progress Notes from anyone, including LVN A about ants being found in her room and outcome of her skin assessment and notifications to other department heads.<BR/>Interview on 08/27/24 at 12:08 pm, Resident #2 stated two weeks ago she was bitten by little black ants, they were in the corner of her room. Maintenance came and sprayed her room, but no one assessed her after she told LVN A she was bitten by ants. She stated there was around 25 black ants behind two boxes in the corner of her room but had not seen any ants since then.<BR/>3) Record review of Resident #3's admission MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to make self-understood, able to see in adequate light with corrective lenses. His BIMS Score was 12 (Moderate cognitive impairment), upper impairment of both sides, used a cane/crutch and walker. He was diagnosed with Cancer, atrial fibrillation,(irregular heart rate) heart failure, gastroesophageal reflux, renal insufficiency (Kidney failure), urinary tract infection and hyperlipidemia (high fat lipids). <BR/>Record review of Resident #3's Nurse Progress Notes from 08/09/24 to 08/29/24 revealed no documentation of ants in his room and steps done to address, prevent and notify department heads. <BR/>Interview on 08/30/24 at 11:30 am, Visitor S stated a week and a half ago she saw four or five small black ants on Resident #3's bed and two or three on the floor and Resident #3 was sitting in his wheelchair. She stated she told RN H who assessed him and added she had not seen any ants since then.<BR/>4) Record review of Resident #4's admission MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with an ability to express ideas and wants and see in adequate light with corrective lenses. His staff assisted BIMS score of 01 (Modified independence cognition) and with upper and lower impairment and no use of device. He was diagnosed with hypertension (high blood pressure), renal insufficiency (kidney failure), pneumonia, Diabetes mellitus (high blood sugar), hyperkalemia (high potassium), cerebrovascular accident (stroke), hemiplegia (partial paralysis), and dependence on renal dialysis. <BR/>Record review of Resident #4's Nurse Progress Note dated 08/22/24 at 4:11 pm, by RN H revealed, Note Text: Residents FM P showed writer several white pustules to right elbow. Resident denies any itching or c/o. NP U notified. Orders noted: Lotrisone Ointment BID X2 weeks and Bactrim DS 1 TAB po BID X 8 days. Skin infection. FM P and resident notified of orders.<BR/>Interview and observation on 08/29/24 at 10:40 am, Resident #4 stated last week he saw little black ants coming from his AC unit, his brown chair across from his bed and on his bed sheets. He stated he did not feel any bites initially and was showered and his nurse did not assess him; and he moved to another room while his room was cleaned and sprayed. He lifted his right arm and said he had some bites on his arm but they went away because he was given skin cream and antibiotics and his skin cleared up. He stated he had not seen any ants since then. <BR/>Interview on 08/29/24 at 12:14 pm, FM P stated around Wednesday (08/21/24) at 6:00 pm or 7:00 pm she saw little black ants moving around underneath Resident #4's bed. She stated they were coming from Resident #4's AC unit at the end of his bed but she did not see any on him but Resident #4 said there were ants on him. She stated she reported it to the nurse at the nurses station and ask the nurse to go to check him out and the nurse said she would take care of it. She stated the nurse called housekeeping and said she would notate it in his record. She stated she returned the next day and she did not see any more black ants. She stated she had not spoken to the DON and Administrator because she notified the nurse.<BR/>5) Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] and rarely/never understood the ability to express ideas and wants with highly impaired vision. His staff assisted BIMS score was 03 (severely impaired cognition) with upper and lower impairments of both sides and used a wheelchair. He used a catheter with was diagnosed with anemia (low iron), hypertension (high blood pressure), neurogenic bladder (bladder dysfunction), hemiplegia (partial paralysis), Multiple sclerosis (nerve damage), seizure disorder and malnutrition. <BR/>Record review of Resident #5's Nurse Progress Note dated 08/25/24 at 1:03 pm by Agency LVN E revealed, Note Text: Resident remains in stable condition. Resting easy and comfortable in bed. As this nurse was administering medications to pt and noted 3 ants. This nurse assessed pt from head to toe. No bites and redness noted to skin. Pt denies any pain or itchiness. This nurse proceeded promptly with CNA to get pt out bed and into wheelchair. As pt was up in wheelchair, this nurse examined bed mattress, and no ants noted. CNA disinfected mattress with cleaning solution. This noted notified responsible party FM R and weekend RN manager. Weekend RN Manager stated that she would have housekeeping to do a deep clean to room. And responsible party the FM R was appeased that I called and informed her of the current situation and pt was promptly up in wheelchair. FM R went on a rant. Per FM R she knew this very thing was going to happen because housekeeping poorly cleans Resident #5's rooms. <BR/>Record review of Resident #5's Nurse Progress Notes on 08/26/24 did not reveal any documentation about LVN A seeing ants in his room on 08/26/24 at 7:30 am, and no documentation of what was done and notifications to department heads. <BR/>Interview on 8/29/24 at 3:56 pm, FM R stated last Sunday 08/25/24 she received a call from Agency LVN E saying they had to get Resident #5 out of bed because ants were on it. She stated LVN A said he was assessed and not bitten and they said he was okay. She stated last Monday 08/26/24, LVN A called her early that morning around 7:00 am or 9:00 am saying he had ants on his bed. She stated being told he was showered and they just wanted her to be aware and said she had never noticed any ants in his room. She stated she was very diligent about Resident #5's care, because he was nonverbal and could not speak for himself. She stated she checked Resident #5 this week and did not notice any ants or ant bites and rashes on him. <BR/>Interview on 08/27/24 at 2:25 pm, the Administrator stated he was not aware Resident #2 had ants in her room and was bitten by them. He stated he would get maintenance to address and talk to DON about it. <BR/>Interview on 08/27/28 at 3:03pm, LVN A stated she had not seen or had any reports of ants in the residents' rooms. She stated she was not aware of ants being reported in Resident #2's room. <BR/>Interview on 08/27/24 at 6:23 pm, the DON stated she heard about some ants in Resident #2's room about a week ago and was not sure why there were no skin assessments for Residents #1, #2, #3, #4, #5. She stated maintenance inspected and sprayed Resident #2's room and she was assessed and she had no bitemarks. She stated she heard about ants in Resident #1's room last week and added the issue with ants had been going on since last week. She stated pest control came out last week and today (08/27/24) and said she had not seen any ants at this facility and not aware of any residents being bitten by any. <BR/>Interview on 08/29/24 on at 12:35 pm, Agency LVN E stated last weekend, she worked the 6:00 am - 2:00 pm shift. She stated on Sunday 08/25/24 around 7:00 am, she went to Resident #5 to administer his medications through his g-tube and noticed three black baby ants on top of his bed and draw sheet he was laying on. She stated she assessed Resident #5 and he did not have any bite marks or red marks and no signs and symptoms of pain. She stated the CNA's came in to get him out of bed and took his sheets and draw sheet out of the room and showered him and he was assessed again with no bite marks seen. She stated Resident #5 stayed in his wheelchair while his room was cleaned and sanitized and sprayed and she did not see any ants after that. She stated she notified his FM R she said 'okay and that she was not surprised because the housekeeping was not that good. She stated she notified RN Supervisor F about it as well and did not call Resident #5's doctor because she did a thorough assessment and he had no signs or symptoms of distress or bite marks. She stated she did not directly see ants on him but they were on the edge of his draw sheet at the end of his bed. She stated she did a head-to-toe skin assessment but did not complete an actual skin assessment because RN Supervisor F told her she could just document it in the nurses note. She stated that was her first time seeing something like that and said if she saw any redness of red marks, she would have definitely notified Resident #5's doctor. She stated Resident #5 was up at the nurses' station most of the day and he did not have any itchiness or signs or symptoms of bitemarks. She stated she did not know she needed to notify the DON because no one told he to. <BR/>Interview on 08/29/24 at 2:32 pm, RN H stated she was not aware of any ants in Resident #4's room but he had a rash on his right elbow, it was some little white pustules on it. She stated there was no mention from Resident #4 and FM P about him having ant bites or ants in his room. She stated she called his doctor and an order for Lotrisone cream and oral antibiotic was started, and stated she did a head-to-toe skin assess and looked at everything. She stated his elbow rash was localized in one spot and did not look like ant bites she said she did not do an incident report because it was localized to the elbow. She stated she documented it in the nurses' notes. She stated his elbow was much better now and had no white pustules (little white bumps) and did not appear inflamed. She stated she was not aware of any reports of ants in Resident #3's room and had not seen any ants in his room. She stated if a resident were to get bitten by ants could cause them to get a skin infection, have an allergic infection or inflammation. She stated ant bites could get systemic really quickly. <BR/>Interview on 08/29/24 2:54 pm, LVN A stated there was some issues with some ants this past Monday 08/26/24 around 7:30 am, Resident #5 was in his room and there was one or two black little sugar ants on his blanket at the foot area. She stated she did not see any ants on him or rashes but she assessed and showered him with no evidence of ant bites. She stated he was up in his chair while housekeeping and maintenance went and cleaned and sprayed his room. She stated she notified the doctor when he came to the facility that same day and he asked were there any bitemarks and she said no. She stated she had not seen any ants since then and added if residents were bitten, they could end up scratching them and could open up a sore. She stated she was not sure why she did not do an incident report or complete a skin assessment form but did assess him. She stated she saw two little black ants on his bed and Resident #5 was showered and a shower sheet was done. She stated she reported the ant sighting to the DON, Administrator and housekeeping and maintenance cleaned and sprayed the room. She stated she did not document the ant incident in Resident #5's nurse progress notes because she got busy that morning but notified the oncoming nurse about it. <BR/>Interview on 08/29/4 at 5:26 pm, the DOR stated on 08/20/24 Resident #2 had a lot of little black specks crawling (approximately 10 ants) around some crumbs on the floor. He stated he reported in their electronic maintenance system and to LVN A to do a skin assessment. He stated he saw LVN A go down to Resident #2's room.<BR/>Interview on 08/29/24 at 5:53 pm, the DON stated she heard about ants on Resident #5's bed sheet from LVN A earlier in the week, 08/26/24. She stated LVN A took Resident #5 out the bed and said there was no incident report completed because there was no skin alterations. She stated LVN A said she got the Maintenance Director to spray treat the room and it was cleaned. She stated not being aware of any ant reports for Residents #3 and #4 and was not aware ants were found in Resident #5's room Sunday 08/25/24. She stated hearing about Residents #1 and #2 having ants in their rooms last week, but Resident #1 ate a lot of food that got on the floor. <BR/>Interview on 08/29/24 at 6:51 pm, the Administrator stated he was not aware of ant sightings in Residents #1, #3, #4 and #5's rooms. He stated the only ant sighting he was aware of was in Resident #2's room last week 08/20/24. He stated he would talk to the DON about checking these residents out. He stated he spoke to Resident #1 daily and he never reported ants in him room or on him. <BR/>Interview on 08/30/34 at 2:49 pm, ADON B stated they had a few residents with ant sightings like Residents #1 and #5 within the past 30 days. She stated she did the head-to-toe assessment of Resident #1 on 08/04/24 around 10:30 am. She said she did his assessment on paper and did not document it in the EMR because she thought LVN A did and said she notified the DON and his charge nurse. She stated on 08/04/24 she was about to do his wound care and she saw about 15 black ants on the floor and a few of the ants were on his bed. She stated at night Resident #1 liked to eat snacks in bed and could not say if the ants got to him but he did not appear to have any ant bites. She stated she was not sure if LVN A did an incident report because he did not have an injury. She stated she did not complete a nurses note after she saw the ants and believed LVN A did it. She stated she heard Resident #5 had ants in his room once and was not aware of ants in his room the second time. She stated if a resident had ants in their rooms they needed to be showered immediately and put in another room then assessed by the nurse and monitored for 72 hours. She stated it should be reported to maintenance to treat and pest control to come out. She stated she was not aware of ants in Residents #3 and #4's rooms and added if the staff did not know how to report in their electronic maintenance system, they needed to let someone know to assist them. She stated the nurses needed to notify the family and Doctor, DON, ADON and following up 72 hours to check the resident's skin and do an incident report. She stated communication was lacking because all the staff did not know what steps to take. <BR/>Interview on 08/30/34 at 4:20 pm, the Administrator they were going to start keeping a better track of the ant sightings by going over the pest sighting log sheets and reviewing skin assessments and ensuring documentation was in place and incident reports. He stated he wanted to ensure the staff knew what to do if they saw ants including if ants were seen in a resident's bed, a skin assessment should be done even if there was no skin alteration, and for the skin assessment to be done daily for a few days afterwards. He stated the Housekeeping Director was responsible for ensuring the cleanliness of the facility. He stated himself and the DON were responsible for ensuring the documentation was accurate. He stated himself and the DON were responsible for ensuring the incident reporting was done. He stated his expectation was for maintenance to check for ants and for everyone to notify maintenance and himself and the DON, if they have any ant sightings, to ensure all steps were done.<BR/>Interview on 08/30/34 at 4:40 pm, the DON stated she started trainings with the nursing department on if ants were seen or reported they needed to notify the Charge Nurses, Nursing Management, Maintenance, family and after assessment notify the resident's Doctor. She stated the Charge Nurse needed to do a resident's skin assessment, shower resident, change the mattress, deep clean. She stated an incident report was only done if the resident had an alteration of their skin, falls, case by case, abuse, medication errors. She stated for ant bite sightings she expected the CNAs to document the resident's skin on a shower sheet and for the charge nurses to do a skin assessment and document their findings in the nurse progress note. She stated for the agency nurses they needed to have better guidelines for management to be notified for ant sightings also. She stated for medical records every nurse was in charge of their own documentation and ultimately, she and nurse management were responsible for ensuring documentation was complete and accurate. She stated Residents #1, #2, #3, #4, and #5 skin assessments were completed on 08/30/24 and they did not have an signs or symptoms of ant bites.<BR/>The facility's Incident policy was requested on 08/27/24 at 11:21 am, 08/30/24 at 8:59 am, 08/30/24 at 3:12 pm and the Administrator stated they did not have an incident/accident policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility for one resident (Resident #2) of four residents reviewed for discharge. <BR/>The facility failed to determine if appropriate and adequate supports were in place to ensure a safe and effective transition of care was provided for Resident #2 when she discharged home as evidenced by:<BR/>There was no evidence of follow up for Resident #2' s durable medical equipment order for a hospital bed, motorized wheelchair, van lift, bedside commode, bed trapeze bar, air mattress, and grab bars, the items were never verified by social services as being delivered to the resident's home.<BR/>This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan.<BR/>Findings included:<BR/>Record review of the admission Record dated 01/18/2023 revealed Resident #2 was an [AGE] year-old female and was admitted to the facility on [DATE]. Primary diagnoses included, amputation of right lower leg surgery, lack of coordination, depression, chronic kidney disease, muscle weakness, and hypertension. Resident #2 was admitted for physical therapy services and would be discharged home with family after completion of therapy.<BR/>Record review of the MDS dated [DATE] for Resident #2 revealed she was anticipated to discharge to her private home. she scored 0 of 15 on the BIMS, indicative of severely impaired cognition. The MDS reflected the resident required extensive assistance from one person for bed mobility, transfers, dressing, and personal hygiene. The resident was incontinent of bowel and bladder.<BR/>Record review of the Care Plan for Resident #2 dated 11/23/2022 revealed the resident required general staff assistance with daily living activities. The goal that was set for Resident #1 included to safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene tasks with extensive assistance from staff through ought her stay in the facility.<BR/>Record review of the Care Plan for Resident #2 dated 11/23/2022 revealed the resident wished to return to her home upon discharge. An intervention was to establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan as needed.<BR/>Record review of the Physician's Active Order's dated 11/1/2022 revealed Resident #2 was to be discharged home. The discharge order read: Home Health to evaluate and treat as indicated outpatient therapy (PT, OT, &/or ST), the following DME: Hospital bed, motorized wheelchair and van lift and trapeze bar. I the physician have reviewed and concur with the Comprehensive Care Plan and Discharge Plan.<BR/>Interview on 01/18/2023 at 10:39 a.m. with the Ombudsman revealed the facility SW called her and explained the problem with Resident #2's PR was having problems with the home health who were unwilling to bring the DME to the resident's home before she was discharged home. The Ombudsman explained the home health service said they do not usually provide the DME beforehand, the reason the home health said it was mainly because sometimes residents sometimes would no be discharged home for some reason or another, so they would have to pick up the DME that had been delivered. The ombudsman said she did not follow up with Resident #2's family and could not say why she had not. <BR/>Interview on 01/18/2023 at 11:15 a.m. with the facilities Social Worker revealed protocol for ordering DME for residents who would be discharging was to fax over the order to HH so they can deliver the items to the resident's home the day they discharge. She said in the past, many years ago, HH would deliver the DME to the resident's home prior to discharge, if they were given a discharge date , but Resident #2 did not have a date for possible discharge. SW could not say why there was not date set for Resident #2 to discharge. The SW revealed she had approached Resident #2's PR member and asked if she could get the DME herself since she worked at a DME company and said the PR told her she would not and demanded the SW work on getting it delivered when Resident #2 discharged home. <BR/>Record review of Resident #2's order summary for DME dated 11/18/2022 revealed the resident required a hospital bed, motorized wheelchair, van lift, a trapeze bar, air mattress, grab bars, bedside commode (3- in -1), and sliding board. The order was faxed to HH on 11/18/2022 at 2:11 p.m. <BR/>Record review of SW care plan note dated 11/18/2022 at 2:00 p m. revealed Resident #2 had been discharged home that day with her family, and SW called HH regarding the DME, she was asked by HH agency to provide an updated MD order that needed a MD signature. SW wrote that she was unable to provide an updated medical information, stating it was due to because of timeframe.<BR/>Record review of NF fax transmission cover dated 11/18/2022 sent to PCP sheet read, Resident #2 went home today and the HH wants updated orders. Please ask PCP to sign! Thanks signed by SW. The document revealed it did not have a TX Result Report printed on it, a TX Result Reports would indicate the transmission result between the machine and the mail server, the reports are printed every time a fax has been transmitted to record whether the transmission was successful or not. <BR/>Interview on 01/18/2022 at 11:30 a.m. with SW, she said faxing the order the same day of Resident #2's discharge day was due because she was not provided by her PCP with a date until the actual day of discharge, therefore she wrote on her careplan notes that due to time constraits she was unable to provide a signed PCP order to the HH agency. She could not say why she did not follow up with the PCP for verification as to whether the order had been received and signed, and whether the PCP office had contacted HH regarding Resident #2's DME needs. <BR/>Interview on 01/18/2022 at 11:45 a.m. with HH administrative assistant revealed Resident #2 had not receive any of the DME supplies as ordered by the facility PCP, he said the order was received on 11/22/2022 from the NF, he said the order was immediately faxed to the DME company and said the DME company is in charge of contacting the PCP in cases where there are questions regarding the orders and getting approval for the items. The administrative assistant said he was still hearing from the family regarding the missing DME supplies and said HH had discharged Resident #2 from PT services and denies knowing what the holdu was and why there was a delay in shipment of the equipment.<BR/>Interview on 01/18/2022 at 12:00 p.m. with PCPs office MA revealed she was unaware there were problems with Resident #2's DME supplies and asked the PCP if he was aware of the needs, and said she was told to have the NF fax the order immediately for approval, the MA denied seeing a fax come through from the NF, DME company or HH requiring an PCP signature of approval. <BR/>Interview on 01/18/2022 at 12:15 p.m. with SW, informed her of the findings, she was appalled and said she would get nursing to call the PCP, get the order reconciled and faxed to HH. She denied knowing that there was a problem from the beginning when the resident was discharged , said no one had called her to inform her of the missing DME, and replied that she had called Resident #2's RP, and left a message on voice mail to inquire how Resident #2 was doing, SW cannot say what day that was and admitted not documenting the attempt to call. <BR/>Interview on 01/18/2022 at 4:30 p.m. with SW, she had refaxed the Resident #2's DME order request to the PCPs office, and after inspection of the document, revealed it was stamped with TX Result Report that verifies the fax was recieved. SW was asked if she had the original fax verification sent on 11/18/2022, and she reported not being able to find it in her files. <BR/>Record review of NF Fax cover sheet provided by SW dated 01/18/2023 sent to PCPs office revealed a request from SW that read: Please sign and make available today, if possible. For some reason the DME Co. never completed this referral. The order read the need for DME: Hospital bed, motorized wheelchair and van lift and trapeze bar, air mattress, grab bars, 3-in-1, sliding board. The document revealed to have a TX Result Report, TX Result Reports indicate the transmission result between the machine and the mail server, these report are printed every time a fax has been transmitted to record whether the transmission was successful or not. The Result read: OK: Communication OK,.<BR/>Interview on 01/18/2022 at 5:00 p.m. with corporate clinical resource nurse acting as the interim DON, she denied knowing about Resident #2's predicament with the order for DME supplies, she said that once a resident is discharged home, it is up to HH to follow up with services. She said once the SW attempts to contact the familly and does not get a call back, it is no longer necessary to follow up. This nurse was filling in for the facility because there was no DON currently on place and the new administrator did not know about the case with Resident #2's missing DME supplies. The nurse said she would provide a policy on resident discharges. <BR/>Record review of facilities policy titled, Criteria for Transfer and Discharge dated 11/2016 and revised on 1/2022 revealed the following:<BR/>-the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. <BR/>-all other necessary information, including a copy of the residents discharge summary, an any other documentation, as applicable, to ensure a safe and effective transition of care.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's kitchen, reviewed for kitchen sanitation. <BR/>The facility failed to ensure liquid Kool Aid stored in the facility's walk-in refrigerator was covered, labelled and dated.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses. <BR/>Findings included:<BR/>Observation on 01/06/2024 from 9:14 AM in the facility's kitchen revealed:<BR/>1. One jar pink liquid Kool Aid in the walk-in refrigerator was not covered, labelled, and dated.<BR/>2. One jar yellow liquid Kool Aid in the walk-in refrigerator was not labelled and dated.<BR/>An interview with the Dietary Manager on 02/06/2024 at 11:39 AM, she stated her expectation of the kitchen staff was to keep the liquid Kool Aid in the refrigerator to be covered, labelled and dated. The liquid Kool Aid which was not covered was considered unsanitary, bugs could fall into the drink, and it had the potential to cross contaminate and cause sickness to the residents. The Dietary Manager stated not labeling and dating the drink could cause confusion about the drink, sickness to the residents since it was difficult to determine when the liquid Kool Aid was kept in the refrigerator. The Dietary Manager stated the cook was responsible to keep the liquid Kool Aid covered, labelled and dated. <BR/>An interview with the [NAME] on 02/08/2024 at 01:45 PM, she stated she realized that morning that the pink liquid Kool Aid jar in the walk in refrigerator was not covered and dated, and a yellow liquid Kool Aid jar was not labelled or dated. The [NAME] stated she did not work the previous night and so she was going to cover it as soon as she saw it in the morning, put label and date on the other one but the state surveyor came to the kitchen before she could do it. The [NAME] stated all the food items in the refrigerator should be covered, labelled and dated. She stated uncovered food items could cause food contamination and make residents sick. Not labelled and dated food items were health risk since it was difficult to determine when it was made. The [NAME] stated all the staff working in the kitchen were responsible to ensure all food items were covered and dated .<BR/>Record review of the facility policy, dated August 2007, reflected It is the policy of this facility that the food storage area shall be maintained in a clean, safe, and sanitary manner. Review revealed the policy did not reflect covering, labelling and dating of stored open food items.<BR/>Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.<BR/>Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that were accurately documented and must contain a record of the resident's assessment for five residents (Residents #1, #2, #3 #4 and #5) of 12 residents reviewed for Medical Records. <BR/>The Nursing staff failed to ensure incident reports, skin assessments and Nurse progress notes were completed after reports of black ants were found in the rooms and beds of Residents #1, #2, #3, #4 and #5. <BR/>These failures could affect all residents by placing them at risk of not being properly monitored and treated if documentation were not completed, accurate or missing which could result in decline in their health and psycho-social well-being. <BR/>Findings included:<BR/>1)Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to express ideas and wants, able to see in adequate light without corrective lenses. He had a staff assisted BIMS score of 01 (Modified independence cognition) and upper and lower one-sided weakness. He used a wheelchair and was diagnosed with anemia (low iron), renal insufficiency (kidney failure), Diabetes Mellitus, Cerebral Vascular Accident (Stroke), Hemiplegia (Partial paralysis), Malnutrition, Anxiety, depression, and pressure ulcer. <BR/>Record review of Resident #1's Nurse Progress Note dated 08/04/24 at 10:12 pm by LVN A revealed, Note Text: This Nurse was called to resident's room and noted a minimal amount of ants on the floor. Resident was transferred to his wheelchair, this Nurse sprayed the areas, disinfected the bed, and asked resident if he wanted a shower, resident stated I quote No I will get a bed bath when my bed is ready. After reassessing the resident's room this Nurse noted no more ants in the area at the time. Will continue with plan of care.<BR/>Record review of Resident #1's EMR did not reveal she had any Incident/accident reports involving ants from 06/27/24/- 08/27/24.<BR/>Record Review of Resident #1's Skin Assessments did not reveal any skin assessments for ants were completed after ants were found in his room and bed on 08/04/24.<BR/>Interview on 08/28/24 at 12:26 pm, Resident #1 stated a couple of weeks ago, while he was in bed, he had little black ants all over him but none bit him. He stated they sprayed and cleaned his room and he had not seen any more ants since then. He stated they were little black ants, more than 20 ants all over his body and the staff were aware. He stated afterwards no one assessed him but they did shower him and stated he had not had any itchiness since then. He stated Maintenance sprayed his room again two days ago.<BR/>Interview on 08/29/24 at 2:25 pm, FM Q stated about two weeks ago Resident #1 complained about black ants in his room and that they were all over him and it was reported to the nurse. He stated he did not get a call from the nurses about the ants on him either. He stated there were no issue with ants since then.<BR/>2) Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with the ability to express ideas and wants and see in adequate light and without corrective lenses. She had a staff assisted BIMS score of 01 (Modified independence cognition) with no upper or lower weakness and used a motorized scooter. Resident #2 was diagnosed with Heart Failure, Hypertension (high blood pressure), Diabetes Mellites (high blood sugar), Aphasia (speech loss), Cerebrovascular Accident, Multiple Sclerosis (nerve damage), Malnutrition and Anxiety and Depression. <BR/>Record review of Resident #2's Nurse Progress Notes from 08/20/24 and thereafter, did not reveal any Progress Notes from anyone, including LVN A about ants being found in her room and outcome of her skin assessment and notifications to other department heads.<BR/> Record review of Resident #2's EMR did not reveal she had any Incident/accident reports involving ants from 06/27/24/- 08/27/24.<BR/>Record review of Resident #2's Skin Assessment after it was reported ants were in her room on 08/20/24. <BR/>Interview on 08/27/24 at 12:08 pm, Resident #2 stated two weeks ago she was bitten by little black ants, they were in the corner of her room. Maintenance came and sprayed her room, but no one assessed her after she told LVN A she was bitten by ants. She stated there was around 25 black ants behind two boxes in the corner of her room but had not seen any ants since then.<BR/>3) Record review of Resident #3's admission MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to make self-understood, able to see in adequate light with corrective lenses. His BIMS Score was 12 (Moderate cognitive impairment), upper impairment of both sides, used a cane/crutch and walker. He was diagnosed with Cancer, atrial fibrillation, heart failure, gastroesophageal reflux, renal insufficiency, urinary tract infection, hyperlipidemia. <BR/>Record review of Resident #3's Nurse Progress Notes from 08/09/24 to 08/29/24 revealed no reports of ants in his room and steps done to address, prevent and notify department heads since he admitted . <BR/>Record review of Resident #3's EMR did not reveal she had any Incident/accident reports involving ants from 06/27/24/- 08/27/24.<BR/>Record review of Resident #3's Skin Assessments were not completed for ant bites in his EMR from 08/01/24 to 08/28/24. <BR/>Interview on 08/30/24 at 11:30 am, Visitor S stated a week and a half ago she saw four or five small black ants were on Resident #3's bed and two or three on the floor. She stated telling RN H who came in to assess Resident #3. She stated Resident #3 was sitting in his chair and since then she had not seen any ants.<BR/>4) Record review of Resident #4's admission MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with an ability to express ideas and wants and see in adequate light with corrective lenses. His staff assisted BIMS score of 01 (Modified independence cognition) and with upper and lower impairment and no use of device. He was diagnosed with hypertension (high blood pressure), renal insufficiency (kidney failure), pneumonia, Diabetes mellitus (high blood sugar), hyperkalemia (high potassium), cerebrovascular accident (stroke), hemiplegia (partial paralysis), and dependence on renal dialysis. <BR/>Record review of Resident #4's Nurse Progress Note dated 08/22/24 at 4:11 pm, by RN H revealed, Note Text: Residents FM P showed writer several white pustules to right elbow. Resident denies any itching or c/o. NP U notified. Orders noted: Lotrisone Ointment BID X2 weeks and Bactrim DS 1 TAB po BID X 8 days. Skin infection. FM P and resident notified of orders.<BR/>Interview and observation on 08/29/24 at 10:40 am, Resident #4 stated last week he saw little black ants coming from his AC unit, his brown chair across from his bed and on his bed sheets. He stated he did not feel any bites initially and was showered and his nurse did not assess him; and he moved to another room while his room was cleaned and sprayed. He lifted his right arm and said he had some bites on his arm but they went away because he was given skin cream and antibiotics and his skin cleared it up. He stated he had not seen any ants since then. <BR/>Interview on 08/29/24 at 12:14 pm, FM P stated last Wednesday (08/21/24) around 6:00 pm or 7:00 pm she saw little black ants moving around underneath Resident #4's bed. She stated they were coming from Resident #4's AC unit at the end of his bed but she did not see any on him but Resident #4 said there were ants on him. She stated she reported it to the nurse at the nurses station and ask the nurse to go to check him out and the nurse said she would take care of it. She stated the nurse called housekeeping and said she would notate it in his record. She stated she returned the next day and she did not see any more black ants. She stated she had not spoken to the DON and Administrator because she notified the nurse.<BR/>Record review of Resident #4's EMR did not reveal he had any Incident/accident reports involving ants from 06/27/24 to 08/27/24. <BR/>Record review of Resident #4's Skin assessment dated [DATE] did not reveal a skin assessment was completed and in his EMR. <BR/>5) Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] and rarely/never understood the ability to express ideas and wants with highly impaired vision. His staff assisted BIMS score was 03 (severely impaired cognition) with upper and lower impairments of both sides and used a wheelchair. He used a catheter with was diagnosed with anemia, hypertension, neurogenic bladder (bladder dysfunction), hemiplegia (partial paralysis), Multiple sclerosis (nerve damage), seizure disorder and malnutrition. <BR/>Record review of Resident #5's Nurse Progress Note dated 08/25/24 at 1:03 pm by Agency LVN E revealed, Note Text: Resident remains in stable condition. Resting easy and comfortable in bed. As this nurse was administering medications to pt and noted 3 ants. This nurse assessed pt from head to toe. No bites and redness noted to skin. Pt denies any pain or itchiness. This nurse proceeded promptly with can to get pt out bed and into wheelchair. As pt was up in wheelchair, this nurse examined bed mattress, and no ants were noted. CNA disinfected mattress with cleaning solution. This noted notified responsible party FM R and weekend RN manager. Weekend RN Manager stated that she would have housekeeping to do a deep clean to room. And responsible party the FM R was appeased that I called and informed her of the current situation and pt was promptly up in wheelchair. FM R went on a rant. Per FM R she knew this very thing was going to happen because housekeeping poorly cleans Resident #5's rooms. <BR/>Record review of Resident #5's Nurse Progress Notes on 08/26/24 did not reveal any documentation by LVN A seeing ants in his room at 7:30 am. <BR/>Interview on 8/29/24 at 3:56 pm, FM R stated last Sunday 08/25/24 she received a call from Agency LVN E saying they had to get Resident #5 out of bed because ants were on it. She stated LVN A said he was assessed and not bitten and they said he was okay. She stated last Monday 08/26/24, LVN A called her early that morning around 7:00 am or 9:00 am saying he had ants on his bed. She stated being told he was showered and they just wanted her to be aware and said she had never noticed any ants in his room. She stated she was very diligent about Resident #5's care, because he was nonverbal and could not speak for himself. She stated she checked Resident #5 this week and did not notice any ants or ant bites and rashes on him.<BR/>Record review of Resident #5's Nurse Progress Notes from 08/26/24 did not reveal any documentation about LVN A seeing ants in his room on 08/26/24 at 7:30 am. <BR/>Record review of Resident #5's EMR did not reveal he had any Incident/accident reports involving ants from 06/27/24 to 08/27/24<BR/>Record review of Resident #5's Skin assessment dated [DATE] did not reveal a skin assessment for ants was completed and in his EMR.<BR/>Record review of Resident #5's Skin assessment dated [DATE] did not reveal a skin assessment for ants was completed and in his EMR.<BR/>Interview on 08/27/28 at 3:03pm, LVN A stated she had not seen or had any reports of ants in the resident's rooms. She stated she was not aware of ants being reported in Resident #2's room. <BR/>Interview on 08/27/24 at 6:23 pm, the DON stated she heard about some ants in Resident #2's room about a week ago. She stated she heard about ants were in Resident #1's room last week and added the issue with ants had been going on since last week. <BR/>Interview on 08/28/24 at 1:12 pm, CNA C stated the morning of 08/12/24, a couple of weeks ago, she saw ants in Resident #1's room. She stated she saw five black sugar ants on the floor in Resident #1's room and pulled his covers back and checked him out and did not seen any ants on him or his bed. She stated she reported seeing the ants to an agency nurse and Maintenance spray treated Resident #1's room.<BR/>Interview on 08/29/24 on at 12:35 pm, Agency LVN E stated last weekend, she worked the 6:00 am - 2:00 pm shift. She stated on Sunday 08/25/24 around 7:00 am, she went to Resident #5 to administer his medications through his g-tube and noticed three black baby ants on top of his bed and draw sheet he was laying on. She stated she assessed Resident #5 and he did not have any bite marks or red marks and no signs and symptoms of pain. She stated she did not directly see ants on him but they were on the edge of his draw sheet at the end of his bed. She stated she did a Head-to-toe skin assessment but did not complete an actual skin assessment because RN Supervisor F told her she could just document it in the nurses note. She stated this was her first time seeing something like that and said if she saw any redness of red marks, she would have definitely notified Resident #5's Doctor. <BR/>Interview on 08/29/24 at 1:38 pm, CNA F stated she worked the 6:00 am to 2:00 pm shift and saw ants a week or 2 weeks ago in Resident #1's room around 11:30 am. She stated she saw a trail of ants on the floor by the side of the wall of his AC unit and reported it to his nurse and the Maintenance Director. She stated there was a trail, a lot of little black ants on the floor and they were going toward Resident #1's bed. She stated she was not sure if the nurse checked him.<BR/>Interview on 08/29/24 at 2:32 pm, RN H stated she was not aware of any ants in Resident #4's room but he had a rash on his right elbow, it was some little white pustules on it. She stated there was no mention from Resident #4 and FM P about him having ant bites or ants in his room. She stated she called his Doctor and an order for Lotrisone cream and oral antibiotic was started, and stated she did a head-to-toe skin assess and look at everything. She stated his elbow rash was localized in one spot and did not look like ant bites and said she did not do an incident report because it was localized to the elbow. She stated she documented it in the nurses notes. She stated his elbow was much better now and had no white pustules (little white bumps) and did not appear inflamed. She stated she was not aware of any reports of ants in Resident #3's room and had not seen any ants in his room. She stated if a resident were to get bitten by ants could cause them to get a skin infection, have an allergic infection or inflammation. She stated ant bites could get systemic really quickly. <BR/>Interview on 08/29/24 2:54 pm, LVN A stated there was some issues with some ants this past Monday 08/26/24 around 7:30 am, Resident #5 was in his room and there was one or two black little sugar ants on his blanket at the foot area. She stated she did not see any ants on him or rashes but she assessed and showered him with no evidence of ants. She stated he was up in his chair while housekeeping and maintenance went and cleaned and sprayed his room. She stated she notified Doctor M when he came to the facility that same day and he asked were there any bitemarks and she said no. She stated she had not seen any ants since then and added if residents were bitten, they could end up scratching them and could open up a sore. She stated she was not sure why she did not do an incident report or complete a skin assessment form but did assess him. She stated she saw two little black ants on his bed and Resident #5 was showered and a shower sheet was done. She stated she did not document the ant incident in Resident #5's nurse progress notes because she got busy that morning but notified the oncoming nurse about it. She stated not doing an incident report or progress note about ants being in resident's rooms could cause the incident to reoccur. <BR/>Interview on 08/29/24 at 3:22 pm, LVN I stated if he saw ants on a resident or it was reported to him, he would do an incident report, notify their doctor, RP, and Administrator. <BR/>Interview on 08/29/4 at 5:26 pm, the DOR stated on 08/20/24 Resident #2 had a lot of little black specks crawling (approximately 10 ants) around some crumbs on the floor. He stated he reported to LVN A to do a skin assessment. He stated he saw LVN A go down to Resident #2's room and was not sure if an incident report done. <BR/>Interview on 08/29/24 at 5:53 pm, the DON stated she heard about ants on Resident #5's bed sheet from LVN A earlier this week 08/26/24. She stated LVN A took Resident #5 out the bed and said there was no skin report completed because there was no skin alterations. She stated not being aware of any ant reports for Residents #3 and #4 and was not aware ants were found in Resident #5's room Sunday 08/25/24. She stated hearing about Resident #1 and #2 having ants in his room last week. She stated there would not be an incident report completed for these ant sightings unless there was an actual injury and she did not feel the Doctor needed to be notified about the ant sightings. She stated if there was no negative outcome, just a nursing judgement was needed for them to continue to monitor them. She stated Doctor M was aware of the ant issue at the facility but was not sure if the Medical Director Doctor N knew about the ant problem. <BR/>Interview on 08/30/24 at 10:56 am, CNA D stated she had not seen any ants and all she could do was report ant sightings to the Electronic Maintenance System. She stated she did not look at the floor to look for any ants because she was too busy taking care of Resident #3. She stated Visitor S said he had ants in his room but she did not see them and did not go into Resident #3's room because it was a busy day. She stated she did not report the ant sighting to the nurse because Visitor S did. She stated she saw Visitor S report the ant sighting to RN H and then saw RN H went to Resident #3's room. She stated she did not shower Resident #3. <BR/>Interview on 08/30/34 at 2:03 pm, the Medical Records Director stated she did not have any skin assessments for Residents #1, #2, #3, #4, #5 and was not aware of any issues with missing documentation such as incident/accident reports, skin assessments or nurse progress notes. <BR/>Interview on 08/30/34 at 2:49 pm, ADON B stated she did the head-to-toe assessment of Resident #1 on 08/04/24 around 10:30 am. She said she did his assessment on paper and did not document it in the EMR and said she notified the DON his charge nurse. She stated on 08/04/24 she was about to do his wound care and she saw about 15 blacks the ants on the floor and a few of the ants were on his bed. She stated she was not sure if LVN A did an incident report because he did not have an injury. She stated she did not complete a nurses note after she saw the ants and believed LVN A did it. She stated if a resident had ants in their room they needed to be assessed by the nurse and monitored for 72 hours. She stated the nurses needed to notify the Family and Doctor, DON, ADON and following up 72 hours to check the resident skin and do an incident report.<BR/>Interview on 08/30/34 at 4:20 pm, the Administrator stated they were going to start reviewing skin assessments and ensuring documentation was in place and incident reports. He stated he would be doing monthly trainings on documentation. He stated he wanted to ensure the nurses documentation was accurate, He stated he wanted to correctly train and have postings up for agency staff to know who to call for various topics. He stated he wanted to ensure the staff knew what to do if they saw ants including if ants were seen in a resident's bed, a skin assessment should be done even if there was no skin alteration, and for the skin assessment to be done daily for a few days afterwards. He stated himself and the DON were responsible for ensuring the documentation was accurate. He stated himself and the DON were responsible for ensure the incident reporting was done. <BR/>Interview on 08/30/34 at 4:40 pm, the DON stated she started trainings with the nursing department if ants were seen or reported they needed to notify the Charge Nurses, Nursing Management, Maintenance, family and after skin assessment notify the resident's Doctor. She stated the Charge Nurse needed to do a resident's skin assessment. She stated an Incident Report was only done if the resident had an alteration of their skin, falls, case by case, abuse, medication errors. She stated for ant bite sightings she expected the CNA's to document the resident's skin on a shower sheet and for the Charge Nurses to do a skin assessment and document their findings in the nurse progress note. She stated for the agency nurses they needed to have better guidelines for management to be notified for ant sightings also. She stated for Medical Records every nurse was in charge of their own documentation and ultimately, she and nurse management were responsible for ensuring documentation was complete and accurate. She stated Residents #1, #2, #3, #4, #5 skin assessments were completed on 08/30/24 and they did not have an signs or symptoms of ant bites.<BR/>The facility's Incident policy was requested on 08/27/24 at 11:21 am, 08/30/24 at 8:59 am, 08/30/24 at 3:12 pm and the Administrator stated they did not have an incident/accident policy. <BR/>Record Review of the facility's Documentation and Charting Policy and Procedures dated 10/2021 revealed, POLICY: It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 3.The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. 4. Nursing service personnel with a record of the physical and mental status of the resident. 5. Assistant in the development of a Plan of Care for each resident. 6. The elements of quality medical nursing care. 7. A legal record that protects the resident, physician, nurse, and the facility. 8. A source of all resident charges. PROCEDURES . 10. Follow-up-Notes: Documentation relating to follow-up notes should include. A. A summary of the resident's condition, until the resident is stable. B. Documentation that the resident's condition has stabilized. C. Signature and title of person recording the data. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 5 residents reviewed for infection control<BR/>LVN A failed to wear appropriate PPE when providing suprapubic catheter care for Resident #2 who supposed to be on EBP ( Enhanced Barrier Precautions).<BR/>This failure placed the residents at risk of exposure to possible infectious agents.<BR/>Findings included:<BR/>Record review of Resident #2's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, neurogenic bladder, mild intellectual disabilities, and needs for assistance with personal care. Resident#2 has a BIMS score of 12/15 indicating moderate cognitive impairment. Her Functional Status reflected she was dependent on staff for toileting hygiene including suprapubic catheter exit site care. <BR/>Record review of Resident #2's care plan, dated 10/19/24, reflected she has Indwelling Suprapubic Catheter: R/t Neurogenic Bladder Secondary to QUADRAPLEGIC (paralysis of all four limbs) CP (Cerebral Palsy). <BR/>Record review of Resident #2's physician orders reflected an order dated 06/27/24:Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wound, Indwelling medical device, infection and/or MDRO (Multi drug resistant organism) status.<BR/>Observation on 01/16/25 at 08:47 AM LVN A prepared to provide care to Resident #2's suprapubic catheter . LVN A washed hands and donned gloves and provided care without donning a gown. There was no signage and no supplies outside or inside of the Resident#2's room for EBP.<BR/>Interview on 01/16/25 at 09:14 AM LVN A stated Resident #2 has an indwelling medical device and there supposed to be a signage and required PPE supplies in front of Resident #2 room, indicating she was on EBP, and that staff were required to wear a gown and gloves when providing care for the resident. LVN A stated she just did not wear required PPE when she went to provide suprapubic exit site care for Resident#2. LVN A stated she had been working in the facility for few months and had in service on EBP during orientation. <BR/>Interview on 01/16/25 at 09:30 AM the DON stated all residents with wounds, catheters, feeding tubes, etc. are placed in EBP to minimize the risk of spreading infections between residents. EBP required the use of a gown and gloves for all high contact care of the resident. She stated the risk of not adhering to the appropriate PPE requirements was spreading infections to other residents.<BR/>Interview on 01/16/25 at 12:06 PM the administrator stated there should be signage in front of the Resident#2 room, and the supplies. He stated staff should don and doff proper PPE for high resident contact care, including gown, and gloves. He stated the last in service on EBP was done in November 2024. <BR/>Record review of LVN A's skills verification checklist dated 11/04/24 reflected she was competent in Peri-care-Foley catheter tubing care. <BR/>Review of the facility's policy IPCP Standard and Transmission-Based Precaution, Revised March 2023, reflected: 3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with (MDROs).

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. These services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four resident rooms (resident #327, #73, #16 and #11) of 24 resident rooms reviewed for clean and sanitary environment.<BR/>1. Resident #327's room had two nails on the floor, a plastic cup and the floor was dirty.<BR/>2. Resident #73's room had a hole behind the door at the entrance to the room.<BR/>3. Resident #16's room had broken blinds, a stain on the wall by the bathroom, and the toilet was running causing the pipes to make a loud whining noise. <BR/>4. Resident #11's room had broken blinds and a hole behind the door at the entrance to the room. <BR/>These failures could affect all residents, staff, and the public by placing them at risk of not having a clean, sanitary, and comfortable environment. <BR/>Findings included: <BR/>1. Observation of Resident #372's room on 2/6/24 at 9:58 a.m. showed two iron nails on the floor, a plastic cup on the floor and the floor was dirty. <BR/>Interview with Resident #327 revealed the rooms were not cleaned frequently by housekeeping staff. She had been in the facility 3 weeks and the room was swept once. Resident #327 said the window blinds were changed last week and the nails were from that day.<BR/>2. Observation of Resident #73's room on 2/6/24 10:22 a.m. showed there was a 5 by 1.5 inch hole in wall behind the entrance door. <BR/>Interview with Housekeeper F on 02/6/24 at 10:23 a.m. revealed she just noticed the hole today and said Maintenance had fixed a hole in the wall in same area previously from door hitting the wall when opened.<BR/>3. Observation of Resident #16's room on 2/6/24 11:20 a.m. showed broken blinds with strips bent and broken in the middle of the blinds. Also, there were marks running down the wall on the wall outside the bathroom door which was an orange-brown color liquid. There was a &frac12; by &frac12; square of drywall missing from the wall directly to the left when you enter the room. Furthermore, the toilet was heard to be running on three different occasions. Each time the toilet stopped running, the pipes in the bathroom made a loud whining noise for about 10 seconds. <BR/>Interview with Resident #16 said the marks on the wall were from a drink that exploded a long time ago. Resident #16 said the issues in the room were fine and she did not want to bother anyone. Resident #16 said she knows there are other people there who need more help than her and she did not want to bother anyone. <BR/>4. Observation of Resident #11's room on 2/6/24 11:57 a.m. showed the window blinds were broken on both sides of the blinds with strips bent in different directions. <BR/>Interview with Resident #11 said the blinds are always messed up. She said they never fix them when she has told them. <BR/>Interview with Maintenance Director on 2/8/24 at 11:05 a.m. stated he had not known about the issues in the Residents rooms. He said he would get new blinds in the rooms today. He looked at the toilet in resident #16's room and said it was a short chain and he would get it fixed. He is over housekeeping and said he would get someone to clean the wall. The Maintenance Director thought the piece of drywall missing from the wall in Resident #16's room was from a glove box dispenser that used to be there. He said he would get it fixed. The Maintenance Director said he would have fixed the items had he been told. <BR/>Interview with the Maintenance Director on 2/8/24 at 3:10 p.m. showed he had fixed the toilet in Resident #16's room which stopped the loud whining noise. Also, the blinds were also replaced in Resident #16's room. The Maintenance Director said he would have to purchase a new blind for Resident #11's room as it is a larger blind than the other rooms. He showed where he had fixed the holes in the walls in Resident #11 and #73's rooms.

**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 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE].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 1 (Resident #1's room) of 8 residents room reviewed for pest. The facility failed to ensure Resident #1's room was free of ants on 07/20/25. As a result of the bites Resident#1 was transported to the local hospital and admitted on [DATE]. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. These failures could affect residents by placing them at risk of allergic reaction, decline in quality of life and death. Findings included: Record review of Resident#1's face sheet revealed, she was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Dementia (decline in cognitive function that affects daily living) in other diseases classified elsewhere, unspecified other severity, with mood disturbance (mental health conditions that primarily affect emotional states), unspecified Dementia, unspecified severity, without behavioral, other disturbance, psychotic disturbance (a condition in which one is unable to distinguish what is and is not real), mood disturbance, and anxiety, erosive (Osteo) arthritis (destruction of joint cartilage and bone erosion), other muscle weakness (Generalized), other unspecified lack of coordination, other personal history of Transient Ischemic attack ( caused by a brief blockage of blood flow to the brain) and cerebral and other infarction without residual deficits (blood flow to a part of the brain is obstructed, leading to tissue death due to lack of oxygen). Record review of Resident#1's MDS, dated [DATE] revealed her BIMS score was undetermined. Resident#1's functional limitation in range of motion reflected impairment on one side, coded for lower extremity (hip, knee, ankle, foot). Resident#1's functional abilities for mobility were undetermined. Record review of Resident#1's care plan, undated revealed, she was at risk for communication problem related to Dementia, at risk for impaired cognitive function/dementia or impaired thought processes r/t long term memory loss, Poor nutrition, short term memory loss, Dementia, and impaired decision making. Resident#1 had bowel/bladder incontinence r/t Alzheimer's, Confusion, Dementia, and impaired Mobility. Record review of Resident#1 EMS report, dated 07/20/25 reflected, Dispatched to nursing home for medical emergency. Upon arrival then [Resident#1] one was found in her wheelchair eyes completely swollen shut and family around her. Family reported that patient was found in her bed, by the family, covered in ants. The [Resident#1]had visible ant bites on her neck, face and eyes. The patient had Alzheimer's and was not able to communicate or provide any information. [Resident#1] was transferred to stretcher by EMS via picking patient up from the wheelchair and placing her on the stretcher. En route to hospital vital perform SPO2, BGL, lung sounds were clear, airway patent. [Resident#1], IV established and right hand 50 milligram of Diphenhydramine given via IV, 2 ants found on patient during transport. Vitals remain stable throughout transportation. Patient transported to [local hospital] for further observation and treatment.Record review of Resident#1's hospital records, dated 07/22/25 reflected, Resident#1 was admitted on [DATE] at 11:28 AM. Per EMS, several small ants were actively crawling around patient. Patient had noted bites around her entire body including her face and neck. Patient had noted eyelid swelling. EMS administered IV Benadryl at 15 mg. Patient's face swollen and red with some insect bites likely allergic reaction from insect bites, will start IV steroids, hydrocortisone and Benadryl cream.Visit diagnosed Insect bite, unspecified site, initial encounter (primary), Urinary tract infection without hematuria, site unspecified Dehydration and Unsatisfactory living conditions. Patient's [family member] also requested new placement to a different facility, case management assisted with placement. [Resident#1] was accepted at another SNF/NF and would be discharged on 07/23/25. Record review of the weekend MOD progress note dated 07/20/25 reflected, Writer was alerted by CNA of rash/swollen eyes. Upon entry to room, no ants present in room, on resident or bed/linen. Resident was removed from area and assessed. Linen had already been removed, bed cleaned, and resident was already showered. Scattered rash like areas noted to body and redness along with bilateral swollen eyes during assessment. Writer notified {medical doctor} made aware of clinical situation and new orders given. Family notified of orders and ER transport. Hydrocortisone cream applied to entire body and PRN pain med and Benadryl administered. EMT present and transferred resident to {local hospital} with family en route. Family provided with Administrator's contact info for any concerns. Record review of the Admin interview with CNA A reflected [CNA A] regarding the incident that took place Sunday 7/20/2025 morning. [CNA A] stated she had been in the room of the affected resident about an hour prior at 8:30 and had checked and changed resident for incontinence. Room was clean, no signs of ants in or around bed or on resident at that time. No signs of clutter in the room or open food to draw pests into the room. Record review of the PCC service Inspection Report dated 4/11/25 reflected, on 05/28/25 the following rooms where treated 106-109 and 405-408 for ants and general pest. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the PCC service Inspection Report dated 07/21/25 reflected the facility was treated for ants on 07/21/25 treated room [ROOM NUMBER] for ants and general pest. On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. Record review of Resident#1 shower sheet, dated 07/20/25 reflected Resident#1 had a scattered rash on chest signed by the weekend MOD and CNA A. Record review of in-service training report dated 07/20/25, titled pest control/homelike environment /abuse prohibition conducted by ED in person and via phone reflected: Summary of in-service reflected: Our residents have the right to a safe, clean comfortable and home like environment. We must be diligent in our processes to ensure this for them. -Rooms need to be clean and free of odors. If you observe issues with cleanliness or odors, you must report it to housekeeping immediately and find the source. Facility needs to be free of pest. If you observe issues with pest control, you must report it to maintenance immediately via MS and notify ED or Maintenance-Facility must monitor food in resident rooms and ensure there aren't items drawing pest attention. If you observe issues, you must report it or correct if able.-Maintenance will adjust interventions as appropriate and as the seasons change. Including checking and treating for ants regularly.-Report to admin and DON if ants observed in residents' room, notify nurse immediately-Head to toe skin assessment to be completed by the nurse on both residents in the room.remove any ants-Remove resident and roommate from the room-check adjacent room for ants, room to be treated for ants,-Resident unable to return to room until treatment and deep cleaning completed During an observation on 07/22/25 at 8:30 am to 9:15 am revealed, the common area, dining area and rm# 301, 302, 303, 304, 305,306,307,308, 309, 310, 311 and 312 were free of ants. In an interview on 07/22/25 at 8:43 am CNA B stated residents in the unit did not eat in their room. CNA B stated snacks were kept in a white container and were given out and staff cleaned up right after. CNA B stated the facility had issues in the past with bugs and they let the MD know. CNA B stated she had not seen ants in Resident#1 room before 07/20/25. CNA B was in serviced over the phone about pest control, resident abuse, homelike environment, and Resident#1 was transported to hospital on [DATE]. In an interview on 07/22/25 at 9:28 am the HKS stated they cleaned and disinfected common areas and resident's rooms daily. HKS stated when notified of a pest sighting, the HKS would first let the MD know. The HKS stated everything would be taken out of the resident's room and washed. The HKS stated Resident#1 room was deep cleaned and then deep cleaned again the following day. The HKS stated she viewed a small number of active and unactive ants in Resident#1 room. In an interview on 07/22/25 at 10:05 am, the MD stated it was reported to him on 07/20/25 that a Resident#1 was bitten by ants. The MD came to the facility and immediately sprayed the Resident#1 room and exterior. The MD stated pest control came out 07/20/25 and 07/21/25 and treated the interior and exterior of the facility. The MD stated the facility had minor problems in the past with residents who had spilled food in their rooms and ants followed the trail. The MD stated staff were supposed to report in MS any pest sighting. MD stated PCC technician came out twice a month to treat the facility. The MD stated the last pest control inspection was on 06/20/25. In an interview on 07/22/25 at 10:20 am the HSW stated Resident #1would be discharged to another SNF/NF. The HSW stated Resident#1's planned discharge was on 07/23/25. In an interview on 07/23/25 at 10:28 am, the HN stated that Resident#1 did not talk and was not ambulatory. The HN stated Resident#1 slept most of the day and a family member had been at her side. The HN stated Resident#1 was in the hospital for an allergic reaction to ant bites from a nursing home. Interview and observation at the local hospital on [DATE] at 10:33 am revealed Resident #1 had bites on her eyelids, face and neck. The Family member stated she visited Resident#1 on the morning of 07/20/25. Resident#1's legs were covered with a blanket and when she moved the blanket ants were crawling on her legs. The Family member stated Resident#1's eyes were swollen shut and there were ants crawling on the wall. The family member stated she went and got CNA A who assisted with Resident#1.Attempted to call LVN I on 07/22/25 at 2:24 pm and did not receive a return call before exit.In an interview on 07/22/25 at 2:30 pm weekend MOD stated LVN I called her about Resident#1 had an allergic reaction to ant bites. The weekend MOD informed the DON about the ant bites. The weekend MOD stated she did a head-to-toe assessment and documented in Resident#1 progress notes the findings. The weekend MOD stated she remember the resident having a rash on her chest and her eyes were swollen. The weekend MOD stated Resident#1 hair was wet and she did not find any ants on her. In an interview on 07/22/25 at 3:36 pm CNA A stated at 8:15 am on 07/20/25 she went into Resident#1's room to provide incontinent care and turned to feed Resident#1 and she would not eat. CNA A stated she did not see any ants in Resident#1's room at that time. CNA A stated the family member came and got her around 10 something. CNA A stated Resident#1's eyes were swollen. CNA A stated she notified LVN I and she called the MD by calling his number. CNA A stated she was in-serviced on 07/20/25 to notified LVN I so they could do a head-to-toe assessment on the resident and roommate. CNA stated Resident#1 was given a shower. CNA A stated no ants were found on the roommate side of the room. CNA A stated nearby rooms should be checked for ants and staff must make sure all food was cleaned up.In an interview on 07/22/25 at 3:40 pm CNA C stated she was not there when the incident happened with Resident#1. CNA C was in-serviced on 07/21/25 on homelike environment, pest control and resident abuse. CNA C stated she had not seen any ants. CNA C stated any sighting of pest should be reported to the MD and tell the nurse so she could do a head-to-toe assessment. Interviews on 07/22/25 from 3:45 pm to 4:10 pm revealed LVN D, CNA E, LVN F, CNA G and LVN H stated if pests were seen, first remove the residents from the room, then the MD and Admin were called, the nurse did a head-to-toe assessment, adjacent rooms were checked for pests, they removed residents' belongings, and the HK deep cleaned the rooms. In an interview on 07/22/25 at 4:12 pm the HK stated if they noticed pests to first notify the MD and then bag residents' items and complete laundry. The HK stated the room was deep cleaned twice and adjacent rooms were checked. In an interview on 07/22/25 at 10:02 am the PCC technician stated the company treated the facility twice a month. PCC stated one exterior treatment would be enough to take care of the ants. PCC technician stated he came in on 07/20/25 and 07/22/25 and treated the interior and exterior of the facility for ants. The PCC technician stated no ants were found in the rooms. The PCC technician stated a lot of things could have led to an ant problem such as the weather. The PCC technician stated little showers and heavy rain caused everything on the ground to move around and food being left out could cause ants. In an interview on 07/22/25 at 4:15 pm the DON and Admin stated the Facility immediately cleared Resident #1, and her bed of ants. Resident #1 was showered and affected areas treated, housekeeping immediately deep cleaned the room, and pest control was called immediately to come and treat the room as well as adjacent rooms. Residents on the hall were checked head to toe for skin assessments, and no other signs of ants or bites were sighted. The DON stated Resident#1 roommate had a head-to-toe assessment and no bites were found on her or in her personal belongings. The DON stated Resident#1 roommate was transferred to 200 hall. Admin stated Pest control treated the exterior of the facility as well as the ant hills on the property. All staff were in-serviced on pest control, safe homelike environment, and abuse prohibition. The MD did exterior rounds of the facility and checked for entrance sights and hills and provided exterior treatment. The PCC Technician came back out the next day for a follow up treatment. Dept heads continue to round twice a day to check for signs of pests. Staff are to notify maintenance via MS and group message as well as the Admin immediately. The DON and Admin stated any pest sighted in the resident rooms will require resident to have a head-to-toe assessment immediately and room deep cleaned. During an observation on 07/22/25 at 4:45 pm the surveyor did an exterior walk through of the facility and ant hills were not noticed at that time of visit. Observed a lot of greenery and shrubbery around the facility. During an observation on 07/22/25 at 5:00 pm, resident rm# 106-109, 206, 211 and 405-408 were checked for ants. The surveyor did not observed pest at the time of visit. During an observation and interview on 07/23/25 at 11:30 am the MD and surveyor did an exterior walk through of the facility. The MD stated ant hills were treated and then knocked down the following day. The MD identified spots where ants had been knocked down and no active ants were observed at the time of the visit. Record review of the PCC service Inspection Report dated 07/21/25 reflected, On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. On 07/21/25 treated room [ROOM NUMBER] for ants and general pest Record review of facility policy titled, safe/comfortable/homelike environment, revised 01/22 revealed: Residents are provided with a safe, clean, comfortable and homelike environment. Record review of a pest contract revealed the agreement was effective October 1, 2021, and reflected .8. Service Provider's Schedule and Availability, service provider shall be reasonably available to the Facility and shall spend sufficient time at the facility premises to fulfill service provider's duties hereunder. Record review of facility policy titled, physical Environment, revised 05/2020 reflected: POLICY:It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.Responsibilities:Facility staff will:1. Report any pest sightings and file a report using the pest observation log.2. Document problems found during inspection and the remedial actions taken.3. Advise staff on preventive measure, unsanitary conditions, etc.4. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment.Pest Identification:The following guidelines for pest identification:1. When pests are sighted, determine why the infestation is occurring and advise department on preventive measures.2. Use pesticides only after all other channels of control are exhausted.3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls.4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information:a. Type of problemb. Locationc. Person reporting and time reported.Pest Prevention:The following are guidelines for pest prevention:1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc.2. Keep grounds free of trash and brush.3. Keep the dumpster area clean.4. Food stored in resident rooms will be in covered containers.5. Clean up food spills.6. Screen foundation areas with mesh.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Hall 400) of three medication carts reviewed for pharmacy services.<BR/>On 06/19/25, LVN A failed to ensure medication cart was locked when not being used at the nursing station on Hall 400.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings included:<BR/>Observation on 06/19/25 at 11:10 am revealed the medication cart was unlocked in front of the nurse's station. The drawers faced the hallway, and no staff was in sight. LVN A walked by the medication cart and pressed the lock closed and left 400 Hall with a resident. The medication cart was left unlocked for approximately 5 minutes and no residents and visitors were in the area at that time. <BR/>Interview on 06/19/25 at 11:20 am, LVN-PRN B stated the medication cart should be locked when not in use because residents could take medications out of the cart and take the wrong medication.<BR/>Interview on 06/19/25 at 12:10 pm, LVN A stated she had a resident that returned from dialysis and went to go check on the resident. LVN A stated she was taking a resident off of the hall, checked the cart, and locked it. LVN A stated she should have locked the cart when she walked away. <BR/>Interview on 06/20/25 at 9:15 am, the DON stated the medication cart should be locked to prevent drug diversion and access to medications by residents. <BR/>Record review of the facility's policy titled Care and Treatment/ Pharmacy revised July 2023 reflected: <BR/>It is the policy of this facility to store all drugs and biological in locked compartments .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 1 (Resident#1) of 4 Residents reviewed for resident rights in that: <BR/>The facility failed to investigate when it was reported that Resident #1 had a second Power of Attorney to ensure the appropriate person was making legal decisions for Resident #1. <BR/> This failure could place residents at risk of not having their wishes or needs met by a Power of Attorney of their choosing. <BR/>Findings included:<BR/>Review of Resident #1's MDS quarterly assessment, dated 12/23/22, revealed the resident was an [AGE] year-old-female admitted to the facility on [DATE]. The MDS assessment reflected Resident #1's cognition was severely impaired with a BIMS score of 04, and her diagnoses included Alzheimer's disease, diabetes, and hypertension (high blood pressure). The resident required the limited assistance of one staff for activities of daily living and was totally dependent for decision making. <BR/>Review of Resident #1's comprehensive care plan dated, 09/27/22 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's Dementia. The care plan reflected goals and approaches related to needing supervision/assistance with all decision making, impaired cognitive function, impaired thought processes, related to Alzheimer's dementia, and communication. <BR/>During an observation and interview on 01/18/2023 at 8:55 a.m., in the secured unit dining room revealed Resident #1 siting and completing her breakfast. Resident #1 was unable to answer any questions about the Power of Attorney, she kept asking about her family. <BR/>An interview on 01/18/23 at 9:00 a.m. with LVN A revealed Resident #1 was a pleasantly confused resident that required assistance with her activities of daily living. She had behaviors of wandering and she could not make safe decisions or herself. LVN A stated that Resident #1 had family member C that she communicated with, she was the Power of Attorney. LVN A stated she was aware there were other family members, family member C had shared that with her, but she had never spoken to them. <BR/>An interview on 01/18/23 at 11:25 a.m. the Marketing Director revealed when a resident admitted to the facility, she always asked the responsible party/or the resident if there was a Power of Attorney, she would get a copy of the Power of Attorney at the time of admission. The copy of the Power of Attorney was uploaded into the computer system. She stated when Resident #1 admitted to the facility her family member C had a Power of Attorney that was provided. The Marketing Director stated that she was working the day when three gentlemen showed up to the facility stating that they were Resident #1's two family members and an older family member, they visited the resident and then left. No one ever mentioned anything to me about there was another Power of Attorney. The marketing director stated she saw the family speaking with the Social Worker.<BR/>In an interview on 01/18/23 at 11:45 a.m. the Social Worker revealed she had met with the family members of Resident #1 on 09/26/22. family member B told the Social Worker that they were Resident #1's family. The Social Worker said the older family member did not appear to be able to make any decisions, he was not responsive to her questions. The Social Worker stated that during the meeting family member B stated they were not aware of where their mother was, family member C had stolen her from Florida, leaving her husband behind. They told me that they had received some mail that had given them an address where she was so they had come here to get her and take her home with her family, but the nurse had told them they could not remove her without the permission of family member C, since she had the Power of Attorney. I told them that was correct. Family member B told me that he had a Power of Attorney, I asked him to see it, but he said he did not have it with him, he had left home in a hurry to come here and get his mother. I told him I could not help him and referred him to the DON. The Social Worker stated she did not report to anyone, not the Administrator or speak further with the DON about the meeting because I had referred them to the DON and I could not help them, since there was already a Power of Attorney. The Social Worker stated she did not think that it was important at the time, since family member B could not show her a Power of the Attorney to follow up. The Social Worker stated the family left the facility, and she had no other contact with them. The Social Worker stated when asked she did not think it was a case that she would think about reporting to the Adult Protective Services, since the resident was cared for and exhibited no signs of abuse or neglect.<BR/>In an interview on 1/18/2023 at 6:12 p.m., the DON and Administrator revealed if they had not been informed of the possibility of two Power of Attorney's with a resident, they would immediately contact their legal department and start an investigation. They stated if they had been informed, they would have investigated the situation to try and resolve the issue and see what family member had the correct Power of Attorney. The Administrator stated that the Social Worker should have informed him. <BR/>Record review of Resident #1's Durable Power of Attorney dated 07/28/21, notarized and signed by Resident #1 naming the family member C the power of attorney. Further review reflected additional dates, notarized on February 28th, 2021, on the Durable Power of Attorney.<BR/>Record review of Resident #1's General Power of Attorney dated 02/16/21, notarized and signed by the Resident #1 naming the family member B the Power of attorney, provided to the investigator by family member B.<BR/>Review of the facility's current policy and procedure entitled Resident Rights dated November 2017 reflected, it is the policy of this facility that each resident has the right to be free from . definitions: . exploitation and mistreatment . exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion . resident representative .a person authorized by State or Federal law including but not limited to agents und power of attorney ) to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or personal information of the resident; manage financial matters

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Hall 400) of three medication carts reviewed for pharmacy services.<BR/>On 06/19/25, LVN A failed to ensure medication cart was locked when not being used at the nursing station on Hall 400.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings included:<BR/>Observation on 06/19/25 at 11:10 am revealed the medication cart was unlocked in front of the nurse's station. The drawers faced the hallway, and no staff was in sight. LVN A walked by the medication cart and pressed the lock closed and left 400 Hall with a resident. The medication cart was left unlocked for approximately 5 minutes and no residents and visitors were in the area at that time. <BR/>Interview on 06/19/25 at 11:20 am, LVN-PRN B stated the medication cart should be locked when not in use because residents could take medications out of the cart and take the wrong medication.<BR/>Interview on 06/19/25 at 12:10 pm, LVN A stated she had a resident that returned from dialysis and went to go check on the resident. LVN A stated she was taking a resident off of the hall, checked the cart, and locked it. LVN A stated she should have locked the cart when she walked away. <BR/>Interview on 06/20/25 at 9:15 am, the DON stated the medication cart should be locked to prevent drug diversion and access to medications by residents. <BR/>Record review of the facility's policy titled Care and Treatment/ Pharmacy revised July 2023 reflected: <BR/>It is the policy of this facility to store all drugs and biological in locked compartments .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with accommodation of resident needs and preferences for one (Resident #1) of five residents reviewed for reasonable accommodation of needs.<BR/>The facility failed to ensure the call light system was within reach of the Resident #1 lying in bed.<BR/>This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers.<BR/>Findings included:<BR/>A record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male with a BIMS score 00 of 15, indicating severe cognitive impairment. Resident #1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses including, neurogenic bladder, multiple sclerosis, and hemiplegia or hemiparesis (Hemiplegia: paralysis of one side of the body) with left elbow, and left wrist contracture. The review further reflected the resident was totally dependent on staff for the ADL's (activity of daily living).<BR/>A record review of Resident #1's Comprehensive Care Plan dated 11/27/24 reflected Focus. At risk for falls r/t MS, seizures, impaired mobility, nonverbal, incontinent. Goal. Will be free of falls through the review date. Interventions. Anticipate and meet needs. Be sure the call light is within reach and encourage to use it to call for assistance as needed. <BR/>Observation and interview on 01/15/25 at 10:32 AM Resident#1 was lying in bed. Resident#1's call light was on top of the nightstand. LVN A entered the room and stated the call light was not within reach of Resident#1 and took the call light from the nightstand and clip it to Resident#1 blanket. <BR/>Interview on 01/15/25 at 10:33 AM LVN A stated the call light should be within residents reach all the time, and the risk to the resident could be not getting help on time could be a fall and possible injury. LVN A stated it was the responsibility of all the staff to make sure the call light was within resident reach before exiting the room.<BR/>Interview on 01/15/25 at 12:14 PM the DON stated the call-light should be always accessible to the resident, and it was the responsibility of all staff to make sure the call lights always within reach of the residents. The DON stated the risk to the residents, if they cannot reach the call light, they could not call for help, and they would not get the help they needed.<BR/>Interview on 01/16/25 at 12:06 PM the Administrator stated his expectation from all the staff was for the call light to be within reach of the resident before living the room either attached to the bed or the resident. He stated the risk to residents, they would not be able to make their needs known, and their needs would not be addressed in timely manner. He stated the in service was done monthly on staff meeting to take care of fall.<BR/>Review of the facility policy titled policy/Procedure-Nursing services. Section: Routine Procedures- Subject: Call Light/Bell, revised 05/2007 revealed It is the policy of (to provide the resident a means of communication with nursing staff . 5. Place the call device within resident's reach before leaving room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior environment for one residents' room (room [ROOM NUMBER] 301 ) of 6 residents' rooms reviewed for clean and sanitary environment.<BR/>The shared bathroom in resident room [ROOM NUMBER] 301 had a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain.<BR/>These failures could affect residents by placing them at risk of not having a clean, sanitary, and comfortable environment. <BR/>Findings included: <BR/>1. Observation of Resident #69, and Resident#32's shared bathroom on 03/18/2 at 10:41 AM showed a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain.<BR/>Observation/Interview with Maintenance Director on 03/19/25 at 09:02 AM he looked at the bathroom floor in room [ROOM NUMBER] 301 and stated it may have a leak somewhere. He flushed the toilet and looked under the toilet tank and stated the leaking is from under the tank. He stated did not know about this leak in the Residents' Bathroom . He stated his staff do water flush monthly in all the residents' bathrooms and check the residents' rooms status at the same time He stated, he would get it fixed. He stated the risk to the resident, resident could slip and fall because of the water in the floor.<BR/>Interview on 03/20/2025 at 09:45 AM with LVN C, she stated did not know about the water in the residents' bathroom. She stated any staff who noticed the water on the floor should put the wet floor signage in front of the bathroom and put an order in the system for the maintenance supervisor to fix it. She stated the risk to residents was they can fall.<BR/>Interview on 03/22/25 at 4:53 PM the DON stated she expected CNAs to report it, log it in the maintenance department log system, called it in to them, and put yellow signage in front of the bathroom. She stated she expected the maintenance supervisor to fix the leak. She stated the risk to residents injury.<BR/>Interview on 03/22/25 at 5:16 the administrator stated, he expected the staff to report the leak in the residents' room toilet to maintenance supervisor, and for maintenance supervisor to fix it. He stated the risk to residents fall.<BR/>Review of facility policy dated 06/2013 titled Policy and procedure for Falls, Standard. This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior environment for one residents' room (room [ROOM NUMBER] 301 ) of 6 residents' rooms reviewed for clean and sanitary environment.<BR/>The shared bathroom in resident room [ROOM NUMBER] 301 had a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain.<BR/>These failures could affect residents by placing them at risk of not having a clean, sanitary, and comfortable environment. <BR/>Findings included: <BR/>1. Observation of Resident #69, and Resident#32's shared bathroom on 03/18/2 at 10:41 AM showed a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain.<BR/>Observation/Interview with Maintenance Director on 03/19/25 at 09:02 AM he looked at the bathroom floor in room [ROOM NUMBER] 301 and stated it may have a leak somewhere. He flushed the toilet and looked under the toilet tank and stated the leaking is from under the tank. He stated did not know about this leak in the Residents' Bathroom . He stated his staff do water flush monthly in all the residents' bathrooms and check the residents' rooms status at the same time He stated, he would get it fixed. He stated the risk to the resident, resident could slip and fall because of the water in the floor.<BR/>Interview on 03/20/2025 at 09:45 AM with LVN C, she stated did not know about the water in the residents' bathroom. She stated any staff who noticed the water on the floor should put the wet floor signage in front of the bathroom and put an order in the system for the maintenance supervisor to fix it. She stated the risk to residents was they can fall.<BR/>Interview on 03/22/25 at 4:53 PM the DON stated she expected CNAs to report it, log it in the maintenance department log system, called it in to them, and put yellow signage in front of the bathroom. She stated she expected the maintenance supervisor to fix the leak. She stated the risk to residents injury.<BR/>Interview on 03/22/25 at 5:16 the administrator stated, he expected the staff to report the leak in the residents' room toilet to maintenance supervisor, and for maintenance supervisor to fix it. He stated the risk to residents fall.<BR/>Review of facility policy dated 06/2013 titled Policy and procedure for Falls, Standard. This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior environment for one residents' room (room [ROOM NUMBER] 301 ) of 6 residents' rooms reviewed for clean and sanitary environment.<BR/>The shared bathroom in resident room [ROOM NUMBER] 301 had a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain.<BR/>These failures could affect residents by placing them at risk of not having a clean, sanitary, and comfortable environment. <BR/>Findings included: <BR/>1. Observation of Resident #69, and Resident#32's shared bathroom on 03/18/2 at 10:41 AM showed a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain.<BR/>Observation/Interview with Maintenance Director on 03/19/25 at 09:02 AM he looked at the bathroom floor in room [ROOM NUMBER] 301 and stated it may have a leak somewhere. He flushed the toilet and looked under the toilet tank and stated the leaking is from under the tank. He stated did not know about this leak in the Residents' Bathroom . He stated his staff do water flush monthly in all the residents' bathrooms and check the residents' rooms status at the same time He stated, he would get it fixed. He stated the risk to the resident, resident could slip and fall because of the water in the floor.<BR/>Interview on 03/20/2025 at 09:45 AM with LVN C, she stated did not know about the water in the residents' bathroom. She stated any staff who noticed the water on the floor should put the wet floor signage in front of the bathroom and put an order in the system for the maintenance supervisor to fix it. She stated the risk to residents was they can fall.<BR/>Interview on 03/22/25 at 4:53 PM the DON stated she expected CNAs to report it, log it in the maintenance department log system, called it in to them, and put yellow signage in front of the bathroom. She stated she expected the maintenance supervisor to fix the leak. She stated the risk to residents injury.<BR/>Interview on 03/22/25 at 5:16 the administrator stated, he expected the staff to report the leak in the residents' room toilet to maintenance supervisor, and for maintenance supervisor to fix it. He stated the risk to residents fall.<BR/>Review of facility policy dated 06/2013 titled Policy and procedure for Falls, Standard. This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Hall 400) of three medication carts reviewed for pharmacy services.<BR/>On 06/19/25, LVN A failed to ensure medication cart was locked when not being used at the nursing station on Hall 400.<BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings included:<BR/>Observation on 06/19/25 at 11:10 am revealed the medication cart was unlocked in front of the nurse's station. The drawers faced the hallway, and no staff was in sight. LVN A walked by the medication cart and pressed the lock closed and left 400 Hall with a resident. The medication cart was left unlocked for approximately 5 minutes and no residents and visitors were in the area at that time. <BR/>Interview on 06/19/25 at 11:20 am, LVN-PRN B stated the medication cart should be locked when not in use because residents could take medications out of the cart and take the wrong medication.<BR/>Interview on 06/19/25 at 12:10 pm, LVN A stated she had a resident that returned from dialysis and went to go check on the resident. LVN A stated she was taking a resident off of the hall, checked the cart, and locked it. LVN A stated she should have locked the cart when she walked away. <BR/>Interview on 06/20/25 at 9:15 am, the DON stated the medication cart should be locked to prevent drug diversion and access to medications by residents. <BR/>Record review of the facility's policy titled Care and Treatment/ Pharmacy revised July 2023 reflected: <BR/>It is the policy of this facility to store all drugs and biological in locked compartments .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.