Every finding on record at Fort Myers Rehabilitation and Nursing Center

Based on observation and staff interviews, the facility failed to follow proper sanitation procedures for the 3-compartment sink, increasing the risk of cross-contamination and foodborne illness with the potential to impact residents receiving cooked food out of the dietary department. The findings included: The policy for the 3-compartment sink provided by the facility, with no effective date, stated, Sink 1= Wash, sink 2= Rinse, sink 3= Sanitize. Three-compartment sink steps: 1. Preparation: Fill sink (1) with warm Pot and Pan Detergent Solution. Fill Rinse sink (#2) with warm water. Fill the Sanitize sink (#3) with warm sanitizer solution to 200 PPM. 2. Pre-wash: Pre-scrape and rinse all items prior to washing in sink #1. 3. Wash: Scrub all surfaces (including handles). 4. Rinse: Submerge item in rinse water. Let rinse water run back into rinse sink. 5. Sanitize: Submerge item in sanitizer sink for a minimum of 60 seconds. Remove item from sink and let air dry. Do not wipe dry. On 4/2/25 from 11:15-11:25 a.m., during a 3-compartment sink observation, Staff O, a full-time Dietary Aide, was observed submerging dishes into the third compartment (containing the sanitizing solution) of the sink for 1-2 seconds. The employee then shook off the excess water and placed the dishes to the side of the sink on a rubber dry mat to dry. On 4/2/25 at 11:28 a.m., during an interview with Staff O, she was unable to speak to the process for washing, rinsing and sanitizing dishes using the 3-compartment sink. She read aloud the instructions posted on the wall that said, the dishes should be soaked for 60 seconds. **Photographic evidence obtained** On 4/2/25 at 4:50 p.m., during an interview with the Assistant Certified Dietary Manager (ACDM) she said, the procedure for the 3-compartment sink was the first sink was to scrub, the second was to rinse, and the third one was to sanitize. Then they are placed on the metal rack above the sink to air dry. When asked how long the dishes should soak in the third compartment, she said 5-15 minutes. The Certified Dietary Manager then read through the posted instructions on the wall above the sink. She read out loud, The dishes should be submerged for 60 seconds. On 4/3/25 at 8:36 a.m., the ACDM said during an interview that Dietary Aide, Staff O incorrectly sanitized the dishes. They should not be submerged for less than 60 seconds.

Based on observation, review of the clinical record, review of the facility job description of the Activity Director and staff interviews, the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident's physical, mental, and psychosocial well-being for 2 ( Resident #3 and #91 ) of 3 residents reviewed for involvement in the activity programs. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being. The findings included: The facility Job Description and Performance Evaluation for the Activity Director documented Responsible for the planning, developing, organizing, implementing, evaluating and directing of activity programs in accordance with current exiting federal, state and local standards. Plan develop, organize, evaluate and direct activity programs to ensure all patients/residents assessed needs are met. Record and maintain activity progress notes as well as a record of resident activities. 1. Review of the clinical record revealed Resident #3 had an admitted [DATE] with diagnoses including dementia with restlessness, anxiety disorder, delusional and adjustment disorder. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 5/19/24 documented Resident #3's preference for routine and activities specified it was very important for Resident #3 to have books, newspapers, and magazines to read, to listen to music she likes, and to keep up with the news. It was somewhat important for Resident #3 to be around animals such as pets, and to do her favorite activities. The MDS noted Resident #3's cognitive skills for daily decision making were moderately impaired. Review of the care plan initiated 10/8/20 documented The Resident needs encouragement and assistance in pursuing activities. The care plan interventions included, Invite and assist resident to music related activities. Offer foods that comply with the residents' ordered diet. Offer pet therapy to resident. On 3/31/25 during random observations at 10:24 a.m., 11:32 a.m., 1:20 p.m., and 3:25 p.m., Resident # 3 was observed in her room with the door open. She was in a wheelchair (w/c) facing the side of the closet. She had a tray table in front of her, that was pushed up against the side of the closet. There was nothing on the table for the resident to eat, drink or to occupy her time. She was not meaningfully engaged and had no radio or television on. Review of the March 2025 Activity Calendar specified the activities on 3/31/25:9:00 a.m., Rise and Shine, 10:00 a.m., What's cooking, 1:00 p.m., Arts and Crafts, 2:00 p.m., Room Visits, 3:00 p.m., Gulf Coast Baptist. On 4/1/25 at 10:00 a.m., Resident # 3 was in her room, in w/c facing the side of the closet with the tray table in front of her and pushed against the closet. She has no liquids, food or items on the table. There was no music and no television on. Review of the April 2025 Activity Calendar specified the activities on 4/1/25: 9:00 a.m., Rise and Shine, 10:00 a.m., Pokeno, 11:00 a.m., Trivia, 1:00 p.m., Movie and Popcorn, 1:45 p.m., room visits. On 4/2/25 at 1:31 p.m., a review of the electronic record for the previous 30 days revealed documentation Resident #3 attended one activity on 3/25/25 at 2:24 p.m., and 3/27/25 at 2:49 p.m. 2. Review of the clinical record revealed Resident #91 was [AGE] years old with diagnoses including senile degeneration of the brain, adjustment disorder, delusional disorder, severe protein calorie malnutrition, dementia, anxiety disorder, restlessness and agitation. The Annual MDS dated [DATE] documented Resident #91's preference for routine and activities specified it was very important to have books, newspapers, and magazines to read, to participate in religious services or practices and do her favorite activities. It was somewhat important for Resident #91 to listen to music she likes and to keep up with the news. The MDS noted Resident #93's cognitive skills for daily decision making were severely impaired. The care plan initiated 1/5/24 identified The Resident requires staff assistance with involvement of activities related to dementia and/or impaired thought process. The interventions for the resident included, invite and assist the resident to group activities, religious services and music related activities and offer the resident pet therapy. During random observations on 3/31/25 at 12:07 p.m., and 3:24 p.m., Resident #91 was observed in her room in her w/c. The bedside table was in front of her and it was push up against a blank wall. No activity items, water or snacks were available on the table for her. She said she was waiting to go to school and looking for her teacher. Observations on 4/1/25 at 9:56 a.m., Resident #91 was in her w/c with a tray table over her and it was pushed up against the blank wall. There were no liquids or food or activity items on the table for the resident. She was anxious repeating, I'm cold and I don't know what I'm doing. At 12:11 p.m., Resident #91 was observed in the w/c in her room with a tray table in front of her that was pushed up against the blank wall. There was a Styrofoam cup of ice water on the table. Continued observations on 4/1/25 at 1:13 p.m., 1:34 p.m., and 3:41 p.m., Resident # 91 was observed in her room in the same position facing a blank wall and yelling out Help me, I want to go to bed. Help me. On 4/2/25 at 9:58 a.m., a review of the electronic record documented in the previous 30 days Resident #91 participated in no activity programs. On 4/2/25 at 9:06 a.m., in an interview Activity Assistant Staff C said she did not have a certification and no training for the position of activity aid. She said she follows the activity calendar on the wall. For residents who don't come out of the room or to activities, I do room visits every day but I can't see everyone in one day. I talk to them, if they need anything I make up packets with word search, coloring and puzzles. I do nail care and hand massage. I can't get to many of the residents, and I spend about 10 minutes with each resident. On 4/2/25 at 9:42 a.m., in an interview Activity Director Staff A said she was the Activity Director here for 4 years. Staff A said we take the residents to the activity room or the day room on the [NAME] Unit. The day room is for the lower functioning residents. We did have activities here on 3/31/25 and 4/1/25 in the [NAME] day room. This writer mentioned that no one was observed in the day room on 3/31/25 and 4/1/25. Staff A replied it is because only 1 resident showed up and we did not do the activity for just one person. For the residents who do not get out of bed or don't come to activities, I do room visits. We are here 9-5 Monday to Sunday. There are 3 of us, but right now one is out sick. The main activity room is for higher functioning residents. Staff A said she documents participation in the activity program in the electronic record for each resident and she maintained no paper documentation. Staff A said Resident #3 is in the main activity room daily and Resident #91 is in the [NAME] Unit Day room daily for activities. The Activity Director said there was documentation in the electronic record Residents #3 and #91 attend all day activities. This writer showed the Activity Director the previous 30 day documentation for both residents and she confirmed Resident #3 attended 2 activities and Resident #91 attended no activity programs. The Activity Director said I don't know why there is no documentation.

Based on review of the facility job description for the Activity Director and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all 131 current residents residing in the facility. The findings included: The facility Job Description and Performance Evaluation documented Responsible for the planning, developing, organizing, implementing, evaluating and directing of activity programs in accordance with current exiting federal, state and local standards. Plan develop, organize, evaluate and direct activity programs to ensure all patients/residents assessed needs are met. Record and maintain activity progress notes as well as a record of resident activities. Qualifications Education College specialization, certification preferred. On 4/2/25 at 9:06 a.m., in an interview Activity Assistant Staff C said she did not have a certification for the position of the Activity Director and no training for the position. She said she had no qualifications for the position of Activity Director, and said I am her assistant. On 4/2/25 at 9:37 a.m., a request was made to Director of Nursing for documentation of the qualifications of the Activity Director. On 4/2/25 at 9:42 a.m., in an interview Certified Nursing Assistant Staff A said she has been the Activity Director for the facility for four years. She said she had not completed training and did not have a certificate for the position of Activity Director. On 4/2/25 at 1:16 p.m., in an interview, the Administrator confirmed Activity Director Staff A did not have the required qualifications for the position of Activity Director.

Based on observation, review of facility policy and procedures, record review and staff and resident interviews, the facility failed to ensure urinary catheters were secured to prevent pulling and injury and failed to maintain the catheters in sanitary manner for 3 (Resident #50, #423, and #274) of 3 residents reviewed with an indwelling urinary catheter. The findings included: The facility policy Catheter-Foley documented Completing the procedure, Secure the catheter to the residents thigh (i.e , Stat Lock or Catheter Strap) to prevent movement, irritation and decrease risk of infection. Never leave the catheter hanging to be pulled by the weight of the bag. Place catheter bag in a dignity bag. 1. Review of the clinical record revealed Resident #50 had a readmitted [DATE] with diagnoses including morbid obesity, paraplegia, type 2 diabetes, chronic kidney disease, urinary retention, dementia, anxiety and delusional disorder. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 3/15/25 documented Resident #50 was dependent for personal hygiene and toileting. The MDS noted Resident #65's cognitive skills for daily decision making were moderately impaired. The care plan initiated 7/21/21 specified the resident wanted to have toileting needs met with dignity and promptly. On 3/31/25 at 11:00 a.m., Resident #50 was observed in bed. She was noted to have an indwelling urinary catheter, that was not secured to her leg. The catheter tubing was noted to be taunt and pulling, the drainage bag was attached to the bed frame and was not in a privacy bag. Resident #50 said sometimes the catheter pulls and she has to hold the tube when the staff are caring for her. On 4/1/25 at 11:47 a.m., Resident #50 was observed in bed and she removed the bed covers to show she did not have a securement device for the catheter. The drainage bag was attached to the bed frame and the tubing was noted to be taunt and stretched. On 4/2/25 at 9:22 a.m., Resident #50 was observed in bed and said she did not want anyone to touch her catheter. She said the staff pour water on it and wash it every day. Resident #50 said she did not have anything on her leg to secure the catheter and said it just hangs there and it hurts. She pulled back the covers to show this writer the catheter was not secured. Resident #50 said I usually hold it when they provide care and if I hold it, then it doesn't hurt when they do the care. 2. Review of the clinical record revealed Resident #423 was admitted [DATE] with a readmission on 3/27/25. Resident #423 had diagnoses including urinary retention, senile degeneration of the brain and acute cystitis with hematuria (inflammation of the bladder with blood in the urine). Review of the physician orders specified to secure catheter tubing to thigh with catheter secure or leg strap. On 3/31/25 at 12:00 p.m., Resident #423 was observed in his bed with a indwelling catheter and the tubing was noted to be pulling taut and was and not secured to his leg to prevent the pulling. The urinary drainage bag was secured to the bed frame and the catheter bag had no privacy cover. On 4/1/25 at 10:07 a.m., Resident #423 was observed in bed with the catheter securement device on the catheter, but it was not secured to his leg. The drainage bag was pulling, and the tubing was stretched tightly. On 4/3/25 at 9:48 a.m., Resident #423 was observed in bed and he did not have a catheter securement device in place. The catheter tubing was pulled tightly and wrapped around the leg of the bedside table. Photographic evidence obtained. On 4/3/25 at 9:49 a.m., Licensed Practical Nurse Staff D observed the resident's catheter and verified in an interview Resident #423's catheter tubing was unsecured and wrapped around the bedside table. On 4/3/25 at 9:55 a.m., in an interview Certified Nursing Assistant (CNA) Staff B said when cleaning the catheter you wipe from front to back and you place the catheter bag in a privacy bag attached to the bed frame. She said she never applies a leg strap; the nurse does that. 51818 3. Resident #274 was admitted to the facility on [DATE] with a diagnosis of muscle wasting and atrophy, pressure ulcer of sacral region, dysphagia, urinary retention, protein-calorie malnutrition, and cardiomyopathy. The resident was last assessed by a nursing assessment as alert and oriented with periods of confusion on 3/27/25. On 3/31/25 at 10:05 a.m., in an interview Resident #274 stated, I have a Foley connected to the end of the bed. Observation of Urinary Catheter bag connected to the bedframe, where the drainage bag, tubing, and valve stem were laying on the floor. On 3/31/25 at 10:10 a.m., an observation was made of a conversation between Registered Nurse (RN) Staff G and Resident #274. Resident #274 asked Staff G, for a dignity bag for his Foley catheter so he can get out of bed. Resident #274 told RN Staff G, You know, if I had a special bag, I could get up and walk around. Can you get me out of bed? Staff G said that he knew the Urinary Catheter should not be touching in the floor, It belongs in a dignity bag. On 4/2/25 at 2:00 p.m., in an interview the Infection Preventionist and Staff Development Coordinator said that maintaining the urinary catheter off the floor is included in staff training for Foley Care.

Based on observation, review of the clinical record, review of the facility job description of the Activity Director and staff interviews, the facility failed to ensure resident records were maintained in accordance with accepted professional standards and practices, that are complete, and accurately documented for 2 (Residents #3, and #91) of 28 residents records reviewed. The findings included: The facility Job Description and Performance Evaluation for the Activity Director documented Responsible to Record and maintain activity progress notes as well as a record of resident activities. 1. Review of the clinical record revealed Resident #3 had an admitted [DATE] with diagnoses including dementia with restlessness, anxiety disorder, delusional and adjustment disorder. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 5/19/24 documented Resident #3's preference for routine and activities specified it was very important for Resident #3 to have books, newspapers, and magazines to read, to listen to music she likes, and to keep up with the news. It was somewhat important for Resident #3 to be around animals such as pets, and to do her favorite activities. The MDS noted Resident #3's cognitive skills for daily decision making were moderately impaired. Review of the care plan initiated 10/8/20 documented The Resident needs encouragement and assistance in pursuing activities. The care plan interventions included, Invite and assist resident to music related activities. Offer foods that comply with the residents' ordered diet. Offer pet therapy to resident. On 3/31/25 during observations at 10:24 a.m., 11:32 a.m., 1:20 p.m., and 3:25 p.m., Resident # 3 was observed in her room with the door open. She was in a wheelchair (w/c) facing the side of the closet. She had a tray table in front of her, that was pushed up against the side of the closet. There was nothing on the table for the resident to eat, drink or to occupy her time. She was not meaningfully engaged and had no radio or television on. Review of the March 2025 Activity Calendar specified the activities on 3/31/25: 9:00 a.m., Rise and Shine, 10:00 a.m., What's cooking, 1:00 p.m., Arts and Crafts, 2:00 p.m., Room Visits, 3:00 p.m., Gulf Coast Baptist. On 4/1/25 at 10:00 a.m., Resident #3 was in her room, in w/c facing the side of the closet with the tray table in front of her and pushed against the closet. She has no liquids, food or items on the table. There was no music and no television on. Review of the April 2025 Activity Calendar specified the activities on 4/1/25: 9:00 a.m., Rise and Shine, 10:00 a.m., Pokeno, 11:00 a.m., Trivia, 1:00 p.m., Movie and Popcorn, 1:45 p.m., room visits. On 4/2/25 at 1:31 p.m., a review of the electronic record for the previous 30 days revealed documentation Resident #3 attended one activity on 3/25/25 at 2:24 p.m., and 3/27/25 at 2:49 p.m. 2. Review of the clinical record revealed Resident #91 was [AGE] years old with diagnoses including senile degeneration of the brain, adjustment disorder, delusional disorder, severe protein calorie malnutrition, dementia, anxiety disorder, restlessness and agitation. The Annual MDS dated [DATE] documented Resident #91's preference for routine and activities specified it was very important to have books, newspapers, and magazines to read, to participate in religious services or practices and do her favorite activities. It was somewhat important for Resident #91 to listen to music she likes and to keep up with the news. The MDS noted Resident #93's cognitive skills for daily decision making were severely impaired. The care plan initiated 1/5/24 identified The Resident requires staff assistance with involvement of activities related to dementia and/or impaired thought process. The interventions for the resident included, invite and assist the resident to group activities, religious services and music related activities and offer the resident pet therapy. During random observations on 3/31/25 at 12:07 p.m., and 3:24 p.m., Resident #91 was observed in her room in her w/c with the bedside table in front of her that was pushed up against a blank wall. No activity items, water or snacks were available on the table for her. She said she was waiting to go to school and looking for her teacher. Observations on 4/1/25 at 9:56 a.m., Resident #91 was in her w/c with a tray table over her and it was pushed up against the blank wall. There were no liquids or food or activity items on the table for the resident. She was anxious repeating, I'm cold and I don't know what I'm doing. At 12:11 p.m., Resident #91 was observed in the w/c in her room with a tray table in front of her that was pushed up against the blank wall. There was a Styrofoam cup of ice water on the table. Continued observations on 4/1/25 at 1:13 p.m., 1:34 p.m., and 3:41 p.m., Resident # 91 was observed in her room in the same position facing a blank wall and yelling out Help me, I want to go to bed. Help me. On 4/2/25 at 9:58 a.m., a review of the electronic record documented in the previous 30 days Resident #91 participated in no activity programs. On 4/2/25 at 9:06 a.m., in an interview Activity Assistant Staff C said she did not have a certification and no training for the position of activity aid. She said she follows the activity calendar on the wall. For residents who don't come out of the room or to activities, I do room visits every day but I can't see everyone in one day. I talk to them, if they need anything I make up packets with word search, coloring and puzzles. I do nail care and hand massage. I can't get to many of the residents, and I spend about 10 minutes with each resident. On 4/2/25 at 9:42 a.m., in an interview Activity Director Staff A said she was the Activity Director here for 4 years. Staff A said we take the residents to the activity room or the day room on the [NAME] Unit. The day room is for the lower functioning residents. We did have activities here on 3/31/25 and 4/1/25 in the [NAME] day room. This writer mentioned that no one was observed in the day room on 3/31/25 and 4/1/25. Staff A replied it is because only 1 resident showed up and we did not do the activity for just one person. For the residents who do not get out of bed or don't come to activities I do room visits. We are here 9-5 Monday to Sunday. There are 3 of us, but right now one is out sick. The main activity room is for higher functioning residents. Staff A said she documents participation in the activity program in the electronic record for each resident and she maintains no paper documentation. Staff A said Resident #3 is in the main activity room daily and Resident #91 is in the [NAME] Unit Day room daily for activities. The Activity Director said there was documentation in the electronic record Residents #3 and #91 attend all day activities. The Activity Director reviewed the previous 30 day documentation for Residents #3 and #91. She confirmed Resident #3 attended 2 activities and Resident #91 attended no activity programs. The Activity Director said, I don't know why there is no documentation. A second review of the documentation for participation in the activity programs for the previous 30 days, showed the documentation was updated and showing that Resident #3 and #91 had participated in one or two activities daily. On 4/2/25 at 1:40 p.m., in an interview the Activity Director confirmed the activity records at this time, for participation in activities documented Resident #3 and #91 attended daily programs in the previous 30 days. When asked why there was now documentation for Resident #3 and #91 participating in daily activity programs, she replied, Late Entries. When asked how Resident #91 was in activity programs on 3/31/25 and 4/1/25 when this writer was monitoring her, she replied I had Resident #91 in the activity room on the [NAME] Unit all day, she was in activities. When asked how the resident could be in the activity programs when she was observed in her room the Activity Director replied, I don't know. On 4/2/25 at 2:39 p.m., Review of the activity participation record documented Resident #3 participated in daily activity programs for the previous 30 days that were not documented when reviewed that morning. The documentation revealed Resident #3 was attending activities daily including Monday 3/31/25 when Resident #3 was monitored and observed in her room all day.

Based on observation, record review, and interview, the facility failed to ensure a clean, comfortable, homelike environment that allows the resident to use the physical layout to maximize independence and does not pose a safety risk for 4 (#52, #57, #273, #274) of 5 residents reviewed. The findings included: Review of an admissions agreement (no date) revealed, The facility will provide resident with room and board, nursing service, and laundering of linens. 1. Record review of Resident #52 was admitted on [DATE] a Brief Interview for Metal Status (BIMS), with a score of 10 on 3/5/25, indicating that he has moderately impaired cognition. Resident #52's diagnoses included Schizophrenia and Schizoaffective disorder. On 3/31/25 at 9:25 a.m., Resident #52 was observed sitting on the side of his bed dressed in personal clothing. A blue incontinent brief soiled with feces like substance was observed on the bathroom floor. On 3/31/25 at 9:25 a.m., during an interview and continuous observation Resident #52 gestured to his wheelchair, side table and dresser and stated, It's too tight, there's not enough room, some of this clutter in the drawer, these wipes, it's not my stuff, it's their stuff. I don't use any of what's in the drawer, so my stuff has to go on top of the drawer, and they (facility staff) said I have to keep the wheelchair here between the bed and the bathroom door, but it is hard for me to get in. When asked how he gets to the bathroom, Resident #52 said, I have to get up and walk past the wheelchair and squeeze into the bathroom. Resident #52 stated, I had to change myself (gestured to the soiled brief). I was dirty, I did the best I could while standing up but it was hard and I left the diaper on the floor because where else would it go, there was no trashcan. Resident #52 said that he has requested to have the wheelchair or the bed moved, but he was told the wheelchair must be next to the bed, and the bed can't be moved. On 3/31/25 at 9:35 a.m., during an observation, the Assistant Director of Nursing (ADON) came to the room of Resident #52 and was unable to walk directly into the bathroom. The ADON turned and side stepped into the bathroom through the narrow opening of the bathroom doorway created by the obstruction and then addressed the soiled brief that was sitting on the floor. He did not make any attempts to move the wheelchair or the bed. 2. Record review of Resident #57 showed an admitted [DATE]. Diagnoses icluded fracture of the left clavicle, pain in left hip and right hip, protein-calorie malnutrition, cutaneous abscess of the chest wall, history of bacterial infection, heart failure, and chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 3/7/25 revealed the resident's cognition was intact with a BIMS score of 13. Review of the care plan initiated on 11/28/24 and revised on 12/3/24 noted the resident was dependent on 1-2 staff assistance for bed mobility and transfer. On 3/31/25 at 9:45 a.m., an observation of Resident #57's room showed there were multiple personal possessions on the floor out of reach of the resident. A duffel bag was sitting on the floor, tucked behind an oxygen concentrator in the back corner of the room. There was a dresser to the left of the resident, which was filled with incontinence care items. In an interview Resident #57 said, They put their stuff in here, so there's no room for my stuff. On the floor at the end of the bed, there was a cardboard box sitting on the floor with miscellaneous possessions which were also out of reach of the resident. Next to the box was a tall closet that contained very few personal possessions. When asked if he preferred having his possessions out in the open, Resident #57 said, Nobody would help me put my things away, nobody has time, or they have no idea what I'm talking about. On 4/1/25 at 11:00 a.m., in an interview, Certified Nursing Assistant (CNA) Staff LL said that he checks on Resident #57 like he is supposed to, but since he can speak for himself, all he has to do is ask if he needs help. 3. Review of the clinical record for Resident #273 revealed an admitted [DATE]. Diagnoses included squamous cell carcinoma of skin, protein-calorie nutrition, weakness, muscle wasting, and gastrointestinal hemorrhage. Resident #273 requires assistance with Activities of Daily Living (ADL's) and requires a mechanical lift to be transferred to a wheelchair. On 3/31/25 at 10:00 a.m., during an observation of Resident #273, there was moderate sized mucous like stain on the pillowcase behind his head, that was brown, yellow and slightly green. The fitted sheet had come off one corner of the mattress, and Resident #273's bare legs were touching the mattress. A portion of the fitted sheet was bunched under his body. In an interview, Resident #273 stated that the bed was hurting him which was surprising to him because he was supposed to be on an air mattress. He described his room accommodations as, It's not home. Registered Nurse (RN) Staff E was at the resident's bedside during the observation. In an interview on 3/31/25 at 10:00 a.m., RN Staff E said that bedding should be changed every day. He said the resident's bedding had likely been changed already. On 3/31/25 at 10:05 a.m., in an interview CNA Staff FF assigned to Resident #273 stated, I am not changing that resident's bedding today, I will change bedding of residents who go to Dialysis and Therapy today. On 3/31/25 at 11:00 a.m., in an interview Resident #273's spouse said she did not feel the staff understood what he was asking for. She said Resident #273 felt that staff did not understand him. She said, He has also been saying all weekend that the bed is hurting him. 4. Review of the clinical record for Resident #274 revealed an admitted [DATE]. Diagnoses included muscle wasting and atrophy, pressure ulcer of sacral region, dysphagia, urinary retention, protein-calorie malnutrition, and cardiomyopathy. Review of the nursing assessment dated [DATE] revealed Resident #274 was alert and oriented with periods of confusion. On 3/31/25 at 9:50 a.m., observed Resident #274 lying in bed watching television. In an interview Resident #274 said he wished the staff would move his bed so he could reach his own phone charger rather than having to rely on them because, I can't reach it over there, and when they plug it in, I can't get to it. He also said he couldn't reach the room phone. On 3/31/25 at 9:50, Resident #274 was observed asking RN Staff G to help him to charge his phone. The resident asked, Can you please move my bed because I can't reach my phone charger. RN Staff G said, The charger won't reach, you will have to call us and ask us to plug in your phone for you. RN Staff G did not attempt to reposition the bed or find an alternative option for charging the phone. On 3/31/25 at 3:00 p.m., in an interview Resident #274 said, No, they didn't move anything for me. On 3/31/25 at 11:26 a.m., a clear plastic bag containing a bedpan and several pieces of paper towel was observed tied to the siderail across from the toilet in Resident #274's shared bathroom. Resident #274 said he wasn't sure who the bedpan belonged to. On 3/31/25 at 11:39 a.m., in an interview CNA Staff H said the bedpan in the plastic bag was, garbage and it has not been there very long, I just came back from my break. Photographic Evidence Obtained

Based on record review and interview, the facility failed to ensure 1 (Resident #96) of 3 residents with newly evident or possible serious mental disorder, or related condition was referred to the appropriate state-designated mental health or intellectual disability authority for review for a Level II screening. The findings included: Resident # 96 was admitted to the facility on [DATE] with a Level I Preadmission Screening and Resident Review (PASRR) with a diagnosis of Anxiety but did not indicate a need for further review. On 7/29/24 a new Level 1 PASRR was completed with mental illness or suspected mental illness including mental disorder, psychosis, and adjustment disorder with anxiety added and indications of lack of focus and adapting to typical change. The new Level 1 PASRR from 7/29/24 was sent for a second level review, with a response on 8/5/25 that Resident #96 was not considered to have a serious mental illness. A review of Resident #96 record revealed the Medication Administration Record contained an order dated 1/14/25 for Seroquel two times a day for schizophrenia. (Seroquel is an antipsychotic medication used to treat schizophrenia). Further review of Resident #96's record revealed a progress notes from the psychiatric provider on 1/14/25 and 4/2/25 in which both notes the medical decision making said dementia with behavioral delusional ro (rule out) schizophrenia and Seroquel for diagnosis of schizophrenia. Record review of Resident #96's chart on revealed the PASRR had never been updated and sent for review for the newly diagnosed /suspected condition of schizophrenia. On 4/3/25 at 9:33 a.m., in an interview the Social Services Director said they had sent a Level II for him in the past, but this time missed the new diagnosis. She said she would follow through and get a new one.

Based on observation, interview, and record review, the facility failed to provide care and services to meet the needs for personal hygiene, nail care, assistance with dressing, and toileting for 1 (Residents #28) of 5 dependent residents reviewed. The findings included: On 3/31/25 at 4:22 p.m., Resident #28 was observed lying in bed. The nails of the resident's right and left hand extended approximately 3/4 inch from the fingertips. The fingers of the left hand were curled with the nails pressing into the resident's palm. On 4/1/25 at 12:31 p.m., observation of Resident #28's fingernails revealed they remained untrimmed and extended approximately 3/4 inch from the fingertips. In an interview Resident #28 said he guesses staff would trim his nails if he asked. On 4/1/25 at 5:16 p.m., in an interview Resident #28 said staff asked maybe once or twice if they could trim the fingernails. He said he was not able to trim his own nails due to reduced dexterity and limited range of motion to the left hand. On 4/2/25 at 10:32 a.m., Resident #28 was observed in bed. His fingernails nails remained long, untrimmed and extended approximately 3/4 inch from the fingertips. The left-hand fingernails were pressing into the palm. Review of the clinical record for Resident #28 revealed an admitted [DATE]. Diagnoses included cerebral infarction, dementia, amputation of right leg above the knee, and legal blindness. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 2/21/25 revealed Resident #28 had functional limitations in range of motion on one side of the lower extremities. The resident was dependent on staff for bathing and personal hygiene. Resident #28's cognition was moderately impaired with a Brief Interview for Mental Status score of 09. The MDS noted the resident refused care. The behavior occurred 1 to 3 days. Resident #28 was transferred to an acute care hospital on 2/10/25 and returned to the facility on [DATE]. Review of the care plan initiated on 9/28/21 and revised on 9/5/24 revealed to check nail length, trim and clean on bath day and as necessary. The care plan noted the resident required assistance from 1-2 staff for personal hygiene. The care plan initiated on 10/4/21 revealed Resident #28 had behaviors of refusing care including labs (laboratory) and therapy. The care plan did not include refusal of nail care. Review of the Certified Nursing Assistant (CNAs) documentation (Documentation Survey Report V2) for January 2025, February 2025 and March 2025 revealed Resident #28 refused personal hygiene on 1/27/25 (Day shift), on 2/13/25 (evening shift), and on 3/20/25 (day shift). No other refusal of care was documented for January 2025, February 2025 and March 2025. On 4/3/25 at 10:19 a.m., in an interview Activity Assistant Staff CNA Staff X said Resident #28's left hand has been that way since he came to the facility. Staff X said he refuses to get out of bed and refuses to get a shower. CNA Staff X said Resident #28 does not want to do anything. On 4/3/25 at 11:00 a.m., in an interview Licensed Practical Nurse (LPN) Staff Y said Resident #28 can be resistant to care and was care planned for refusing care. She said Resident #28 was not as bad now with refusing. She said when she checked the resident this week she did not see his nails, they were covered by the blanket. She said if the resident refuses care, the CNA documents on the Documentation Survey Report V2 and tells the nurse. She said the resident tended to cooperate with his current nurse. On 4/3/25 11:09 a.m., LPN Staff Y went to the resident's room and observed Resident #28's fingernails. In an interview LPN Staff Y confirmed the resident's fingernails were long and needed to be trimmed. Resident #28 told LPN Staff Y the CNA did not offer to trim his nails and he has not refused to have his nails trimmed.

Based on record review, interview and observation, the facility failed to maintain ongoing communication, coordination and collaboration between the nursing home and the dialysis staff for 1 (Resident #87) of 1 sampled resident receiving dialysis services reviewed. The findings included: Record review of Resident #87 revealed an admitted [DATE]. Diagnoses included End Stage Renal Disease. Review of the Admission Minimum Data Set (MDS) assessment with a target date of [DATE] revealed Resident #87's cognition was mildly impaired with a Brief Interview for Mental Status score of 12. 1. Review of the physician's orders in the Electronic Medical Record (EMR) revealed Resident #87 dialysis days were scheduled for Monday, Wednesday and Friday. The physician order dated [DATE] noted the resident's code status was Do not resuscitate (DNR) meaning not to initiate Cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. Review of a Circle of Care meeting dated [DATE] revealed documentation, A circle of care meeting was held today with team: DON opened . Resident at dialysis, his son (name) in attendance. Collaboration with dialysis center. Recommendations noted. On [DATE] at 11:28 a.m., Resident #87's dialysis communication binder (used to exchange information between the dialysis center and the facility) was reviewed. It did not include the resident's current DNR code status. A green sheet of paper in the binder read, FULL CODE (administer cardiopulmonary resuscitation in the event of cardiac or respiratory arrest). The binder contained Physician's Orders and a Medication List that was printed on [DATE]. On [DATE] at 11:35 a.m., in an interview, Licensed Practicing Nurse (LPN) Staff I stated that the Dialysis Communication Binder travels with Resident #87 three times a week to the dialysis center. LPN Staff I stated, It's the nurse's responsibility to make sure the communication binder is updated. If there are new orders and I am working, then I put them in the binder. I don't know what happens to the binder when I am not here, and I don't go to care rounds. I am the desk nurse and the admissions nurse. This is the only way that the nursing staff communicates with the dialysis staff is through the binder. LPN Staff I reviewed the electronic and physical clinical record. She verified that Resident #87 has an active advanced directive for Do Not Resuscitate order dated [DATE]. LPN Staff I also verified that that the Physician Orders and Medication List in the communication binder were out of date. She stated, These are his admission meds (medications) and orders. On [DATE] at 3:00 p.m., during a concurrent interview the Director of Nursing (DON) and Regional Nurse were asked whether it was concerning to them that the Dialysis Communication Binder was not up to date for advanced directives and orders. The DON said, It would be up to the dialysis center to do their own thing for advanced directives, we can tell you that for sure, our record wouldn't matter. The Regional Nurse agreed with the statement. On [DATE] at 7:45 a.m., in a telephone interview a dialysis nurse working at the Dialysis Center for Resident #87 stated, The dialysis communication binder is how we communicate with the facility, I can show no record of a meeting held on [DATE] with the facility in his chart here. If our Social Worker were part of the meeting they would have their notes, but the nurses look in the communication binder and, in our chart, which has no record of advanced directives planning. 2. Review of the progress notes for Resident #87 revealed a psychiatry note dated [DATE] which noted Resident #87 was unaware of his medical condition and has breaks with reality and confusion at dialysis. On [DATE] at 9:30 a.m., Resident #87 was observed freely propelling himself throughout the facility. Resident #87 appeared calm. He was not answering to questions appropriately. The resident was using inappropriate words to respond to questions. On [DATE] at 11:00 a.m., Record Review of the Dialysis Communication Binder for Resident #87 showed an information with letters written in bold stating Sevelamer (medication) sent to dialysis with resident on T-TH-S (Tuesday-Thursday-Saturday) for self-administration x 1 dose. Record review of Resident #87's assessment for self-administration of medications dated [DATE] showed that the resident may not self-administer medications. Review of the Medication Administration Record (MAR) for [DATE] revealed an order dated [DATE] to send Sevelamer to dialysis with resident one time a day every Monday, Wednesday, Friday for ESRD (End Stage Renal Disease). On Wednesday [DATE] the nurse entered 13 (At dialysis with meds) for the 12:00 p.m. dose of Sevelamer. On [DATE] at 11:10 a.m., an observation of Resident #87 dressed in personal clothing with a bagged lunch packed hanging from his wheelchair. On [DATE] at 12:00 p.m., an interview with staff J LPN, said that she only prepped him for dialysis because she doesn't know him that well, not because the paper in the binder said he goes on Tuesday-Thursday-Friday.

Based on observations and staff interviews, the facility failed to establish and maintain an effective infection prevention and control program, which increased the risk of communicable diseases and infections for 3 (Residents #23, #274 and #278) of 3 residents reviewed for catheter care and enhanced barrier precautions. The findings included: 1. The policy for Catheter-Foley Care provided by the facility, last revised on 4/25/22, stated, Keep the bag below the level of the bladder at all times to prevent the backflow of urine and decrease the risk for infection. Never leave the catheter hanging to be pulled by the weight of the bag. Do not leave the catheter bag/tubing laying on the floor. Place the catheter bag in a dignity bag. To avoid this issue and avoid infection control issues, the catheter bag/dignity bag may also be placed in a wash basin to avoid direct contact with the floor. Clinical record review revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included a past medical history of bacterial infection and urinary tract infection. Resident #23 required a Foley catheter. Physician orders dated 2/15/25 stated, Foley catheter care every shift, and as needed every day and night shift and Secure catheter tubing to thigh with cath secure or leg strap at all times every day and night shift for Foley care. He was also under Enhanced Barrier Precautions every day and night shift ordered on 3/17/25, and there was a sign posted on his room door. On 3/31/25 at 3:47 p.m., observation revealed Resident #23 lying in his bed, awake, alert, and oriented. His urinary catheter drainage bag was observed on the floor under his bed, outside of a dignity bag. Photographic evidence obtained On 4/1/25 at 9:15 a.m., Resident #23 was observed sitting in his wheelchair; his urinary catheter was observed unsecured and lying on the floor beneath the wheelchair Photographic evidence obtained On 4/1/25 at 9:19 a.m., in an interview, Registered Nurse Staff G said he had worked at the facility for [AGE] years. Staff G said the urinary catheter requires keeping the catheter clean, placed in a dignity bag, and off the floor. Resident #23 was observed in his room. Staff G verified that the Foley catheter bag was lying on the floor, not in a dignity bag. Staff G said, It shouldn't be on the floor. 51818 2. Resident #274 was admitted to the facility on [DATE]. He has a diagnosis of muscle wasting and atrophy, pressure ulcer of sacral region, dysphagia, urinary retention, protein-calorie malnutrition, and cardiomyopathy. He was last assessed by a nursing assessment as alert and oriented with periods of confusion on 3/27/25. On 3/31/25 at 9:25 a.m., during an interview, Resident #274 said, I have a Foley connected to the end of the bed. Observation of Urinary Catheter bag connected to the bedframe, where the drainage bag, tubing, and valve stem were laying on the floor. On 3/31/25 at 9:30 a.m., during an interview Registered Nurse (RN) Staff G said that he knew the Urinary Catheter should not be touching in the floor, It belongs in a dignity bag (bag for privacy and cleanliness). 3. On 4/1/25 at 10:30 a.m., an observation of wound care was conducted for Resident #278. The Resident's door has a sign posted that read, STOP Enhanced Barrier Precautions. Licensed Practical Nurse (LPN), Staff A, Certified Nursing Assistant (CNA) Staff N, and CNA Staff O entered the room. Hand Hygiene was performed and gloves worn, no gowns were worn by any staff. CNA Staff N and CNA Staff O assisted the resident to turn to his side and removed Resident #278's brief while LPN Staff A used Normal Saline and Gauze to clean the resident's wound. LPN Staff A removed her gloves, performed hand hygiene and donned new gloves. LPN Staff A who then opened clean dressing onto clean surface. LPN Staff A applied clean Xeroform gauze and sacral dressing to the resident's wound. CNAs Staff N and Staff O were observed leaning over the bed to assist repositioning the resident. Their scrubs were touching the bed at the hip level. LPN Staff A changed her gloves and applied barrier cream to the resident's groin. On 4/1/25 at 10:45 a.m., in an interview LPN Staff A said she was not sure which resident in the room was on Enhanced Barrier Precautions, or why, and that she didn't need to use a gown to provide wound care. On 4/1/25 at 10:47 a.m., in an interview the Assistant Director of Nursing (ADON) who is also the Infection Preventionist, walked towards the wound care cart and explained that any resident receiving contact care activity, including wound care, would require Enhanced Barrier Precautions, including anyone in the room who is observing, even if they are not touching anything. On 4/1/25 at 10:48 a.m., the Director of Nursing (DON) informed the ADON and Staff A that the only person who is required to wear a gown during wound care is the person who is performing the wound care, because wound care is a high-contact resident care activity. On 4/1/25 at 11:00 a.m., the Personal Protective Equipment (PPE) drawer closest to the room of Resident #278 was observed to be empty. On 4/1/25 at 11:15 a.m., during a follow up interview LPN staff A stated, I know better, it's just only me that needs to wear the gown and I do. I was just nervous, it's not that there wasn't PPE available, I should have gotten some.

Based on observation, staff and resident interviews, review of facility policy and procedure, and record review, the facility failed to ensure 4 (Residents # 16, #69, #78 and #98) of 5 residents reviewed for accidents were assessed for alternative interventions prior to the use of bed rails. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized. The findings included: The facility policy Side Rail Use/ Enabler Use revised 3/22, documented, The policy addresses safety measures to reduce the risk of bed entrapment related to the use of side rails/enablers. Side rails/enablers will only be used by a resident to assist his or her bed mobility in accordance with the individual's interdisciplinary team assessment. Side rails/enablers will not interfere with the residents' ability to egress from the bed. Review of the facility's Consent for use of side rails showed, . It is the policy of this facility to use side rail(s) only after evaluation and care planning deem it appropriate to assist the resident in attaining or maintaining his or her highest practicable physical and psychological well-being, and other methods or interventions are inadequate. In all instances the least restrictive device, which is effective will be used . 1. On 8/15/22 at 9:45 a.m., Resident #16 was observed in his bed with 1/4 side rails in the raised position on both sides of the bed. Resident #16 said he did not request the rails but used them to move in bed. Review of Resident #16's clinical record showed on 5/17/22 Resident #16 signed the Consent for Use of Side Rails. The clinical record showed an admission side rail assessment dated [DATE] recommending the use of bilateral enablers. The form documented alternatives have been discussed with the resident. The form did not document the alternatives attempted prior to the use of the enablers. 2. On 8/16/22 at 1:45 p.m., Resident #69 was observed in bed, with 1/2 side rails on both sides of the bed in the raised position. Resident #69 said the rails were on the bed when she was admitted , and she used the rails for mobility in bed. Review of Resident #69's clinical record showed a Consent for Use of Side rails dated 6/28/22 and signed by the resident. The record showed an admission side rail assessment dated [DATE], documented side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails. 3. On 8/16/22 at 1:45 p.m., Resident #78 was observed in bed with 1/2 side rails on both sides of the bed in the raised position. Resident #78 was confused and not able to answer questions. Review of Resident #78's clinical record showed a Consent for Use of Siderails dated 7/17/22 and signed by the resident's family member. The record showed an admission side rail assessment dated ,d+[DATE]/ 22, documented side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails. 4. On 8/15/22 at 10:10 a.m., Resident #98 was observed in bed with side rails in the raised position on both sides of the bed. Review of Resident #98's clinical record showed a Consent for Use of Side rails dated 7/27/22 and signed by the resident's family member. The record showed an admission side rail assessment dated [DATE] documenting side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails. On 8/17/22 at 12:57 p.m., the Director of Nursing confirmed the side rail assessments did not show documentation of the interventions attempted prior to the use of the side rails for Residents #16, #69, #78 and #98.

Based on observation, clinical record review and staff interviews, the facility failed to ensure its medication error rate remains below 5%. Five licensed nurses on two different shifts with 27 opportunities were observed. Four medication errors were observed resulting in a 14.81% error rate. The findings included: The facility policy 1.0, Medication Dispensing System (No effective date), documented, . Crushing oral medications requires a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .g., time release capsules, coated tablets, etc.). Medications are to be crushed in accordance with pharmacy guidelines and /or facility policy . Prior to medication administration: Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer. Verify that the MAR [Medication Administration Record] reflects the most recent medication order. 1. On 8/15/22 at 4:25 p.m., Licensed Practical Nurse (LPN) Staff F was observed administering two different medications to Resident #2, including one tablet of [MEDICATION(S)] (antibiotic) 550 milligrams (mg), and three tablets of [MEDICATION(S)] 800 mg (medication used to treat too much [MEDICATION(S)] in the blood for [CONDITION(S)] patients). LPN Staff F placed the four tablets into a plastic medication bag and crushed them. LPN Staff F mixed the crushed medications with pudding and administered them to Resident #2. LPN Staff F discarded the medication cup leaving a portion of the medication mixture in the cup. A review of the manufacturer's guidelines for the use of Xifaxin and [MEDICATION(S)] specified Do not crush or chew tablets. 2. On 8/15/22 at 5:06 p.m., LPN Staff J was observed administering 14 different medications to Resident #63, including two tablets of [MEDICATION(S)] (a muscle relaxer) 20 mg, and two tablets of [MEDICATION(S)] (medication used to treat seizures and nerve pain) 800 mg. On 8/15/22 at 5:30 p.m., review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22 at 7:00 p.m., in an interview, LPN Staff J confirmed she had administered two tablets of [MEDICATION(S)] 20 mg and two tablets of [MEDICATION(S)] 800 mg to Resident #63.

Based on observation and staff interview, the facility failed to ensure proper storage/labeling of medications for 1 (Resident #108) of 1 resident observed with unsecured medications at the bedside, 2 (100 odd and even medication carts) of 3 medication carts and 1(East unit) of 2 medication rooms. This has the potential for expired medications to be administered to residents. The findings included: The facility policy 5.0 Medication Storage (Undated), documented Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and in accordance with FL (Florida) Department of Health Guidelines. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy . 1. On 8/15/22 at 10:40 a.m., observation of the 100 odd numbered hallway medication cart with Licensed Practical Nurse (LPN) Staff F revealed the following: One box of [NAME]/[MEDICATION(S)] suppositories expired 7/31/22. One unopened bottle of [MEDICATION(S)] ([MEDICATION(S)]) insulin with directions to keep refrigerated until opened. The medication was warm to touch. One opened bottle of [MEDICATION(S)] ([MEDICATION(S)]) insulin with no date to indicate when the insulin was opened. One unopened bottle of [MEDICATION(S)] insulin with directions to keep refrigerated until opened. The insulin was warm to touch. LPN Staff F verified the findings in the medication cart. 2. On 8/15/22 at 10:45 a.m., observation of the 100 even numbered hallway, medication cart with Registered Nurse (RN) Staff G, revealed the following: One opened bottle of [MEDICATION(S)] insulin with no open date. One insulin [MEDICATION(S)] ([MEDICATION(S)]) pen not opened with directions to keep refrigerated until opened for Resident #26. One unopened bottle of [MEDICATION(S)] insulin stored in the cart. The label specified to keep refrigerated until opened. One bottle of [MEDICATION(S)] insulin opened and undated. One [MEDICATION(S)] insulin pen not opened with directions to keep refrigerated until opened. One opened bottle of [MEDICATION(S)] insulin with no date. One unopened insulin [MEDICATION(S)] pen with directions to keep refrigerated until opened. One open insulin [MEDICATION(S)] pen with no date open. One unopened bottle of [MEDICATION(S)] insulin with directions to keep refrigerated until opened for Resident #83. 3. On 8/15/2022 at 11:00 am, observation of the medication storage room of the East Unit with the Unit Manager revealed the following: One bottle of Two Cal HN tube feeding solution with an expiration date of July 1, 2022. One bottle of Senna Syrup with an expiration date of 1/22. One bottle of regular strength antacid and anti-gas with expiration date of 3/22. The Unit Manager verified the Two Cal HN solution, the Senna Syrup and the bottle of antacid were expired. 4. Record review of the Minimum Data Set (MDS) with Assessment Reference Date of 8/4/22 indicated Resident #108 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS revealed several active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22 at 4:30 p.m., during an observation and interview with Resident #108 she said she keeps her medicine in her chest drawers. Resident #108 stood up from bed, walked to the chest of drawers across from her bed and removed a red, 7-day pill [MEDICATION(S)] from the top drawer. She opened one section of the pill [MEDICATION(S)] and placed several pills in her hand, including a large pink pill identified as [MEDICATION(S)] 500 milligrams (mg), which is used to treat seizures and mood disorders. Resident #108 confirmed the chest drawer was not locked and she possessed no key for access to the contents inside. Photographic evidence obtained. Review of the medical record indicated Resident #108 was admitted to the facility on [DATE]. Resident #108's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 at 9:24 a.m., Licensed Practical Nurse (LPN) Staff W said she gave Resident #108 her medication this morning. Staff W said Resident #108 was diagnosed with Stage 3 Kidney Disease and Paranoid [CONDITION(S)] and was sometimes confused. On 8/17/22 at 9:33 a.m., during an observation, Resident #108 was lying in bed dressed in street clothes. Resident #108 said she takes both the pills in the [MEDICATION(S)] and the ones the staff give her at the facility. The red pill [MEDICATION(S)] was in a plastic bag in the top drawer of the dresser. On 8/17/22 at 9:37 a.m., LPN Staff W entered Resident #108's room. Staff W shook the pill [MEDICATION(S)]. The pill [MEDICATION(S)] contained pills in each section except for 2 sections. On 8/17/22 at 9:50 a.m., Registered Nurse (RN) Unit Manager Staff L entered Resident #108's room and acknowledged the medications in the pill [MEDICATION(S)]. RN Unit Manager Staff L told Resident #108 she was not allowed to have the medication in her room because the facility administers her medication. RN Unit Manager Staff L left the room with the pill [MEDICATION(S)]. Review of Resident #108's electronic record including assessments, care plans, miscellaneous records, progress notes, and MARs did not indicate Resident #108 was deemed safe for to keep or self-administer medication while she was admitted to the facility. Review of Resident #108's paper chart revealed no indication Resident #108 had been deemed safe to keep or self-administer medications while at the facility. On 08/17/22 at 12:56 p.m., RN Unit Manager Staff L verified Resident #108 was not evaluated to keep or self-administer medications.

Based on observation, record review and resident and staff interviews, the facility failed to implement adequate supervision for 1(Resident #78) of 19 residents reviewed with known unsafe wandering behaviors. The findings included: Review of the clinical record for Resident #78 revealed an admitted [DATE] with diagnoses including altered mental status, and anxiety. The Admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #78 scored a 10 on the Brief Interview for Mental Status, indicative of moderately impaired cognition. On 7/28/22 the psychiatric Advanced Practice Registered Nurse (APRN) documented Resident #78 had poor insight or judgement, was constantly pacing the halls, and had significant cognitive processing deficits. The APRN ordered to start [MEDICATION(S)] 0.25 mg twice a day, and [MEDICATION(S)] 0.25 milligram (mg) every two hours as needed for anxiety. On 8/5/22 at 9:57 p.m., the psychiatric APRN documented Resident #78 was very agitated, exit seeking, not responding to the current medication regimen. The APRN ordered to administer [MEDICATION(S)] (medication that acts on the brain and nerves to produce a calming effect) intramuscularly (IM) as needed for 14 days. On 8/11/22 at 9:24 a.m., the psychiatric APRN documented Resident #78 overall was restless, behavioral sundowning (worsening of restlessness, agitation as daylight begins to fade), impulsive not responding to redirection. The IM [MEDICATION(S)] had moderate effectiveness. The plan was to add routine [MEDICATION(S)] and discontinue the [MEDICATION(S)] (Antianxiety). Staff support behavioral interventions have been tried and are not successful. On 8/11/22 at 3:02 p.m., the psychiatric APRN documented an urgent telephone call with the director. Resident #78 was now combative, paranoid (feelings of extreme distrust, suspicion), not responding to any behavioral interventions. The plan was to resume [MEDICATION(S)] 1 milligram (mg) IM every eight hours as needed. On 8/11/22 the Social Service Director documented in a grievance form a concern of Disruptive roommate voiced by Resident #78's roommate. A room change was initiated. On 8/15/22 at 9:33 a.m., Resident #78 was observed barefoot wandering in the 400 hall. Resident #78 was going in and out of other residents' rooms with no staff intervention or redirection. On 8/15/22 at approximately 9:40 a.m., Licensed Practical Nurse (LPN) Staff E confirmed Resident #78 was wandering unsupervised into other residents' rooms. She said Resident #78 wandered all the time and was combative. On 8/15/22 at 9:45 a.m., Resident #16 said he used to share a room with Resident #78. He said three or four days ago, Resident #78 placed his hands around his throat and tried to choke him. Resident #16 said he punched Resident #78 in the face to protect himself. He reported the incident to the staff on duty, and an incident report was filed. On 8/15/22 at 10:00 a.m., LPN Staff E was informed Resident #16 said three or four days ago Resident #78 placed his hands around his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. LPN Staff E said Resident #78 was combative and wandered in and out of other residents' rooms. On 8/15/22 at 10:10 a.m., Resident #78 was observed barefoot at the back hallway exit door. Resident #78 pushed the exit door, activating the alarm. Three staff members were observed in the hallway conversing and did not attempt to redirect Resident #78. Approximately three minutes later, LPN Staff E redirected Resident #78 away from the exit door. On 8/15/22 at 4:00 p.m., Resident #78 was observed wandering unsupervised in the hallway and going in and out of other residents' rooms. LPN Staff E said Resident #78 was combative and wandered. A wandering device was applied to alert staff of attempts to exit the facility. On 8/16/22 at 12:00 p.m., Resident #98 said during the night, between 2:30 a.m., and 3:30 a.m., Resident #78 wandered in and out of her room, dressed in a hospital gown. He was rummaging through her belongings and got close to her face. She said Resident #78 tried to get in her bed which frightened her. She activated the call light, but no one responded for over an hour. Resident #98 said she was frightened and was screaming. Finally, the nurse came and removed him from the room. The nurse just kept saying Resident #78 was confused. On 8/16/22 at 12:10 p.m., Resident #16 said Resident #78 wandered into his room several times last night and was going through his belongings. He said, I told him to get out. I get upset because I don't want him going through my things. I want to sleep, and he comes in and will go through my things. Resident #16 said he reported it to the nurse on duty. On 8/16/22 at 12:15 p.m., LPN Staff D said she did not know anything about Resident #78 wandering. LPN Staff D was informed Resident #16 said three or four days ago Resident #78 placed his hands around his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. LPN Staff D was also informed Resident #98 complained the night before Resident #78 wandered in her room and tried to get in her bed. On 8/16/22 at 12:25 p.m., Resident #78 was observed wandering in the hallway on the unit by the back door attempting to exit the facility. Resident #78 wandered into another resident's room and then back to the exit door. Patient Care Assistant (PCA) Staff A was observed attempting to redirect Resident #78 away from the door. PCA Staff A said she was assigned to sit with the resident after lunch due to the wandering. On 8/16/22 1:15 p.m., Occupational Therapist (OT) Staff M said Resident #98 complained to her about Resident #78 wandering in and out of her room. OT Staff M said Resident #78 constantly wanders and goes in and out of resident rooms. On 8/16/22 at 1:20 p.m., Unit Manager Staff L said sometimes Resident #78 wanders in other residents' rooms. Unit Manager Staff L was informed Resident #16 said Resident #78 placed his hands around his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. She was also informed Resident #98 complained about Resident #78 wandering in her room and trying to get in her bed. She said she was not aware of the incidents. On 8/17/22 at 9:15 a.m., Resident #98 said the previous evening (8/16/22) Resident #78 wandered in her room and tried to get into her bed again. She said, I had the call light on, and no one came. I called my daughter in law, and she called the facility last night to report it. They removed him and then they had a staff member stand guard at my room to keep him out. On 8/17/22 at 9:38 a.m., in a telephone interview, Resident #98's daughter in law said Resident #98 called her on 8/16/22 at approximately 6:30 p.m. and complained there was a man in her room who was trying to get into her bed. She called the facility and reported the incident to Registered Nurse (RN) Supervisor Staff I. RN Supervisor Staff I called her back and verified Resident #78 was found in her mother in law's room. The care plan initiated on 7/15/22, and revised on 7/21/22 did not include individualized interventions, and supervision to address the wandering behavior. On 8/18/22 at 12:45 p.m., the Social Service Director said on 8/11/22 she wrote a grievance noting Resident #16 complained of a disruptive roommate but did not elaborate on it. She said Resident #16 complained on 8/11/22 at approximately 4:00 a.m., his roommate (Resident #98) was acting crazy, knocking things off the wall, pulling cords off the wall. He knocked over his tray table and Resident #98 fell on his bed. On 8/18/22 at 1:20 p.m., the Director of Nursing (DON) said Resident #78 should have been supervised to prevent the multiple incidents of wandering into other residents' rooms.

Based on observation, resident council, and staff interview, the facility failed to keep the most recent survey results in a place readily accessible to residents, visitors, and the public. The findings included: On 8/17/22 at 10:02 a.m., a resident council meeting was conducted with six residents (#103, #73, #40, #37, #65 and #31) who regularly attend resident council meetings. Members of the resident council stated they did not know where to locate the results of the State inspections, including the most recent survey of the facility. On 8/17/22 at 11:23 a.m., a joint observation of the facility lobby with the Resident Council President failed to show a posting of the most recent State survey report. Receptionist Staff P present during the observation said she keeps all survey results in a binder behind the reception area. She said the survey results are available upon request. On 8/18/22 at 4:10 p.m., the Director of Nursing said the binder will be moved to an accessible area.

Based on observation, policy review and staff interview, the facility failed to follow the manufacturer's specification to clean and disinfect multiuse Evencare G3 blood glucose meters for 5 (Residents #16, #24, #63, #116 and #371) of 5 residents observed with a physician's orders [REDACTED]. The facility failed to apply the disinfectant necessary for the minimum wet contact time per manufacturer's instructions to kill bloodborne pathogens on shared multiuse blood glucose meters. Inadequate disinfection may result in indirect contact transmission (the transfer of an infectious agent through a contaminated inanimate object) of pathogens through the improperly disinfected glucometers. The facility had a total of 12 blood glucose meters used for 42 diabetic residents with orders for blood glucose checks. The failure to properly disinfect the blood glucose meters used for multiple residents resulted in a pattern of noncompliance at Immediate Jeopardy (IJ), scope and severity of K starting on 2/23/21. The Administrator was notified of the IJ on 2/25/21 at 7:20 p.m. The Immediate Jeopardy was removed on 2/26/21 at 4:22 p.m., and the scope and severity lowered to E after the facility provided an acceptable removal plan. The findings included: According to the Journal of Diabetes Science and Technology (March 2009, Volume 3, Issue 2): Finger-stick devices, blood glucose testing meters, or even a health care worker's hands may all become vehicles for indirect transmission of viruses if they become contaminated with blood. Since [MEDICAL CONDITION] Virus (HBV) is highly infectious and environmentally stable, even invisible amounts of blood are sufficient to spread infection. According to the Food and Drug Administration (Content current as of 12/27/2017): For blood glucose meters, the primary viruses of concern for bloodborne pathogen transmission between multiple patients are Human Immunodeficiency Virus ,[MEDICAL CONDITION]., HBV, and [MEDICAL CONDITION] Virus (HCV). However, due to its robust nature, HBV is the most [MEDICAL CONDITION] in the observed outbreaks to date. Therefore, Blood Glucose Monitoring System sponsors should demonstrate that their disinfection protocol is effective against human [MEDICAL CONDITION] Virus. Studies have demonstrated [MEDICAL CONDITION] can remain infective on surfaces for different time periods. The disinfection solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. The Food and Drug Administration, https://www.fda.gov/medical-devices/vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda, accessed on 2/25/21. According to the Centers for Disease Control and Prevention: Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include: . Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. (Blood glucose meters are devices that measure blood glucose levels.) . .Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. .If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. The Centers for Disease Control and Prevention, https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, accessed on 2/25/21. Review of facility's policy titled Blood glucose monitoring, last revised September 2020 read . Clean and disinfect blood glucose meter after each use according to manufacturer's specifications. (See Cleaning of Glucose Monitoring Device Policy) . Train the licensed staff on the use of the glucose monitors and cleaning process. The facility's policy and procedure titled Blood Glucose Monitor/[MEDICATION NAME] Time Meter Cleaning and Disinfecting last revised on September 2020 read . Remove a disposable disinfectant wipe from the storage container. Clean the outside of the meter with a disposable disinfectant wipe. Avoid coming in contact with the electronic components and/or strip insertion area. Follow manufacturer's label regarding time disinfectant must remain in contact with meter (visibly wet) for effectiveness. Place meter on protective surface/towel/paper towel and allow the meter to air dry. On 2/22/21 at 4:40 p,m., in an interview the Director of Nursing (DON) said the facility uses the Evencare G3 glucometer and the Micro-Kill Bleach wipes to disinfect the blood glucose meters. The Evencare G3 user manual procedure for disinfecting the Evencare G3 meter read Clean the meter with a disinfecting wipe. All external areas of the meter including both front and back surfaces until visibly wet. Allow the surface of the meter to remain wet at room temperature for the contact time/kill time listed on the canister. Then wipe meter or allow to air dry . The Micro-Kill Bleach germicidal bleach wipes directions for use read In health care settings or other settings in which there is an expected likelihood of soiling of inanimate surfaces/objects likely to be soiled with blood/body fluids can be associated with the potential for transmission of HIV-1 (associated with AIDS), HBV ([MEDICAL CONDITION] virus) and HCV ([MEDICAL CONDITION] virus) . Special instructions for cleaning and decontamination against HIV-1, HBV, and HCV on surfaces/objects soiled with blood/body fluids . Allow surface(s) to remain wet for 30 seconds to kill all of the bacteria [MEDICAL CONDITION] . Photographic evidence obtained. 1. On 2/23/21 at 3:38 p.m., Licensed Practical Nurse (LPN) Staff C (training with Registered Nurse Staff E) was observed doing a blood glucose check for Resident #24. LPN Staff C and Registered Nurse (RN) Staff E performed a fingerstick, used the blood glucose meter and left Resident #24's room at 3:40 p.m. LPN Staff C used a Micro-Kill bleach wipe, wiped the blood glucose meter for 6 seconds and placed it on a Styrofoam tray. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. Staff C did not reapply the Micro-Kill wipe to ensure a 30 seconds wet contact time as per the manufacturer's specification. On 2/23/21 at 3:44 p.m., observed LPN Staff C preparing to perform the next blood sugar check. She said since the blood glucose meter had been drying three minutes, I can check the next blood sugar. On 2/23/21 at 3:55 p.m., LPN Staff A was observed removing a blood glucose meter from a plastic bag. She wiped the meter for 5 seconds with a Micro-Kill bleach wipe placed it on the medication cart. LPN Staff A said, and dry to 3 minutes. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. The nurse did not reapply the Micro-Kill bleach disinfectant to the blood glucose meter to ensure a 30 seconds wet contact time as per the manufacturer's specification. 2. On 2/23/21 at 4:00 p.m., LPN Staff A was observed doing a blood sugar check for Resident #371. LPN Staff A performed a fingerstick, used the blood glucose meter and left the resident's room at 4:02 p.m. LPN Staff A wiped the blood glucose meter with a Micro-Kill bleach wipe for 10 seconds and placed the meter on the medication cart. Continued observation of the meter from the time the nurse started to wipe the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. LPN Staff A made no attempt made to reapply the Micro-Kill bleach wipe to the glucometer to ensure a 30 seconds wet contact time as per the manufacturer's specification to ensure proper disinfection. On 2/24/21 at 9:49 a.m., in an interview Registered Nurse (RN) Staff B said she was assigned to 2 diabetic residents receiving blood sugar checks. She said she cleans the blood glucose meter between residents. She said the process was to wipe the glucometer and let air dry for 30 seconds to 3 minutes. She said to ensure the meter is really clean she lets it dry the longer time. 3. On 2/24/21 at 11:32 a.m., RN Staff D was observed doing a blood sugar check on Resident #116. RN Staff D performed a fingerstick, used to blood glucose meter and left the resident's room at 11:39 a.m. RN Staff D wiped the blood glucose meter for 6 seconds with a Micro-Kill bleach wipe and placed it on the medication cart. Continued observation of the meter from the time the nurse wiped the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. Staff D made no additional attempts to reapply the Micro-Kill bleach wipe to ensure a wet contact time of 30 seconds to properly disinfect the glucometer. 4. On 2/24/21 at 11:55 a.m., RN Staff B was observed doing a blood sugar check for Resident #63. She left the resident's room at 11:58 a.m. She wiped the glucometer for 8 seconds with a Micro-Kill bleach wipe. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. RN Staff B made no attempt to reapply the Micro-Kill bleach disinfectant to ensure a 30 seconds contact time to disinfect the meter. 5. On 2/25/21 at 4:39 p.m., LPN Staff F was observed performing a blood sugar via fingerstick for Resident #16 ([MEDICAL TREATMENT] resident). After performing the blood sugar, she donned a pair of gloves and wiped the blood glucose meter for 5 seconds with a Micro-Kill bleach wipe. She placed the meter on a Styrofoam tray on the medication cart. She said she would allow it to air dry for 2 minutes. Continued observation of the meter from the time the nurse started to wipe the meter revealed the meter progressively drying. The meter was completely dry at 20 seconds. LPN Staff F said she alternates the use of both blood glucose meters on the medication cart. She said she usually lets the meters dry for 2 minutes except when the resident has an infection such as [MEDICAL CONDITION] (infection that causes severe diarrhea). In that case she lets the meter dry longer. 6. On 2/25/21 at 3:50 p.m., the Nurse Educator said she has been employed at the facility since 8/1/19. She described the process to disinfect the blood glucose meters as follows: Pull a wipe out of the tub. Make sure to wipe the whole glucometer. Don't get any water on the port. Wipe the glucometer and then put it on the Styrofoam tray to dry. The Nurse Educator said, the contact time is the time you allow the glucometer to dry to kill the pathogens. The Nurse Educator said she routinely conducts audits of the nurses disinfecting the blood glucose meters but she did not have a piece of paper to show. The Nurse Educator said the CDC (Centers for Disease Control and Prevention) says the contact time is the time to allow the glucometer (also known as glucose meter) to dry. The Nurse Educator provided a competency (not dated) titled Disinfecting of blood glucose testing machine which she said she used to teach the licensed nurses. It read .To disinfect the meter, use Germicidal Cloth. Remove wipe from container and thoroughly wipe down the meter. Allow the meter to dry for at least one (1) to five (5) minutes to gain full benefit of the disinfecting. Note: If the wipe is very saturated (wet), squeeze or gently wring excess liquid before use. *CLEAN and disinfect daily between patient use. The education did not address the wet contact time for proper disinfection of the glucometers. 7. On 2/25/21 at 4:00 p.m., the DON who was present during the interview said, The nurses are basically doing it the way they were instructed to. The Immediate Jeopardy was removed on 2/26/21 at 4:22 p.m., and the scope and severity lowered to E after verification the facility completed a removal plan which included: All facility glucometers were disinfected according to manufacturer's specification on 2/25/21. Documentation that 32 licensed nurses were educated and demonstrated competency on proper disinfection of the glucometers on 2/26/21. Documentation of an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting on 2/25/21 to develop a new competency checklist that specified To disinfect the meter: Use Germicidal Cloth to wipe down the meter, then wrap the meter in the Germicidal cloth. Allow the surface of the meter to remain wet at room temperature for 3 minutes or reference the manufacturer recommended time. Observation on 2/26/21 of 6 licensed nurses, including the Staff Educator disinfecting the blood glucose meters according to manufacturer's specification of wet contact time to ensure disinfection of the shared blood glucose meters.

Based on record review and staff and resident interviews the facility failed to ensure they considered the views of Resident Council and act promptly upon their grievances, concerns, and recommendations for 7 (,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]) of 7 months reviewed. The findings included: On [DATE] at 3:50 p.m., the Director of Activity (DOA) said because of Coronavirus Disease 2019 (COVID-19) and the death of the Resident Council President, the facility residents elected Resident #16 as the Interim Resident Council President (IRCP) in the [DATE] resident council meeting. Since the facility stopped all group meetings, they determined Resident #16 would be the representative for all the residents in the monthly resident council meetings starting [DATE]. The DOA said Resident #16 talked with most of the residents in the facility and when they had the monthly resident council meeting, he voiced all the residents' concerns and grievances for that month. On [DATE] at 10:05 a.m., Resident #43 said Resident #16 is the IRCP and the residents tell him all their concerns, grievances, and recommendations. She has told the IRCP and facility staff over the past 5 to 6 months her room floor was sticky, and her wheelchair was dirty and not being cleaned. She also said she told the IRCP sometimes the meals arrived cold and she did not always get her clothes back from laundry. On [DATE] at 10:30 a.m., Resident #16 said he became the IRCP in [DATE] after the Resident Council President died . He said the facility told him he would be the voice for the facility residents and every month the DOA would do a monthly resident council meeting with him. He said over the past few months he had expressed to the DOA in the resident council meetings and the Administrator (AD) during his weekly routine rounds, all the concerns, grievances, and recommendations the facility residents had told him during the month. He said residents told him their rooms and wheelchair were not cleaned on a routine basis, laundry did not always return their clothes, staff was slow answering call lights and meals were cold when delivered to the residents' rooms. He said he asked the DOA and AD several months ago if the residents could start having resident council meetings outside while [MEDICATION NAME] social distancing but as of this time neither the DOA and AD had gotten back to him related to any of his concerns, grievances or recommendations. On [DATE] review of the Resident Council Minutes dated [DATE], [DATE] and [DATE] noted the minutes were divided into sections that covered the Nursing department, Dietary department, Maintenance department, Housekeeping/Laundry, Activity department and Other Discussions. The minutes revealed the residents had multiple areas of concerns, grievances, and recommendations which the facility addressed at that time. Resident #16 was elected as the Interim Resident Council President in the [DATE] resident council meeting. Review of the Resident Council Minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] revealed it had 2 sections, the first section talked about COVID-19 testing and monitoring of all residents and staff were ongoing and the second section said the activity department was ongoing. The resident council minutes from [DATE] to [DATE] did not note any of the facility residents' concerns, grievances and/or recommendations. On [DATE] at 11:44 a.m., in an interview the Administrator said Resident #16 has been the IRCP since [DATE]. He confirmed Resident #16 had talked with him during his routine weekly rounds related to concerns and recommendations he had as the facility IRCP. He said if he thought the concerns and recommendations were true grievances, he would have filled out a grievance form. The AD said he did not document any of the IRCP concerns or recommendations. On [DATE] at 4:26 p.m., the DOA said the IRCP had spoken to her related to some concerns and recommendations over the past several months but did not document them on the resident council meeting minutes. She confirmed the resident council meeting minutes reviewed from [DATE] to [DATE] noted she talked with the IRCP about COVID-19 testing and monitoring and the activity program was ongoing but didn't note any concerns or recommendations mentioned by the IRCP.

Based on interview and staff and resident interviews the facility the facility failed to ensure 10 (#43, #12, #23, #97, #9, #95, #90, #113, #40 and #98) of 14 resident's wheelchairs were clean and kept in a sanitary condition to prevent the spread of disease-causing organisms. The findings included: 1. On 2/22/21 at 9:49 a.m., Resident #43 said the housekeeping staff did not always mop her floor causing it to be sticky. She further said her wheelchair had not been cleaned in the past several months and the wheelchair was very dusty and sticky. Observation of Resident #43's wheelchair noted a thick layer of dust on the frame of the wheelchair. 2. On 2/22/21 at 10:06 a.m., observation of Resident #12's wheelchair revealed a thick layer of dust and dried food on the frame of the wheelchair. Resident #12 said his wheelchair had not been cleaned in a long time even though he had asked staff several times to clean his wheelchair. 3. On 2/25/21 at 9:25 a.m., observation of Resident #23 and Resident #97's wheelchairs revealed a thick layer of dust on the frames of their wheelchairs. Resident #97 said he had not seen the facility staff clean their wheelchairs in the past several months. 4. On 2/25/21 at 9:45 a.m., observation of Resident #9's wheelchair revealed a thick layer of dust on the frame of her wheelchair. Resident #9 said the facility had not cleaned her wheelchair in the past several months. 5. On 2/25/21 at 9:53 a.m., observation of Resident #95's wheelchair revealed a thick layer of dust on the frame of their wheelchair. 6. On 2/25/21 at 9:55 a.m., observation of Resident #90's wheelchair revealed a thick layer of dust on the frame of his wheelchair. Resident #90 said the facility had not cleaned his wheelchair in the past several months. 7. On 2/25/21 at 10:01 a.m., observation of Resident #113's wheelchair revealed a thick layer of dust on the wheelchair. 8. On 2/25/21 at 10:08 a.m., observation of Resident #40 and Resident #98's wheelchairs revealed a thick layer of dust on their wheelchairs. Resident #98 said the facility had not cleaned his wheelchair since his admission to the facility several weeks ago. 9. On 2/25/21 at 3:46 p.m., the Housekeeping/Laundry Director (HLD) said the Housekeeping Department was responsible to clean the entire facility to include all resident's wheelchairs. She said every 2 weeks all wheelchairs in the facility were taken out to the courtyard where they were washed/cleaned and scrubbed with a brush to remove the dust and grime which builds up on the wheelchairs over time. She said this was the week all the wheelchairs in the facility would be cleaned/washed. On Monday (2/22/21) all the wheelchairs on the 100 hallway and part of the 300 hallway were washed, Tuesday (2/23/21) all the wheelchairs on the 200 hallway, and on Wednesday (2/24/21) all the wheelchairs on the 400 hallway to include the rest of the 300 hallway were washed. Thursday (2/25/21) the wheelchairs on the back end of the 200 hallway, rooms 217 to 228 will be washed and then they will repeat the same schedule in 2 weeks. She said she did not keep any paperwork on what wheelchairs were completed but was positive all the wheelchairs were cleaned this week as required. 10. On 2/25/21 at 4:00 p.m., a tour of the facility was conducted with the HLD and we inspected Residents #43, #12, #23, #97, #9, #95, #90, #113, #40 and #98's wheelchairs. She confirmed all 10 wheelchairs we reviewed had a thick layer of dust on the frame, wheels, and the brakes. She stated it appeared the wheelchairs had not been washed/cleaned in several weeks. She said the pressure washer had been broken for a long time and the staff were required to use the scrub brush to clean all parts of the wheelchairs to include the frame, brakes, and wheels. She confirmed the 10 wheelchairs we reviewed were not washed/cleaned as required. She said she didn't have any documentation/paperwork stating the last time all the wheelchairs in the facility were washed/cleaned by the housekeeping department on a 2-week rotation. 11. On 2/25/21 at 5:50 p.m., the Administrator said all the wheelchairs in the facility are pressure washed every 2 weeks. He said he was unaware the pressure washer was broken, and the housekeeping staff were not using the pressure washer to clean the resident's wheelchair.

Based on observation, resident and staff interview, the facility failed to accommodate the food allergies and offer appropriate alternative for 1 (Resident #28) of 3 residents reviewed for food allergies, intolerances, and preferences. The findings included: Review of the clinical record revealed a Patient demographic form from a local hospital printed on 2/9/21 with documentation Resident #28's had an allergy to tea. The reactions to the tea were hives and itching. Review of the progress notes revealed on 10/6/20 the advanced practice registered nurse (APRN) documented Resident #28 was allergic to tea. On 2/23/21 at 3:03 p.m., in an interview Resident #28 said he was given iced tea daily. Resident #28 said he was allergic to tea, it caused him to itch. On 2/23/21 at 3:04 p.m., in an interview resident #93 (Resident #28's roommate) said he had heard Resident #28 tell staff he was allergic to tea. He said Resident #28 was only given options if he raises hell. On 2/24/21 at 12:07 p.m., Resident #28 was observed having lunch. He exclaimed they did it again. He pointed to the cup of liquid on his tray and said it was iced tea. On 2/24/21 at 12:15 p.m., Resident #28's lunch tray was observed with Registered Nurse (RN) Staff D. RN Staff D said all drinks come from the kitchen, he could not speculate what drink was served on the lunch tray. On 2/24/21 at 12:24 p.m., Dietary Aide Staff U said iced tea was on the lunch trays. She said all lunch trays were served with iced tea. On 2/24/21 at 12:41 p.m., the Dietary Director said iced tea was the house beverage and all residents received iced tea if they didn't request otherwise. On 2/24/21 at 1:36 p.m., the Dietary Director said he and Registered Dietician dealt with food allergies. The process was to identify an allergy and add the allergy to the resident's meal ticket. On 2/25/21 at 8:26 a.m., the Dietary Director said he was familiar with Resident #28 and believed he had an allergy to tea. He said he believed his staff were placing tea on Resident #28's tray because there was no other beverage selected. The Dietary Director said he would speak with Resident #28 to discuss his preferences and alternatives to the tea.

Based on record review and interview the facility failed to maintain complete and accurately documented medical records for 5 (Resident #2, #30, #40, #59, and #122) of 27 residents records reviewed. Accurate and complete records are necessary to document the course of a resident's care provided by the facility. The findings included: Review of the facility's policy (CN-3) with a revision date of ,[DATE] revealed pertinent information should be documented in the individual's record in an accurate, timely, and legible manner. 1. On [DATE] at 8:49 a.m., review of the clinical record for Resident #30 showed multiple missing documentation on the Treatment Administration Record (TAR) for [DATE]. Resident #30 had a daily wound care order with [MEDICATION NAME] ointment 2% to the left and right buttock on the day shift. The treatment was not recorded on the TAR [DATE] through [DATE]. Resident #30 also had daily wound care orders with Santyl ointment to the right buttock. The treatment was not recorded on the TAR [DATE] through [DATE]. On [DATE] at 9:56 a.m., in an interview Licensed Practical Nurse (LPN) Staff G said when you are done the treatment, you check the box. If you don't check the box, you haven't done the treatment. I don't know why those aren't done. 2. A review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE] revealed the resident had one stage 3 (partial thickness skin injury) and two stage 4 (full thickness skin injury) pressure injuries. The MDS noted the pressure injuries were all present on admission. A review of Resident #2's Wound Care Assessment/Consultation forms for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] noted the wounds were not present on admission. On [DATE] at 10:20 a.m., in an interview RN Staff N said the physician incorrectly filled out the wound care notes from [DATE] through [DATE]. The resident was sent to the hospital and was readmitted with the wounds in October of 2020. On [DATE] at 10:23 a.m., in an interview Resident #2's physician said the wound care notes were not documented correctly. 3. A review of the resident record for Resident #59 revealed missing or incomplete vital sign entries for [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] resident did not have documentation of administration for 2 doses of intravenous fluids for abnormal labs. No behavior monitoring, barrier cream treatment, and skin prep treatment to heels were documented for the evening of [DATE]. The resident record did not note Resident #59 was out of the facility on these dates. 4. On [DATE] clinical record review showed Resident #40 was medicated with [MEDICATION NAME] 1 milligram (mg) intramuscularly for anxiety on [DATE] at 3:53 p.m., ,[DATE] at 7:40 p.m., [DATE] at 12:30 a.m., [DATE] at 9:17 p.m., [DATE] at 09:37 a.m., [DATE] at 12:00 a.m., and [DATE] at 07:26 a.m. On [DATE] at 9:32 a.m., in an interview Licensed Practical Nurse (LPN) Staff J said Resident #40 sometimes is aggressive, yelling and can occasionally hit. Staff J said, the behavior was worse when Resident #40 was up in the wheelchair. LPN Staff J said staff document aggressive behaviors on the Treatment Administration Record (TAR) in the behavior monitoring section each time the [MEDICATION NAME] is administered. On [DATE] at 10:27 a.m., review of the treatment administration record (TAR) for resident #40 showed a behavior monitoring guide used to document the behaviors, interventions, outcome, and side effects of the [MEDICATION NAME] use. The behavior monitoring guide did not document the behavior for the [MEDICATION NAME] administered on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 5. Review of the clinical record for Resident #122 revealed the resident expired at the facility on [DATE]. The death record document dated [DATE] at 2:30 p.m., did not note the time of death, the time the physician was notified; the time the funeral home was notified. The form did not note the name of Funeral Home Personnel.

Based on observation, interview and record review, the facility failed to prevent the potential spread of harmful bacteria [MEDICAL CONDITION] generated from rodent infestation in the dry food storage and central supply rooms. This is a result of: 1) Failure to ensure the dry food storage room of the kitchen was free from evidence of rodent infestation; 2) Failure to ensure that all holes and crevices in the dry food storage room were sealed and secure; 3) Failure to take measures to appropriately clean and sanitize dry food storage room, kitchen, and central supply room after having knowledge of rodent infestation; 4) Failure of management and staff to understand contamination and cross contamination, and how bacteria [MEDICAL CONDITION] are spread through contamination and cross contamination. This system failure placed vulnerable residents, staff working in the kitchen area, and visitors that consumed food from the kitchen, at immediate risk of serious health problems resulting from diseases transmitted by rats. Rats and mice can potentially transmit Salmonellosis, which can cause severe gastrointestinal infection, manifested by diarrhea, fever, and abdominal cramps. Salmonellosis has the can lead to long term effects of pain in the joints, irritation of the eyes, painful urination and chronic arthritis. This disease can result in serious illness or death. The findings included: Observation at approximately 1:00 p.m. on 07/12/13, reveals 2 large baited traps near a hole in the wall of the northeast corner of the dry storage room. The Certified Dietary Manager (CDM) stated they have a rodent in the kitchen they are trying to catch. Observation outside, by the dumpster reveals another rodent bait station, a large black box with hole on one side, and a box on the other, set by a drainage pipe. During an interview on 07/12/13, at 1:09 p.m., Dietary staff member (A) stated something ate through the bread wrapper around a week ago. She stated the maintenance man put the trap out this week. During an interview on 07/12/13 at 1:16 p.m., Dietary staff member (B) stated, "We have rats here." When asked how she knew, she said she heard everyone talking about it. She stated she came in at 5:30 a.m. one morning and saw a dead rat in the trap, but has not seen one since. She stated the maintenance man disposed of the rat body. During an interview on 07/12/13, Dietary staff member (C), who comes in at 5:30 a.m., said she often would see both traps with dead rats and one was about the size of a raccoon, I guess it was the "granddaddy." She said when she sees them she runs out; there are always droppings on the floor. Dietary staff member stated she has worked at the facility for 2 years. The first year I did not see any rats. A few months ago, the rat problem started. She was asked how many dead rats she has seen and replied, "I have stopped counting." When asked how she feels about working in a kitchen with rats, she said, "I feel nasty." During an interview on 07/12/13, Dietary staff member (D) said she comes in at 5:30 a.m. (sometimes 6:30 a.m.) and has heard the rats squeaking in traps several times within the last couple of months. She stated she saw a dead rat in the trap about a month ago and it was about the size of a gerbil. Dietary staff member (D) stated there are always rat droppings (feces) in the dry food storage room, but we keep it cleaned up. She said she goes into the dry storage and gets out as fast as she can because she hates to see rats. During an interview on 07/12/13 at 2:49 p.m., the Administrator stated the problem began during a dry spell. He stated they did some renovation on the front of the building leaving areas exposed. He thinks that is how they got in. He stated there is a swell in the back of the building and they may be coming from there, as well. At one time they caught rats daily. He stated pest control supplied big bear-like traps because there were some large ones. He said the pest control company does not want to use poison because the rats will eat it and die somewhere in the walls or ceilings of the building and stink until you find them. The Administrator said they have cleaned all of the resident rooms and cleaned out clutter. He said there have not been any rats in the resident care areas; there are traps there, but he did not think any rats have been trapped. He stated they have had the trees around the building trimmed trying to eliminate all avenues for the rats to enter the building. During a phone interview on 07/12/13 at 4:27 p.m., the Maintenance Assistant stated the last time he disposed of rodents in the dry storage area was the end of June and he caught 2 in 2 days. He could not recall how many dead rats he had disposed. During an interview on 07/12/13 at 4:30 p.m., the Director of Maintenance stated he started working at the facility in May and by word of mouth, has heard it used to be a lot worse. He was advised by the pest control company on 07/02/13, that if they are still finding evidence of rodents they recommend the facility continue to set the traps. He said the trees have been trimmed and traps have been set. During a more detailed observation of the dry food storage on 07/12/13 in the late afternoon, evidence of rats was found in each corner and inside of a box of dishes on a shelf. There was another hole in the baseboard to the left of the entrance door, with additional traps set, and there were 2 traps by the bread rack. There was no evidence of any chewed packages of food, as the dietary staff said they were thrown away. When asked why the food was not removed out of the dry storage to another location, the Administrator said it is in packages. During the interview, the Administrator did not demonstrate an understanding that if rodents are running around the dry storage area, then much of the food (even packaged) would be contaminated. Nor, that cross contamination would then occur when food is taken into the clean area of the kitchen, where it would be opened and served to residents. After this discussion, the Administrator concluded the food should be moved or contained from the rodents. The bread was observed to be on open racks, the cookie and cake mix were in packages on the shelves. During an interview on 07/16/13 at 2:41 p.m., the Medical Director was asked if he was aware of a rat problem and stated he was made aware of it in February and discussed it with the Administrator. He was told it "was being taken care of." He was not aware the dietary staff are not thoroughly disinfecting the dry storage area and the staff was not taking precautions to prevent cross contamination. When the surveyor discussed this with him, he stated "I see what you are saying." During an interview on 07/12/13 at approximately 3:30 p.m., the Ameritech Pest Control Services technician stated he came to the facility in January and set traps and sealed the building. The maintenance crew at the facility asked him to leave some glue boards. The facility signed a yearly rodent control contract. He said the technicians have been coming to the facility monthly and check the traps around the building, but do not ask how many rodents have been found in the interior traps. He stated they supply the Maintenance Department with glue boards when needed. He stated he feels the facility is doing all that it can to get rid of the rodents; it may be an ongoing problem as they are not sure how the rodents are entering the facility. Review of the monthly visit documentation reveal reference only follow-up for rodents. On 07/13/13 at 3:30 p.m. observation of the central supply room revealed rodent tracks in the red plastic container in with the urinary drainage bags. The Central Supply Clerk stated the rodents like the Med Pass?, a nutritional supplement, and lotion with olive oil. The central supply clerk stated she puts the lotion in a sealed box and the Med Pass? in the hall medication rooms. She pointed out a string in the ceiling where the maintenance man has placed a trap. She said the rodent problem is much better than it was a few months ago. She said maintenance staff removed the traps from the central supply room today. She said maintenance staff place traps in central supply during the week, but removes them during the weekend. Central supply is located directly across the hall from the kitchen. During a telephone interview on 07/17/13 at 10:41 a.m., the previous Maintenance Director stated evidence of rats was found in the dry food storage area in January and they had the pest control company come and set traps. He stated they caught a few now and then in the dry food storage area. He left the facility a couple of months ago. 2. During a tour of the kitchen dry food storage area on 07/12/13 at 1:05 p.m. with the facility's Certified Dietary Manager (CDM), two surveyors observed a hole (approximately 4 by 5 inches) in the base of a wall next to a pipe. There were 2 baited rodent stations on the floor next to the hole. The CDM stated the baited rodent stations were traps to catch "a mouse" that had been running around and the hole had not been there very long. There were several bread products stored on a rack, and dried food goods stored on the shelves. It was noted there were 2 more baited rodent stations on the floor next to the wall behind the bread rack. During an interview on 07/12/13 at 2:25 p.m., a dietary staff member stated he saw two live "rats" with their feet caught in the "sticky traps (rodent glue boards)" about a week ago in the dry food storage area. The dietary staff member stated he notified maintenance, and they came and got them. On 7/12/13, small brown cylinder-shaped rat feces were observed in the corners of the floor under the storage shelves that contained dried food products, and in a cardboard box containing dishes. This was discussed with the Administrator and CDM at the time of the observation. 3. On 07/16/13 at 1:35 p.m., during a tour of the dry food storage room with the Certified Dietary Manager (CDM), observation revealed a plastic pipe located on the north side of the room, in the back where the canned food was stored. The pipe had an accumulation of rat feces and urine, and was coated with a yellowish substance. On the outer rims of numerous sections of metal shelving, the food packaging was visibly contaminated with a yellow dried liquid substance. Underneath the shelving, near the south wall, was a large stain on the floor. The kitchen supervisor could not identify the substance, but did say, it looked like dirt. On 07/16/2013 at 1:35 p.m., the CDM was asked if he took any action to discard the food when he learned about the rodent infestation. The CDM said he did not think it was necessary to discard the food, but said, "We clean the top of the can off before emptying the contents." He did not think it was necessary to remove the labels or sanitize the can before opening. The CDM failed to take any action to address the contaminated food. The CDM was asked if the dry food storage room had been thoroughly cleaned. The kitchen supervisor stated she cleaned some of the walls and the floor, but did not remove any of the food products stored in the room. The Administrator was present during the conversation with the CDM and the kitchen supervisor and stated, "There was no need to remove the food as they have fixed the problem." The Administrator was asked about the pest control company, and if the vendor had not been effective, why they did not get a second opinion from another exterminating company. The Administrator said there was no need to because they were happy with the exterminator they had. The Administrator also said the food was not moved into another storage area because "that would not do any good... there were no more rats in the building so there was no need to do that." The Administrator said, "There are rats in every restaurant and building. We live in Florida, and we should expect rodents and cockroaches in buildings, and for every cockroach or rodent we find you expect us to shut down the kitchen." The Administrator stated, "This would have never happened if we had not terminated that employee last Thursday; that is why I am in trouble." During an interview on 07/16/13 at 3:00 p.m., the CDM was asked about the rodent infestation and why he did not remove the food from the dry food storage room. He said, "Between me and you, the food should have been removed." The CDM was asked why they did not think about catering food for the residents until the situation was remedied . The CDM sated he did make recommendations to the Administrator as to his thoughts. On 07/17/13 at 1:35 a.m., a meeting was held with the Registered Dietitian Consultant (RDC). The RDC was asked if she was aware of the rodent infestation in the building. The RDC stated she had heard something about rats in the building, but she could not remember who told her. When asked if she audits the kitchen for infection control issues, she said yes. When asked if she had seen any remnants of rodents in the kitchen or dry food storage room, she replied no. She was asked if she has seen any rat traps in the dry food storage room, and said no. The RDC added that she does a monthly audit of infection control in the kitchen. Review of the monthly "Infection Control Summary" from January, 2013 through May, 2013 did not document any signs of rodent infestation.

Based on observation and interview, the Certified Dietary Manager (CDM) and the Administrator did not inform the Director of Nursing (DON)/Infection Control Coordinator that the dry food storage area had a rat infestation problem. This resulted in the inability of the infection control coordinator to implement infection control precautions and staff education in order to prevent contamination of the food from the dry storage area to the food preparation area. Through unsanitary food storage procedures, the facility failed to prevent the possible spread of harmful bacteria and viruses generated from rodent infestation in the dry food storage and central supply rooms. Open areas in the walls and the exposed food resulted in rodents entering and eating food in these areas. The facility failed to take measures to appropriately clean and sanitize the kitchen, dry food storage and central supply rooms, after learning of rodent infestation. This system failure resulted in contamination and cross contamination of food from dry storage to the food preparation area for more than a six-month period (January, 2013). The facility census at survey was 106. Medical admission record sheets review identified 10 vulnerable residents (#1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), at significant risk to diseases transmitted by rats. Also at risk are the staff working in the kitchen area, and facility visitors. The diseases that can be transmitted from rats include: Hanta virus, [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], Salmonellosis, and the Plague. These diseases can cause damage or failure of the major organs; gastrointestinal infection; bloodstream infection; or severe, sometimes fatal, respiratory disease in humans. These diseases can result in serious illness or death. The findings include: Observation at approximately 1:00 p.m. on 07/12/13 reveals 2 large baited traps near a hole in the wall of the northeast corner of the dry storage room. The Certified Dietary Manager (CDM) stated they have a rodent in the kitchen they are trying to catch. Observation outside, by the dumpster reveals another rodent bait station, a large black box with hole on one side, and a box on the other, set by a drainage pipe. During a random interview on 07/12/13 when asked where he had seen rats, Resident #11, who is unable to speak, pointed to the nurses' station on the west wing. Review of the resident's Quarterly Social Work note, dated 07/05/13, documents he is alert, oriented to name and some situations. He understood, despite vocabulary of mainly "yeah" and "hey." He is unable to complete BIMS, per staff, he is aware of location of room, responds by nodding. Staff reports no concerns or behaviors at this time. Brother is his guardian. During an interview on 07/12/13, at 1:09 p.m., Dietary staff member (A) stated something ate through the bread wrapper around a week ago. She stated the maintenance man put the trap out this week. She has not seen any evidence the rodent has been back. Nothing else has been eaten through. During an interview on 07/12/13 at 1:16 p.m., Dietary staff member (B) stated, We have rats here. When asked how she knew, she said she heard everyone talking about it. She stated she came in at 5:30 a.m. one morning and saw a dead rat in the trap, but has not seen one since. She stated the maintenance man disposed of the rat body. During an interview on 07/12/13, Dietary staff member (C), who comes in at 5:30 a.m., said she often would see both traps with dead rats and one was about the size of a raccoon, I guess it was the "granddaddy." She said when she sees them she runs out; there are always droppings on the floor. Dietary staff member stated she has worked at the facility for 2 years. The first year I did not see any rats. A few months ago, the rat problem started. She was asked how many dead rats she has seen and replied, "I have stopped counting." When asked how she feels about working in a kitchen with rats, she said, "I feel nasty." During an interview on 07/12/13, Dietary staff member (D) said she comes in at 5:30 a.m. (sometimes 6:30 a.m.) and has heard the rats squeaking in traps several times within the last couple of months. She stated she saw a dead rat in the trap about a month ago and it was about the size of a gerbil. Dietary staff member (D) stated there are always droppings (feces) in the dry food storage room, but we keep it cleaned up. She said she goes into the dry storage and gets out as fast as she can because she hates to see rats. During an interview on 07/12/13 at 2:49 p.m., the Administrator stated the problem began during a dry spell. He stated they did some renovation on the front of the building leaving areas exposed. He thinks that is how they got in. He stated there is a swell in the back of the building and they may be coming from there, as well. At one time they caught rats daily. He stated pest control supplied big bear-like traps because there were some large ones. He said the pest control company does not want to use poison because the rats will eat it and die somewhere in the walls or ceilings of the building and stink until you find them. The Administrator said they have cleaned all of the resident rooms and cleaned out clutter. He said there have not been any rats in the resident care areas; there are traps there, but he did not think any rats have been trapped. He stated they have had the trees around the building trimmed trying to eliminate all avenues for the rats to enter the building. During a phone interview on 07/12/13 at 4:27 p.m., the Maintenance Assistant stated the last time he disposed of rodents in the dry storage area was the end of June and he caught 2 in 2 days. He could not recall how many dead rats he had disposed. During an interview on 07/12/13 at 4:30 p.m., the Director of Maintenance stated he started working at the facility in May and, by word of mouth, has heard it used to be a lot worse. He was advised by the pest control company on 07/02/13, that if they are still finding evidence of rodents they recommend the facility continue to set the traps. He said the trees have been trimmed and traps have been set. During a more detailed observation of the dry food storage on 07/12/13 in the late afternoon, evidence of rats was found in each corner and inside of a box of dishes on a shelf. There was another hole in the baseboard to the left of the entrance door, with additional traps set, and there were 2 traps by the bread rack. There was no evidence of any chewed packages of food, as the dietary staff said they were thrown away. When asked why the food was not removed out of the dry storage to another location, the Administrator said it is in packages. During the interview, the Administrator did not demonstrate an understanding that if rodents are running around the dry storage area, then much of the food (even packaged) would be contaminated. Nor, that cross contamination would then occur when food is taken into the clean area of the kitchen, where it would be opened and served to residents. After this discussion, the Administrator concluded the food should be moved or contained from the rodents. The bread was observed to be on open racks, the cookie and cake mix were in packages on the shelves. During an interview on 07/16/13 at 2:41 p.m., the Medical Director was asked if he was aware of a rat problem and stated he was made aware of it in February and discussed it with the Administrator. He was told it was being taken care of. He was not aware the dietary staff are not thoroughly disinfecting the dry storage area and the staff was not taking precautions to prevent cross contamination. When the surveyor discussed this with him, he stated "I see what you are saying." During an interview on 07/12/13 at approximately 3:30 p.m., the Ameritech Pest Control Services technician stated he came to the facility in January and set traps and sealed the building. The maintenance crew at the facility asked him to leave some glue boards. The facility signed a yearly rodent control contract. He said the technicians have been coming to the facility monthly and check the traps around the building, but do not ask how many rodents have been found in the interior traps. He stated they supply the Maintenance Department with glue boards when needed. He stated he feels the facility is doing all that it can to get rid of the rodents; it may be an ongoing problem as they are not sure how the rodents are entering the facility. Review of the monthly visit documentation reveal reference only follow-up for rodents. On 07/13/13 at 3:30 p.m. observation of the central supply room revealed rodent tracks in the red plastic container in with the urinary drainage bags. The Central Supply Clerk stated the rodents like the Med Pass?, a nutritional supplement, and lotion with olive oil. The central supply clerk stated she puts the lotion in a sealed box and the Med Pass? in the hall medication rooms. She pointed out a string in the ceiling where the maintenance man has placed a trap. She said the rodent problem is much better than it was a few months ago. She said maintenance staff removed the traps from the central supply room today. She said maintenance staff place traps in central supply during the week, but removes them during the weekend. Central supply is located directly across the hall from the kitchen. During a telephone interview on 07/17/13 at 10:41 a.m., the previous Maintenance Director stated evidence of rats was found in the dry food storage area in January and they had the pest control company come and set traps. He stated they caught a few now and then in the dry food storage area. He left the facility a couple of months ago. During an interview on 07/12/13, and again when asked on 07/16/13 around 12:53 p.m., the Director of Nursing (DON) stated he did not know anything about the dry food storage area having a rat infestation. He agreed it would be an important thing for the DON to know. The Administrator was asked if he was aware of the diseases rodents carry on their bodies, including the rodent urine and feces. The Administrator did not respond. During review of residents' admission record sheets noted: ? Resident #1 has [DIAGNOSES REDACTED]. ? Resident #2 has [DIAGNOSES REDACTED]. ? Resident #3 has [DIAGNOSES REDACTED]. ? Resident #4 has [DIAGNOSES REDACTED]. ? Resident #5 has [DIAGNOSES REDACTED]. ? Resident #6 has [DIAGNOSES REDACTED]. ? Resident #7 has a [DIAGNOSES REDACTED]. ? Resident #8 has [DIAGNOSES REDACTED]. ? Resident #9 has [DIAGNOSES REDACTED]. ? Resident #10 has [DIAGNOSES REDACTED]. Due to pulmonary or other compromising diagnoses, Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 are at increased risk for contracting diseases that the Centers for Disease Control and Prevention warns have the potential for causing serious harm, injury or death. Some of the potential diseases are: ? Lymphocytic Chorio-meningitis (LCM) http://www.cdc.gov/rodents/diseases/direct.html#hps> and http://www.cdc.gov/hantavirus/hfrs/index.html); ? [DIAGNOSES REDACTED] (http://www.cdc.gov/healthypets/lcmv_rodents.htm); ? Salmonellosis (http://www.cdc.gov/nczved/divisions/dfbmd/diseases/salmonellosis); and ? Plague (http://www.cdc.gov/plague). (cross reference to F371, F465, and F469)

Based on observation and interview, the Certified Dietary Manager (CDM) and the Administrator did not inform the Director of Nursing (DON)/Infection Control Coordinator that the dry food storage area had a rat infestation problem. This resulted in the inability of the infection control coordinator to implement infection control precautions and staff education in order to prevent contamination of the food from the dry storage area to the food preparation area. Through unsanitary food storage procedures, the facility failed to prevent the possible spread of harmful bacteria and viruses generated from rodent infestation in the dry food storage and central supply rooms. Open areas in the walls and the exposed food resulted in rodents entering and eating food in these areas. The facility failed to take measures to appropriately clean and sanitize the kitchen, dry food storage and central supply rooms, after learning of rodent infestation. This system failure resulted in contamination and cross contamination of food from dry storage to the food preparation area for more than a six-month period (January, 2013). The facility census at survey was 106. Medical admission record sheets review identified 10 vulnerable residents (#1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), at significant risk to diseases transmitted by rats. Also at risk are the staff working in the kitchen area, and facility visitors. The diseases that can be transmitted from rats include: Hanta virus, [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], Salmonellosis, and the Plague. These diseases can cause damage or failure of the major organs; gastrointestinal infection; bloodstream infection; or severe, sometimes fatal, respiratory disease in humans. These diseases can result in serious illness or death. The findings include: 1. Observation at approximately 1:00 p.m. on 07/12/13 reveals 2 large baited traps near a hole in the wall of the northeast corner of the dry storage room. The Certified Dietary Manager (CDM) stated they have a rodent in the kitchen they are trying to catch. Observation outside, by the dumpster reveals another rodent bait station, a large black box with hole on one side, and a box on the other, set by a drainage pipe. During a random interview on 07/12/13 when asked where he had seen rats, Resident #11, who is unable to speak, pointed to the nurses' station on the west wing. Review of the resident's Quarterly Social Work note, dated 07/05/13, documents he is alert, oriented to name and some situations. He understood, despite vocabulary of mainly "yeah" and "hey." He is unable to complete BIMS, per staff, he is aware of location of room, responds by nodding. Staff reports no concerns or behaviors at this time. Brother is his guardian. During an interview on 07/12/13, at 1:09 p.m., Dietary staff member (A) stated something ate through the bread wrapper around a week ago. She stated the maintenance man put the trap out this week. She has not seen any evidence the rodent has been back. Nothing else has been eaten through. During an interview on 07/12/13 at 1:16 p.m., Dietary staff member (B) stated, We have rats here. When asked how she knew, she said she heard everyone talking about it. She stated she came in at 5:30 a.m. one morning and saw a dead rat in the trap, but has not seen one since. She stated the maintenance man disposed of the rat body. During an interview on 07/12/13, Dietary staff member (C), who comes in at 5:30 a.m., said she often would see both traps with dead rats and one was about the size of a raccoon, I guess it was the "granddaddy." She said when she sees them she runs out; there are always droppings on the floor. Dietary staff member stated she has worked at the facility for 2 years. The first year I did not see any rats. A few months ago, the rat problem started. She was asked how many dead rats she has seen and replied, "I have stopped counting." When asked how she feels about working in a kitchen with rats, she said, "I feel nasty." During an interview on 07/12/13, Dietary staff member (D) said she comes in at 5:30 a.m. (sometimes 6:30 a.m.) and has heard the rats squeaking in traps several times within the last couple of months. She stated she saw a dead rat in the trap about a month ago and it was about the size of a gerbil. Dietary staff member (D) stated there are always droppings (feces) in the dry food storage room, but we keep it cleaned up. She said she goes into the dry storage and gets out as fast as she can because she hates to see rats. During an interview on 07/12/13 at 2:49 p.m., the Administrator stated the problem began during a dry spell. He stated they did some renovation on the front of the building leaving areas exposed. He thinks that is how they got in. He stated there is a swell in the back of the building and they may be coming from there, as well. At one time they caught rats daily. He stated pest control supplied big bear-like traps because there were some large ones. He said the pest control company does not want to use poison because the rats will eat it and die somewhere in the walls or ceilings of the building and stink until you find them. The Administrator said they have cleaned all of the resident rooms and cleaned out clutter. He said there have not been any rats in the resident care areas; there are traps there, but he did not think any rats have been trapped. He stated they have had the trees around the building trimmed trying to eliminate all avenues for the rats to enter the building. During a phone interview on 07/12/13 at 4:27 p.m., the Maintenance Assistant stated the last time he disposed of rodents in the dry storage area was the end of June and he caught 2 in 2 days. He could not recall how many dead rats he had disposed. During an interview on 07/12/13 at 4:30 p.m., the Director of Maintenance stated he started working at the facility in May and, by word of mouth, has heard it used to be a lot worse. He was advised by the pest control company on 07/02/13, that if they are still finding evidence of rodents they recommend the facility continue to set the traps. He said the trees have been trimmed and traps have been set. During a more detailed observation of the dry food storage on 07/12/13 in the late afternoon, evidence of rats was found in each corner and inside of a box of dishes on a shelf. There was another hole in the baseboard to the left of the entrance door, with additional traps set, and there were 2 traps by the bread rack. There was no evidence of any chewed packages of food, as the dietary staff said they were thrown away. When asked why the food was not removed out of the dry storage to another location, the Administrator said it is in packages. During the interview, the Administrator did not demonstrate an understanding that if rodents are running around the dry storage area, then much of the food (even packaged) would be contaminated. Nor, that cross contamination would then occur when food is taken into the clean area of the kitchen, where it would be opened and served to residents. After this discussion, the Administrator concluded the food should be moved or contained from the rodents. The bread was observed to be on open racks, the cookie and cake mix were in packages on the shelves. During an interview on 07/16/13 at 2:41 p.m., the Medical Director was asked if he was aware of a rat problem and stated he was made aware of it in February and discussed it with the Administrator. He was told it was being taken care of. He was not aware the dietary staff are not thoroughly disinfecting the dry storage area and the staff was not taking precautions to prevent cross contamination. When the surveyor discussed this with him, he stated "I see what you are saying." During an interview on 07/12/13 at approximately 3:30 p.m., the Ameritech Pest Control Services technician stated he came to the facility in January and set traps and sealed the building. The maintenance crew at the facility asked him to leave some glue boards. The facility signed a yearly rodent control contract. He said the technicians have been coming to the facility monthly and check the traps around the building, but do not ask how many rodents have been found in the interior traps. He stated they supply the Maintenance Department with glue boards when needed. He stated he feels the facility is doing all that it can to get rid of the rodents; it may be an ongoing problem as they are not sure how the rodents are entering the facility. Review of the monthly visit documentation reveal reference only follow-up for rodents. On 07/13/13 at 3:30 p.m. observation of the central supply room revealed rodent tracks in the red plastic container in with the urinary drainage bags. The Central Supply Clerk stated the rodents like the Med Pass?, a nutritional supplement, and lotion with olive oil. The central supply clerk stated she puts the lotion in a sealed box and the Med Pass? in the hall medication rooms. She pointed out a string in the ceiling where the maintenance man has placed a trap. She said the rodent problem is much better than it was a few months ago. She said maintenance staff removed the traps from the central supply room today. She said maintenance staff place traps in central supply during the week, but removes them during the weekend. Central supply is located directly across the hall from the kitchen. During a telephone interview on 07/17/13 at 10:41 a.m., the previous Maintenance Director stated evidence of rats was found in the dry food storage area in January and they had the pest control company come and set traps. He stated they caught a few now and then in the dry food storage area. He left the facility a couple of months ago. During an interview on 07/12/13, and again when asked on 07/16/13 around 12:53 p.m., the Director of Nursing (DON) stated he did not know anything about the dry food storage area having a rat infestation. He agreed it would be an important thing for the DON to know. 2. The Administrator was asked if he was aware of the diseases rodents carry on their bodies, including the rodent urine and feces. The Administrator did not respond. During review of residents' admission record sheets noted: ? Resident #1 has [DIAGNOSES REDACTED]. ? Resident #2 has [DIAGNOSES REDACTED]. ? Resident #3 has [DIAGNOSES REDACTED]. ? Resident #4 has [DIAGNOSES REDACTED]. ? Resident #5 has [DIAGNOSES REDACTED]. ? Resident #6 has [DIAGNOSES REDACTED]. ? Resident #7 has a [DIAGNOSES REDACTED]. ? Resident #8 has [DIAGNOSES REDACTED]. ? Resident #9 has [DIAGNOSES REDACTED]. ? Resident #10 has [DIAGNOSES REDACTED]. Due to pulmonary or other compromising diagnoses, Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 are at increased risk for contracting diseases that the Centers for Disease Control and Prevention warns have the potential for causing serious harm, injury or death. Some of the potential diseases are: ? Lymphocytic Chorio-meningitis (LCM) http://www.cdc.gov/rodents/diseases/direct.html#hps> and http://www.cdc.gov/hantavirus/hfrs/index.html); ? [DIAGNOSES REDACTED] (http://www.cdc.gov/healthypets/lcmv_rodents.htm); ? Salmonellosis (http://www.cdc.gov/nczved/divisions/dfbmd/diseases/salmonellosis); and ? Plague (http://www.cdc.gov/plague). (cross reference to F371, F465, and F469) 3. Entered the facility on 08/02/2013 at 12:30 p.m. and met with the new Administrator. Explained the purpose of the visit, and requested to begin a tour of area in the building of concern. The tour was conducted with the Administrator and the Director of Maintenance. A. Toured the dry storeroom in the kitchen. The walls and floor of the store room, were observed to be newly painted. All the cracks and holes in the wall had been professionally sealed. All the food products that were originally in the storeroom were discarded, and replaced by new food products. All food items that were not in a metal can were in large plastic storage bends, with lid on them. There was no evidence of any rodent feces or urine observed in the storeroom. B. Toured the Central Supply storage room. Observed the walls had been freshly painted, and the floor was clean.. All supplies had been removed from the floor, and were placed on shelves. There was no evidence of rodent feces or urine in the Central Supply room. C. Toured Mechanical room [ROOM NUMBER] Floor and walls observed to be newly painted, screen to the window replaced. Did observed that the base board located under the window which was observed to be approximately 1 foot in length needed to be sealed more securely. Did not observe any rodent urine or feces. D. Tour Mechanical room [ROOM NUMBER] Floors and wall had been freshly painted. Window screen had been replaced. There was no rodent urine or feces observed. E. Tour the exterior of the building. The shrubs and trees had been cut back so they were not touching the building. Landscapers were on the property continuing to cut vegetation from surrounding properties, to ensure the deterrence of the rodents. Two trees on the property 1 south end of the building and 1 on the west end of the building were observed to need a little more pruning. Observed were numerous rate traps surrounding the entire building. Administrator said the exterminator had place 52 rate traps around the building. Did not observe any cracks, holes, or crevices on the exterior of the building. During an exit conference on 8/2/2013 at 1:30 p.m., with the Administrator, Registered Dietitian, Director of Nursing, Regional Clinical Manager, and Regional Vice President survey status was reviewed. The facility staff was made aware as a result the implementation of the Allegation of Complaince and observations made during the revisit, the Immediate Jeopardy has been removed and the Scope and Severity changed from a K to an E effective 07/31/13, the date of the alleged compliance. Although the Immediate Jeopardy was removed, ongoing noncompliance continues until all corrective actions are completed to achieve substantial compliance.

Based on observation, interview, and record review, the facility failed to ensure vulnerable residents (10 of the 106 census), staff, and visitors to the facility were free from cross contamination of harmful bacteria [MEDICAL CONDITION] that are carried by rats. This was a result of: 1) Failure to ensure the kitchen was free from rodent infestation and potential diseases rodents carry; 2) Failure to ensure the central supply room, which stores nutritional supplements and medical supplies for the residents, was free from rodent infestation; and 3) Failure to recognize the concept of contamination caused from rodent infestation and contamination from rat urine and feces. This system failure resulted in cross contamination of food from dry storage to the food preparation area for more than a six-month period. This placed vulnerable residents, kitchen staff, and visitors who consume food from the kitchen at immediate risk of serious health problems that can result from diseases transmitted by rats. The diseases that can be transmitted from rats include: [MEDICAL CONDITION], [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], Salmonellosis, and the Plague. These diseases can cause damage or failure of the major organs; gastrointestinal infection; bloodstream infection; or severe, sometimes fatal, respiratory disease in humans. These diseases can result in serious illness or death. The findings include: Observation at approximately 1:00 p.m. on 07/12/13 reveals 2 large baited traps near a hole in the wall of the northeast corner of the dry storage room. The Certified Dietary Manager (CDM) stated they have a rodent in the kitchen they are trying to catch. Observation outside, by the dumpster reveals another rodent bait station, a large black box with hole on one side, and a box on the other, set by a drainage pipe. During a more detailed observation of the dry food storage on 07/12/13 in the late afternoon, evidence of rats was found in each corner and inside of a box of dishes on a shelf. There was another hole in the baseboard to the left of the entrance door, with additional traps set, and there were 2 traps by the bread rack. There was no evidence of any chewed packages of food, as the dietary staff said they were thrown away. When asked why the food was not removed out of the dry storage to another location, the Administrator said it is "in packages." During the interview, the Administrator did not demonstrate an understanding that if rodents are running around the dry storage area, then much of the food (even packaged) would be contaminated. Nor, that cross contamination would then occur when food is taken into the clean area of the kitchen, where it would be opened and served to residents. After this discussion, the Administrator concluded the food should be moved or contained from the rodents. The bread was observed to be on open racks, the cookie and cake mix were in packages on the shelves. During an interview on 07/16/13 at 2:41 p.m., the Medical Director was asked if he was aware of a rat problem and stated he was made aware of it in February and discussed it with the Administrator. He was told it "was being taken care of." He was not aware the dietary staff are not thoroughly disinfecting the dry storage area and the staff was not taking precautions to prevent cross contamination. When the surveyor discussed this with him, he stated "I see what you are saying." During an interview on 07/12/13 at 1:09 p.m., Dietary staff member (A) stated something had eaten through a bread wrapper, about a week ago. She has not seen any critters or droppings. She said the maintenance man put the trap out this week, and has not seen any evidence the rodent has returned. Nothing else has been eaten through. During an interview on 07/12/13 at 1:16 p.m., Dietary staff member (B) stated, "We have rats here." When asked how she knew, she said she heard everyone talking about it. She stated she came in at 5:30 a.m. one morning and saw a dead rat in the trap, but has not seen one since. She stated the maintenance man disposed of the dead rat body. During an interview on 07/12/13, Dietary staff member (C), who comes in at 5:30 a.m., said she often would see both traps with dead rats and one was about the size of a raccoon, "I guess it was the 'granddaddy.'" She said when she sees them she runs out; "there are always droppings on the floor." Dietary staff member stated she has worked at the facility for 2 years. "The first year I did not see any rats. A few months ago, the rat problem started." She was asked how many dead rats she has seen and replied, "I have stopped counting." When asked how she feels about working in a kitchen with rats, she said, "I feel nasty." During an interview on 07/12/13, Dietary staff member (D) said she comes in at 5:30 a.m. (sometimes 6:30 a.m.) and has heard the rats squeaking in traps several times within the last couple of months. She stated she saw a dead rat in the trap about a month ago and it was about the size of a gerbil. Dietary staff member (D) stated there are always droppings in the dry food storage room, but "we keep it cleaned up." She said she goes into the dry storage and gets out as fast as she can because she hates to see rats. During an interview on 07/12/13 at 2:49 p.m., the Administrator stated the problem began during "a dry spell." He stated they did some renovation on the front of the building leaving areas exposed. He thinks that is how they got in. He stated there is a swell in the back of the building and they may be coming from there, as well. At one time they caught rats daily. He stated pest control supplied big bear-like traps because there were some large ones. He said the pest control company does not want to use poison because the rats will eat it and die somewhere in the walls or ceilings of the building and stink until you find them. The Administrator said they have cleaned all of the resident rooms and cleaned out clutter. He said there have not been any rats in the resident care areas; there are traps there, but he did not think any rats have been trapped. He stated they have had the trees around the building trimmed trying to eliminate all avenues for the rats to enter the building. During an interview on 07/12/13 at approximately 3:30 p.m., the Ameritech Pest Control Services technician stated he came to the facility in January and set traps and sealed the building. The maintenance crew at the facility asked him to leave some glue boards. The facility signed a yearly rodent control contract. He said the technicians have been coming to the facility monthly and check the traps around the building, but do not ask how many rodents have been found in the interior traps. He stated they supply the Maintenance Department with glue boards when needed. He stated he feels the facility is doing all that it can to get rid of the rodents; it may be an ongoing problem as they are not sure how the rodents are entering the facility. Review of the monthly visit documentation reveal reference only follow-up for rodents. During a phone interview on 07/12/13 at 4:27 p.m., the Maintenance Assistant stated the last time he disposed of rodents in the dry storage area was the end of June and he caught 2 in 2 days. He could not recall how many dead rats he had disposed. During an interview on 07/12/13 at 4:30 p.m., the Director of Maintenance stated he started working at the facility in May and, by word of mouth, has heard it used to be a lot worse. He was advised by the pest control company on 07/02/13, that if they are still finding evidence of rodents they recommend the facility continue to set the traps. He said the trees have been trimmed and traps have been set. During a random interview on 07/12/13 when asked where he had seen rats, Resident #11, who is unable to speak, pointed to the nurses' station on the west wing. Review of the resident's Quarterly Social Work note, dated 07/05/13, documents he is alert, oriented to name and some situations. He understood, despite vocabulary of mainly "yeah" and "hey." He is unable to complete BIMS (Brief Interview for Mental Status), per staff, he is aware of location of room, responds by nodding. Staff reports no concerns or behaviors at this time. Brother is his guardian. On 07/13/13 at 3:30 p.m. observation of the central supply room revealed rodent tracks in the red plastic container in with the urinary drainage bags. The Central Supply Clerk stated the rodents like the Med Pass?, a nutritional supplement, and lotion with olive oil. The central supply clerk stated she puts the lotion in a sealed box and the Med Pass? in the hall medication rooms. She pointed out a string in the ceiling where the maintenance man has placed a trap. She said the rodent problem is much better than it was a few months ago. She said maintenance staff removed the traps from the central supply room today. She said maintenance staff place traps in central supply during the week, but removes them during the weekend. Central supply is located directly across the hall from the kitchen. During a telephone interview on 07/17/13 at 10:41 a.m., the previous Maintenance Director stated evidence of rats was found in the dry food storage area in January and they had the pest control company come and set traps. He stated they caught a few now and then in the dry food storage area. He left the facility a couple of months ago. 2. During a tour of the kitchen dry food storage area on 07/12/13 at 1:05 p.m. with the facility's Certified Dietary Manager (CDM), two surveyors observed a hole (approximately 4 by 5 inches) in the base of a wall next to a pipe. There were 2 baited rodent stations on the floor next to the hole. The CDM stated the baited rodent stations were traps to catch "a mouse" that had been running around and the hole had not been there very long. There were several bread products stored on a rack, and dried food goods stored on the shelves. It was noted there were 2 more baited rodent stations on the floor next to the wall behind the bread rack. During an interview on 07/12/13 at 2:25 p.m., a dietary staff member stated he saw two live "rats" with their feet caught in the "sticky traps (rodent glue boards)" about a week ago in the dry food storage area. The dietary staff member stated he notified maintenance, and they came and got them. On 7/12/13, small brown cylinder-shaped rat feces were observed in the corners of the floor under the storage shelves that contained dried food products, and in a cardboard box containing dishes. This was discussed with the Administrator and CDM at the time of the observation. 3. On 07/16/13 at 1:35 p.m., during a tour of the dry food storage room with the Certified Dietary Manager (CDM), observation revealed a plastic pipe located on the north side of the room, in the back where the canned food was stored. The pipe had an accumulation of rat feces and urine, and was coated with a yellowish substance. On the outer rims of numerous sections of metal shelving, the food packaging was visibly contaminated with a yellow dried liquid substance. Underneath the shelving, near the south wall, was a large stain on the floor. The kitchen supervisor could not identify the substance, but did say, it looked like dirt. On 07/16/2013 at 1:35 p.m., the CDM was asked if he took any action to discard the food when he learned about the rodent infestation. The CDM said he did not think it was necessary to discard the food, but said, "We clean the top of the can off before emptying the contents." He did not think it was necessary to remove the labels or sanitize the can before opening. The CDM failed to take any action to address the contaminated food. The CDM was asked if the dry food storage room had been thoroughly cleaned. The kitchen supervisor stated she cleaned some of the walls and the floor, but did not remove any of the food products stored in the room. The Administrator was present during the conversation with the CDM and the kitchen supervisor and stated, "There was no need to remove the food as they have fixed the problem." The Administrator was asked about the pest control company, and if the vendor had not been effective, why they did not get a second opinion from another exterminating company. The Administrator said there was no need to because they were happy with the exterminator they had. The Administrator also said the food was not moved into another storage area because "that would not do any good... there were no more rats in the building so there was no need to do that." The Administrator said, "There are rats in every restaurant and building. We live in Florida, and we should expect rodents and cockroaches in buildings, and for every cockroach or rodent we find you expect us to shut down the kitchen." The Administrator stated, "This would have never happened if we had not terminated that employee last Thursday; that is why I am in trouble." During an interview on 07/16/13 at 3:00 p.m., the CDM was asked about the rodent infestation and why he did not remove the food from the dry food storage room. He said, "Between me and you, the food should have been removed." The CDM was asked why they did not think about catering food for the residents until the situation was remedied . The CDM sated he did make recommendations to the Administrator as to his thoughts. On 07/17/13 at 1:35 a.m., a meeting was held with the Registered Dietitian Consultant (RDC). The RDC was asked if she was aware of the rodent infestation in the building. The RDC stated she had heard something about rats in the building, but she could not remember who told her. (cross reference to F371, F441, and F469)

Based on interview and record review, the facility failed to ensure adequate pest control measures. The facility failed to assess effectiveness of the pest control program and make revisions when the rodent infestation continued. This on-going rat infestation resulted in the Immediate Jeopardy identified on 07/17/13, beginning on 01/17/13, and is ongoing. This system failure resulted in contamination and cross contamination of food from dry storage to the food preparation area for more than a six-month period (January, 2013). The facility census at survey was 106. Medical record review identified 10 vulnerable residents (#1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), at significant risk to diseases transmitted by rats. Also at risk are the staff working in the kitchen area, and facility visitors. The diseases that can be transmitted from rats include: [MEDICAL CONDITION], [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], Salmonellosis, and the Plague. These diseases can cause damage or failure of the major organs; gastrointestinal infection; bloodstream infection; or severe, sometimes fatal, respiratory disease in humans. These diseases can result in serious illness or death. The findings include: During a random interview on 07/12/13 when asked where he had seen rats, Resident #11, who is unable to speak, pointed to the nurses' station on the west wing. Review of the resident's Quarterly Social Work note, dated 07/05/13, documents he is alert, oriented to name and some situations. He understood, despite vocabulary of mainly "yeah" and "hey." He is unable to complete BIMS, per staff, he is aware of location of room, responds by nodding. Staff reports no concerns or behaviors at this time. Brother is his guardian. In an interview on 07/16/13 at 1:35 p.m., the Dietary Manager (DM) stated the facility has had a problem with rodents since January of this year (2013). The exterminator comes to the facility often to deal with the infestation of rodents, but "I do not think the problems was that bad." During an interview on 07/16/13 at 1:35 p.m., the Administrator said he did not feel the problems were so bad, "The exterminator comes in often, when we have a problem with the rodents." The Administrator explained that this problem has existed since January, and the exterminator seems to be doing a good job getting rid of the rodents. The Administrator stated he did not think it was necessary to seek a second opinion from another exterminating company, because this company was doing a "great job." When asked to provide documentation and logs of when the exterminator had come in the building, and what was accomplished during those visits, the Administrator was not able to provide that information. On 07/17/13 at 12:25 p.m., the pest control serviceman was contacted and asked what type of rodent he was seeing at the facility. He stated they were Norwegian roof rats. The serviceman stated this type of rat is very common to this area and is usually found in palm trees. He stated he thought this problem was caused by exterior construction/remodeling being done on the building. The serviceman stated tarps were being used and the rats were probably entering the building via the loose tarps. Invoices of the visits from the pest control company documented: 1. On 12/26/12 the pest control company provided a proposal for pest control services. A.) Quote for rodent control B.) Rodent exclusion Service includes baiting, trapping, and sealing up building to keep rodents from entering structure. This proposal was signed and dated by the Administrator on 01/15/13; 2. Invoice for 01/17/13 - Monthly pest control inside common areas. Rodent control 1-year agreement; 3. Invoice for 01/18/13 - Follow-up rodents; 4. Invoice 01/22/13 - Follow-up rodents; 5. Invoice 01/25/13 - Follow-up rodents; 6. Invoice 01/28/13 - Follow-up rodents; 7. Invoice 01/28/13 - Follow-up rodents; 8. Invoice 02/20/13 - Bring out more glue boards, and rodents monthly pest control inside common areas; 9. Invoice 03/28/13 - Monthly pest control common areas (for) rodents; 10. Invoice 03/29/13 - Rodents; 11. Invoice 04/12/13 - Monthly pest control inside common areas, tiny bugs all over computer screen, and rodent monitoring; 12. Invoice 05/02/13 - Monthly pest control inside common areas, rodent monitoring; 13. Invoice 06/06/13 - Monthly pest control inside common areas, rodent monitoring; and 14. Invoice 07/02/13 - Monthly pest control inside common areas, roaches inside some rooms and closets, rodent monitoring. (cross reference to F371, F441, and F465)

Based on interview and record review, the facility failed to ensure adequate pest control measures. The facility failed to assess effectiveness of the pest control program and make revisions when the rodent infestation continued. This on-going rat infestation resulted in the Immediate Jeopardy identified on 07/17/13, beginning on 01/17/13, and is ongoing until 07/30/2013. This system failure resulted in contamination and cross contamination of food from dry storage to the food preparation area for more than a six-month period (January, 2013). The facility census at survey was 106. Medical record review identified 10 vulnerable residents (#1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), at significant risk to diseases transmitted by rats. Also at risk are the staff working in the kitchen area, and facility visitors. The diseases that can be transmitted from rats include: [MEDICAL CONDITION], [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], Salmonellosis, and the Plague. These diseases can cause damage or failure of the major organs; gastrointestinal infection; bloodstream infection; or severe, sometimes fatal, respiratory disease in humans. These diseases can result in serious illness or death. The findings include: 1. During a random interview on 07/12/13 when asked where he had seen rats, Resident #11, who is unable to speak, pointed to the nurses' station on the west wing. Review of the resident's Quarterly Social Work note, dated 07/05/13, documents he is alert, oriented to name and some situations. He understood, despite vocabulary of mainly "yeah" and "hey." He is unable to complete BIMS, per staff, he is aware of location of room, responds by nodding. Staff reports no concerns or behaviors at this time. Brother is his guardian. In an interview on 07/16/13 at 1:35 p.m., the Dietary Manager (DM) stated the facility has had a problem with rodents since January of this year (2013). The exterminator comes to the facility often to deal with the infestation of rodents, but "I do not think the problems was that bad." During an interview on 07/16/13 at 1:35 p.m., the Administrator said he did not feel the problems were so bad, "The exterminator comes in often, when we have a problem with the rodents." The Administrator explained that this problem has existed since January, and the exterminator seems to be doing a good job getting rid of the rodents. The Administrator stated he did not think it was necessary to seek a second opinion from another exterminating company, because this company was doing a "great job." When asked to provide documentation and logs of when the exterminator had come in the building, and what was accomplished during those visits, the Administrator was not able to provide that information. On 07/17/13 at 12:25 p.m., the pest control serviceman was contacted and asked what type of rodent he was seeing at the facility. He stated they were Norwegian roof rats. The serviceman stated this type of rat is very common to this area and is usually found in palm trees. He stated he thought this problem was caused by exterior construction/remodeling being done on the building. The serviceman stated tarps were being used and the rats were probably entering the building via the loose tarps. Invoices of the visits from the pest control company documented: 1. On 12/26/12 the pest control company provided a proposal for pest control services. A.) Quote for rodent control B.) Rodent exclusion Service includes baiting, trapping, and sealing up building to keep rodents from entering structure. This proposal was signed and dated by the Administrator on 01/15/13; 2. Invoice for 01/17/13 - Monthly pest control inside common areas. Rodent control 1-year agreement; 3. Invoice for 01/18/13 - Follow-up rodents; 4. Invoice 01/22/13 - Follow-up rodents; 5. Invoice 01/25/13 - Follow-up rodents; 6. Invoice 01/28/13 - Follow-up rodents; 7. Invoice 01/28/13 - Follow-up rodents; 8. Invoice 02/20/13 - Bring out more glue boards, and rodents monthly pest control inside common areas; 9. Invoice 03/28/13 - Monthly pest control common areas (for) rodents; 10. Invoice 03/29/13 - Rodents; 11. Invoice 04/12/13 - Monthly pest control inside common areas, tiny bugs all over computer screen, and rodent monitoring; 12. Invoice 05/02/13 - Monthly pest control inside common areas, rodent monitoring; 13. Invoice 06/06/13 - Monthly pest control inside common areas, rodent monitoring; and 14. Invoice 07/02/13 - Monthly pest control inside common areas, roaches inside some rooms and closets, rodent monitoring. (cross reference to F371, F441, and F465) 2. Entered the facility on 08/02/2013 at 12:30 p.m. and met with the new Administrator. Explained the purpose of the visit, and requested to begin a tour of area in the building of concern. The tour was conducted with the Administrator and the Director of Maintenance. A. Toured the dry storeroom in the kitchen. The walls and floor of the store room, were observed to be newly painted. All the cracks and holes in the wall had been professionally sealed. All the food products that were originally in the storeroom were discarded, and replaced by new food products. All food items that were not in a metal can were in large plastic storage bends, with lid on them. There was no evidence of any rodent feces or urine observed in the storeroom. B. Toured the Central Supply storage room. Observed the walls had been freshly painted, and the floor was clean.. All supplies had been removed from the floor, and were placed on shelves. There was no evidence of rodent feces or urine in the Central Supply room. C. Toured Mechanical Room 2 Floor and walls observed to be newly painted, screen to the window replaced. Did observed that the base board located under the window which was observed to be approximately 1 foot in length needed to be sealed more securely. Did not observe any rodent urine or feces. D. Tour Mechanical room #3 Floors and wall had been freshly painted. Window screen had been replaced. There was no rodent urine or feces observed. E. Tour the exterior of the building. The shrubs and trees had been cut back so they were not touching the building. Landscapers were on the property continuing to cut vegetation from surrounding properties, to ensure the deterrence of the rodents. Two trees on the property 1 south end of the building and 1 on the west end of the building were observed to need a little more pruning. Observed were numerous rate traps surrounding the entire building. Administrator said the exterminator had place 52 rate traps around the building. Did not observe any cracks, holes, or crevices on the exterior of the building. During an exit conference on 8/2/2013 at 1:30 p.m., with the Administrator, Registered Dietitian, Director of Nursing, Regional Clinical Manager, and Regional Vice President survey status was reviewed. The facility staff was made aware as a result the implementation of the Allegation of Complaince and observations made during the revisit, the Immediate Jeopardy has been removed and the Scope and Severity changed from a K to an E effective 07/31/13, the date of the alleged compliance. Although the Immediate Jeopardy was removed, ongoing noncompliance continues until all corrective actions are completed to achieve substantial compliance.

Based on facility record review and staff interviews, the facility Administrator failed to effectively attain and maintain the highest practicable physical, medical, and psychosocial well-being through facility processes significantly impacting 10 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) residents with [MEDICAL CONDITION] or other compromising diagnoses. The review of these records revealed the facility administrator failed to identify the problem and utilize facility resources to ensure staff follow the Infection Control policy and procedure for cross contamination assessment, coordinating care and notification of clinical staff of rodent infestation issues. This resulted in residents being exposed to immediate risk of serious health problems transmitted from diseased rats. The facility Administrator failed to provide effective Infection Control and Quality Assurance and Performance Improvement resource management to promote and ensure the health well-being of all facility residents and dietary staff. The Administrator failed to provide administrative oversight to ensure a complete and thorough investigation was conducted resulting in the lack of Quality Assurance and Performance Improvement examination and root cause analysis. Administration failed to implement effective approaches to rodent infestation and ensure that all dietary staff had demonstrated understanding of facility expectations in competency to implement Infection Control practices. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to vulnerable residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE] was identified on [DATE] and is ongoing. The findings include: Observation at approximately 1:00 p.m. on [DATE] reveals 2 large baited traps near a hole in the wall of the northeast corner of the dry storage room. The Certified Dietary Manager (CDM) stated they have a rodent in the kitchen they are trying to catch. Observation outside, by the dumpster reveals another rodent bait station, a large black box with hole on one side, and a box on the other, set by a drainage pipe. During an interview on [DATE], at 1:09 p.m., Dietary staff member (A) stated something ate through the bread wrapper around a week ago. She stated the maintenance man put the trap out this week. She has not seen any evidence the rodent has been back. Nothing else has been eaten through. During an interview on [DATE] at 1:16 p.m., Dietary staff member (B) stated, "We have rats here." When asked how she knew, she said she heard everyone talking about it. She stated she came in at 5:30 a.m. one morning and saw a dead rat in the trap, but has not seen one since. She stated the maintenance man disposed of the dead rat body. During an interview on [DATE], Dietary staff member (C), who comes in at 5:30 a.m., said she often would see both traps with dead rats and one was about the size of a raccoon, "I guess it was the 'granddaddy.'" She said when she sees them she runs out; "there are always droppings on the floor." Dietary staff member stated she has worked at the facility for 2 years. "The first year I did not see any rats. A few months ago, the rat problem started." She was asked how many dead rats she has seen and replied, "I have stopped counting." When asked how she feels about working in a kitchen with rats, she said, "I feel nasty." During an interview on [DATE], Dietary staff member (D) said she comes in at 5:30 a.m. (sometimes 6:30 a.m.) and has heard the rats squeaking in traps several times within the last couple of months. She stated she saw a dead rat in the trap about a month ago and it was about the size of a gerbil. Dietary staff member (D) stated there are always "rat" droppings (feces) in the dry food storage room, but "we keep it cleaned up." She said she goes into the dry storage and gets out as fast as she can because she hates to see rats. During an interview on [DATE] at 1:35 p.m., the Administrator said he did not feel the problems were so bad, "The exterminator comes in often, when we have a problem with the rodents." The Administrator explained that this problem has existed since January, and the exterminator seems to be doing a good job getting rid of the rodents. The Administrator stated he did not think it was necessary to seek a second opinion from another exterminating company, because this company was doing a "great job." During an interview on [DATE], and again when asked on [DATE] around 12:53 p.m., the Director of Nursing (DON) stated he did not know anything about the dry food storage area having rats. He said it has not been discussed at the Quality Assurance (QA) meetings he has attended in the last few months. He said there has not been any clusters of residents with unexplained rashes, respiratory illnesses or unusual gastrointestinal problems in the last 6 months. This was validated through review of the monthly infection control summaries from January through [DATE]. He agreed it would be an important thing for the DON to know about. During an interview on [DATE] at 2:41 p.m., the Medical Director was asked if he was aware of a rat problem and stated he was made aware of it in February and discussed it with the Administrator. He was told it "was being taken care of." He was not aware the dietary staff are not thoroughly disinfecting the dry storage area and the staff was not taking precautions to prevent cross contamination. When the surveyor discussed this with him, he stated "I see what you are saying." On [DATE] at 3:00 p.m. during an interview regarding the rodent infestation, the actions to prevent cross contamination (in reference to food storage, and food preparation) the Certified Dietary Manager (CDM) was asked why the food was not removed from the dry store room and why the room was not thoroughly cleaned and sanitized. The CDM was asked, also, why catered meals were not considered as a source to serve the residents until the potential rodent cross contamination was remedied . The CDM stated he could bring suggestions to the Administrator, "It is the Administrator's responsibility to act on my suggestions." The Administrator was requested to provide the documentation and logs of when the exterminator had come in the building, and what was accomplished during the visits by the exterminator. The Administrator was not able to provide the information requested. The Administrator was asked if the food in the dry storage room was discarded after there was evidence the rodents had eaten through boxes and food wrappers. Administrator said they had discarded the food that was evidently eaten/chewed on by the rodents, but did not take any actions to sanitize or remove the rest of the food from the room the rodents may have contaminated with urine or other bacteria. The Administrator was then asked why the food was not removed and stated, "It was not necessary, because the rats would follow the food to another area." The Administrator stated, "We live in Florida you know, and there are rats in every building, not just here. So anytime I have a rat in the building I have to move the food, is that what you are saying?" The Administrator was asked if he was aware of the diseases rodents carry on their bodies, including the rodent urine and feces. The Administrator did not respond. During review of residents' admission record sheets noted: Resident #1 has [DIAGNOSES REDACTED]. Resident #2 has [DIAGNOSES REDACTED]. Resident #3 has [DIAGNOSES REDACTED]. Resident #4 has [DIAGNOSES REDACTED]. Resident #5 has [DIAGNOSES REDACTED]. Resident #6 has [DIAGNOSES REDACTED]. Resident #7 has a [DIAGNOSES REDACTED]. Resident #8 has [DIAGNOSES REDACTED]. Resident #9 has [DIAGNOSES REDACTED]. Resident #10 has [DIAGNOSES REDACTED]. Due to [MEDICAL CONDITION] or other compromising diagnoses, Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 are at increased risk for contracting diseases that the Centers for Disease Control (CDC) warns have the potential for causing serious harm, injury or death. Some of the potential diseases are: ? [DIAGNOSES REDACTED] Infection (<http://www.cdc.gov/[DIAGNOSES REDACTED]/infection/index.html>; ? [DIAGNOSES REDACTED] with Renal Syndrome http://www.cdc.gov/rodents/diseases/direct.html#hps> and http://www.cdc.gov/hantavirus/hfrs/index.html); ? Lymphocytic Chorio-meningitis (LCM) (http://www.cdc.gov/rodents/diseases/direct.html#hps>; ? [DIAGNOSES REDACTED] (http://www.cdc.gov/healthypets/lcmv_rodents.htm); and ? Salmonellosis (<http://www.cdc.gov/rodents/diseases/direct.html#lassa> and <http://www.cdc.gov/nczved/divisions/dfbmd/diseases/salmonellosis>). Review of the approved cooperate job description for the Administrator's position documents: "Basic Function - "Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state and local standards, guidelines and regulations and directed by cooperate office and for ensuring that the highest degree of quality patient/resident care is maintained at all times." Characteristic Duties and Responsibilities - Essential functions include the following: ? "Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. (Includes personnel policies, patient/resident care policies, procedure manuals, position descriptions. Etc.) ? "Assist in the development and implementation of departmental policies and procedures and establish a rapport in and between departmental policies so that each can see the importance of team work. ? "Ensure that all personnel, patient/residents visitors and the general public follow established policies and procedures." "Marginal Functions" include: ? "Responsible for the overall quality assessment and improvement activities. ? "Ensure that the facility is maintained in a clean and safe manner for patient/resident comfort and convenience by ensuring that necessary equipment and supplies are maintained to perform such duties/services. ? "Receive advice from department supervisors concerning the operation of their departments, and other related areas, to assist in eliminating problem areas, author improvement of services. "Specific Requirements" include: ? "Knowledgeable of nursing and medical practices and procedures, as well as laws, regulations and guidelines pertaining to hospital and skilled nursing facility operation. ? "Ability to plan, organize, develop implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality patient/resident care and maintaining a sound operation." The job description documents: "I have read the above position description and fully understand the requirements set forth therein. I hereby accept the position of Administrator and agree to abide by the requirement set forth and will perform all duties and responsibilities to the best of my ability." (cross reference to F371, F441, F465, and F469)

Based upon interview with the administrator and review of the Quality Assessment and Assurance Committee, the facility failed to bring the issue of an ongoing rodent problem to the Quality Assessment and Assurance committee (QAA). As a result of lack of notification, this contributed to the failure of the facility to develop an integrated pest management plan since the QAA committee had no opportunity to assist. The open areas in the walls and the exposed food resulted in rodents eating the food in the dry food storage and central supply areas beginning on 01/17/13 and continuing to exit of the facility on 7/17/13. This system failure has resulted in contamination of dry food supply and cross contamination of food from dry storage to the food preparation area for more than a six-month period. This placed vulnerable residents, kitchen staff, and visitors who consumed food from the kitchen at immediate risk of serious health problems that can result from diseases transmitted by rats. Rats and mice can potentially transmit Salmonellosis, which can cause severe gastrointestinal infection, manifested by diarrhea, fever, and abdominal cramps. Salmonellosis has the can lead to long term effects of pain in the joints, irritation of the eyes, painful urination and chronic arthritis. This disease can result in serious illness or death. The findings include: During an interview on 07/16/13 in the late afternoon, when asked to review the agenda of the Quality Assessment and Assurance meetings since January the Administrator stated he did not think the issue of rodents had been discussed. During an interview on 07/16/13 at 2:41 p.m., the Medical Director was asked if he was aware of a rat problem and stated he was made aware of it in February and discussed it with the Administrator. He was told it "was being taken care of." He was not aware the dietary staff are not thoroughly disinfecting the dry storage area and the staff was not taking precautions to prevent cross contamination. When the surveyor discussed this with him, he stated "I see what you are saying." During an interview on 07/12/13, and again when asked on 07/16/13 around 12:53 p.m., the Director of Nursing (DON) stated he did not know anything about the dry food storage area having rats. He said it has not been discussed at the Quality Assurance (QA) meetings he has attended in the last few months. He said there have not been any clusters of residents with unexplained rashes, respiratory illnesses or unusual gastrointestinal problems in the last 6 months. This was validated through review of the monthly infection control summaries from January through June 2013. He agreed it would be an important thing for the DON to know about. During interviews on 07/12/13, the Certified Dietary Manager (CDM) and the Administrator stated they did not inform the Director of Nursing and the Medical Director that the dry food storage area had an ongoing rat / rodent infestation problem. This resulted in the failure to implement infection control precautions and staff education (in order to prevent cross contamination of the food from dry food storage into the kitchen food preparation area) and had the potential for residents, staff and visitors to be served food contaminated with diseases carried by rats. The choice of the Administrator and the CDM not to include the clinical staff in eliminating the rat / rodent infestation demonstrates a lack of understanding of the seriousness of the situation and a system failure to protect and care for the vulnerable residents. The facility failed to store food in a sanitary manner to prevent contamination of harmful bacteria [MEDICAL CONDITION] generated from rodent infestation in the dry food storage and central supply rooms. This is a result of the facility's: 1) Failure to ensure the dry store room was free from evidence of rodent infestation. 2) Failure to ensure that all holes and crevices in the dry store room were sealed up and secure. 3) Failure for the facility to take measures to appropriately clean and sanitize the dry store room, kitchen, and central supply room after they had knowledge of rodent infestation. 4) Failure for management and staff to understand what cross contamination is, and how bacteria [MEDICAL CONDITION] are spread through cross contamination. This has the potential of exposing residents, staff, and the visiting public to diseases that result in serious illness or death. The facility failed to ensure the residents, staff, and public visiting the facility were free from contamination of bacteria [MEDICAL CONDITION] that are carried by rats. This was due to the: 1) Facility failure to ensure that the kitchen was free from rodent infestation, and the disease that rodents carry on their bodies. 2) Facility failure to ensure the central supply room, where nutritional supplements are stored, as well as medical supplies for the residents, was free from rodent infestation. 3) Facility failure to recognize the concept of cross contamination caused by rodent infestation. This has the potential of breaching the safety, health, and wellbeing of residents that live in the facility, staff that work in the facility, and public who visit the facility. The facility failed to ensure there was an effective pest control program in place. The facility failed to seek secondary opinions and advice when the rodent infestation continued. This has the potential of effecting the health and wellbeing of residents, staff, and the public that visits the facility as it pertains to transmission of disease from bacteria [MEDICAL CONDITION] that rats carry on their bodies. (cross reference to F371, F441, F465, F469, and F490)

Based upon interview with the administrator and review of the Quality Assessment and Assurance Committee, the facility failed to bring the issue of an ongoing rodent problem to the Quality Assessment and Assurance committee (QAA). As a result of lack of notification, this contributed to the failure of the facility to develop an integrated pest management plan since the QAA committee had no opportunity to assist. The open areas in the walls and the exposed food resulted in rodents eating the food in the dry food storage and central supply areas beginning on 01/17/13 and continuing to exit of the facility ongoing until 07/30/2013. This system failure has resulted in contamination of dry food supply and cross contamination of food from dry storage to the food preparation area for more than a six-month period. This placed vulnerable residents, kitchen staff, and visitors who consumed food from the kitchen at immediate risk of serious health problems that can result from diseases transmitted by rats. Rats and mice can potentially transmit Salmonellosis, which can cause severe gastrointestinal infection, manifested by diarrhea, fever, and abdominal cramps. Salmonellosis has the can lead to long term effects of pain in the joints, irritation of the eyes, painful urination and chronic arthritis. This disease can result in serious illness or death. The findings include: During an interview on 07/16/13 in the late afternoon, when asked to review the agenda of the Quality Assessment and Assurance meetings since January the Administrator stated he did not think the issue of rodents had been discussed. During an interview on 07/16/13 at 2:41 p.m., the Medical Director was asked if he was aware of a rat problem and stated he was made aware of it in February and discussed it with the Administrator. He was told it "was being taken care of." He was not aware the dietary staff are not thoroughly disinfecting the dry storage area and the staff was not taking precautions to prevent cross contamination. When the surveyor discussed this with him, he stated "I see what you are saying." During an interview on 07/12/13, and again when asked on 07/16/13 around 12:53 p.m., the Director of Nursing (DON) stated he did not know anything about the dry food storage area having rats. He said it has not been discussed at the Quality Assurance (QA) meetings he has attended in the last few months. He said there have not been any clusters of residents with unexplained rashes, respiratory illnesses or unusual gastrointestinal problems in the last 6 months. This was validated through review of the monthly infection control summaries from January through June 2013. He agreed it would be an important thing for the DON to know about. During interviews on 07/12/13, the Certified Dietary Manager (CDM) and the Administrator stated they did not inform the Director of Nursing and the Medical Director that the dry food storage area had an ongoing rat / rodent infestation problem. This resulted in the failure to implement infection control precautions and staff education (in order to prevent cross contamination of the food from dry food storage into the kitchen food preparation area) and had the potential for residents, staff and visitors to be served food contaminated with diseases carried by rats. The choice of the Administrator and the CDM not to include the clinical staff in eliminating the rat / rodent infestation demonstrates a lack of understanding of the seriousness of the situation and a system failure to protect and care for the vulnerable residents. The facility failed to store food in a sanitary manner to prevent contamination of harmful bacteria [MEDICAL CONDITION] generated from rodent infestation in the dry food storage and central supply rooms. This is a result of the facility's: 1) Failure to ensure the dry store room was free from evidence of rodent infestation. 2) Failure to ensure that all holes and crevices in the dry store room were sealed up and secure. 3) Failure for the facility to take measures to appropriately clean and sanitize the dry store room, kitchen, and central supply room after they had knowledge of rodent infestation. 4) Failure for management and staff to understand what cross contamination is, and how bacteria [MEDICAL CONDITION] are spread through cross contamination. This has the potential of exposing residents, staff, and the visiting public to diseases that result in serious illness or death. The facility failed to ensure the residents, staff, and public visiting the facility were free from contamination of bacteria [MEDICAL CONDITION] that are carried by rats. This was due to the: 1) Facility failure to ensure that the kitchen was free from rodent infestation, and the disease that rodents carry on their bodies. 2) Facility failure to ensure the central supply room, where nutritional supplements are stored, as well as medical supplies for the residents, was free from rodent infestation. 3) Facility failure to recognize the concept of cross contamination caused by rodent infestation. This has the potential of breaching the safety, health, and wellbeing of residents that live in the facility, staff that work in the facility, and public who visit the facility. The facility failed to ensure there was an effective pest control program in place. The facility failed to seek secondary opinions and advice when the rodent infestation continued. This has the potential of effecting the health and wellbeing of residents, staff, and the public that visits the facility as it pertains to transmission of disease from bacteria [MEDICAL CONDITION] that rats carry on their bodies. (cross reference to F371, F441, F465, F469, and F490) 2. Entered the facility on 08/02/2013 at 12:30 p.m. and met with the new Administrator. Explained the purpose of the visit, and requested to begin a tour of area in the building of concern. The tour was conducted with the Administrator and the Director of Maintenance. A. Toured the dry storeroom in the kitchen. The walls and floor of the store room, were observed to be newly painted. All the cracks and holes in the wall had been professionally sealed. All the food products that were originally in the storeroom were discarded, and replaced by new food products. All food items that were not in a metal can were in large plastic storage bends, with lid on them. There was no evidence of any rodent feces or urine observed in the storeroom. B. Toured the Central Supply storage room. Observed the walls had been freshly painted, and the floor was clean.. All supplies had been removed from the floor, and were placed on shelves. There was no evidence of rodent feces or urine in the Central Supply room. C. Toured Mechanical room [ROOM NUMBER] Floor and walls observed to be newly painted, screen to the window replaced. Did observed that the base board located under the window which was observed to be approximately 1 foot in length needed to be sealed more securely. Did not observe any rodent urine or feces. D. Tour Mechanical room [ROOM NUMBER] Floors and wall had been freshly painted. Window screen had been replaced. There was no rodent urine or feces observed. E. Tour the exterior of the building. The shrubs and trees had been cut back so they were not touching the building. Landscapers were on the property continuing to cut vegetation from surrounding properties, to ensure the deterrence of the rodents. Two trees on the property 1 south end of the building and 1 on the west end of the building were observed to need a little more pruning. Observed were numerous rate traps surrounding the entire building. Administrator said the exterminator had place 52 rate traps around the building. Did not observe any cracks, holes, or crevices on the exterior of the building. During an exit conference on 8/2/2013 at 1:30 p.m., with the Administrator, Registered Dietitian, Director of Nursing, Regional Clinical Manager, and Regional Vice President survey status was reviewed. The facility staff was made aware as a result the implementation of the Allegation of Complaince and observations made during the revisit, the Immediate Jeopardy has been removed and the Scope and Severity changed from a K to an E effective 07/31/13, the date of the alleged compliance. Although the Immediate Jeopardy was removed, ongoing noncompliance continues until all corrective actions are completed to achieve substantial compliance.