Every finding on record at Siesta Key Health and Rehabilitation Center

Based on interviews and record review, the facility failed to promptly notify the physician of a resident change in condition for 1 (Resident #1) of 3 residents reviewed for nutritional concerns.The findings included:Record review for Resident #1 revealed an admission date of 8/31/2008. Diagnoses included Adult Failure to Thrive (physical and cognitive decline often characterized by unintentional weight loss, malnutrition, decreased appetite and functional impairment), Hemiplegia (paralysis that affects one entire side of the body and Hemiparesis (partial weakness or inability to move one entire side of the body) following a cerebral infarction (death if brain tissue caused by disrupted blood supply) affecting the right side, and Vitamin D Deficiency.The care plan last revised 6/12/26 noted that Resident #1 was at nutrition risk. The goals included for the resident to maintain adequate nutritional status. The interventions included, Dietary consult as needed . Encourage adequate food and fluid intake . Provide, serve diet as ordered. Monitor intake and record every meal. Staff was also to monitor, document, and report as needed when the resident refuses to eat.Review of the Nutritional Assessment completed on 6/12/26 noted that Resident #1 was malnourished.On 7/14/26 at 10:29 a.m., in a telephone interview, Resident #1's family member said that the resident was not being fed. The family member said that Resident #1 was unrecognizable when she saw him at the hospital. He had stopped eating around 6/24/26. He had been vomiting and not taking in food. He was malnourished. Review of the Percentage of Meal Eaten documentation on the Nutrition - Amount eaten log revealed, Resident refused was entered on 6/25/26 at 1:00 p.m. and 10:37 p.m.A Provider's note dated 6/25/26 documented that the nurse called to report that the resident continues to vomit yellow liquid. Orders given for intramuscular ondansetron 4 milligrams (used to prevent nausea and vomiting) and intravenous fluids if unable to take oral fluids. The Practitioner also ordered a STAT (immediate) KUB (imaging of Kidney, Ureter and Bladder) to be done at bedside, urinalysis and close monitoring of Resident #1. The Provider documented, Will await results, follow up required. Nurse to report results.A Health Status progress note dated 6/26/26 at 7:48 a.m., documented that Resident #1 was uncooperative with accepting fluids.On 6/26/26 at 12:06 p.m., 2:59 p.m., and 10:18 p.m., Resident refused was entered on the Nutrition - Amount eaten log for What percentage of meal was eaten?.The logs for Nutrition-HS (bedtime) Snacks, and Nutrition - Fluids had no entries.Resident #1's medical record lacked documentation that on 6/26/26, the provider was notified of the resident's refusal to eat breakfast, lunch, or dinner.On 6/27/26 at 9:00 a.m., 1:00 p.m., and 10:56 p.m., Resident refused was entered on the Nutrition - Amount eaten log for What percentage of meal was eaten?.The logs for Nutrition-HS (bedtime) Snacks, and Nutrition - Fluids had no entries.A Change in Condition form dated 6/27/26 at 11:55 p.m., noted the provider was notified on 6/27/26 at 9:00 p.m., that Resident #1 had nausea/vomiting, failure to thrive and no intake or urinary output.No other change in condition forms or provider notifications was completed on 6/27/26.On 7/14/26 at 10:21 a.m., in a telephone interview, the Registered Dietitian said that he was not notified that Resident #1 was not eating or drinking. He said that the staff was expected to notify him right away if the resident was refusing to eat or drink. After reviewing the documentation in the medical record, the Registered Dietitian said that the staff should have notified him because of how long Resident #1 went without eating or drinking.On 7/14/26 at 12:00 p.m., in an interview, the Director of Nursing (DON) confirmed the documentation that Resident #1 refused all meals on 6/25/26 and 6/26/26. The DON said she expected staff to notify the provider if the resident was refusing to eat or drink. She said that not eating or drinking can have negative outcome for the resident, including dehydration and further malnutrition.On 7/14/26 at 12:40 p.m., in an interview, the Advanced Practice Registered Nurse (APRN) said on 6/25/26 she was notified that Resident #1 had two episodes of nausea. She ordered an antiemetic (medication to prevent nausea and vomiting). On 6/26/26, she was not there but a provider should have been notified that the resident was not eating or drinking. The APRN said Resident #1 could have become malnourished, have low energy, protein malnutrition and dehydrated. The APRN said they rely on staff communication, the staff needed to call the provider to report that the resident was not eating or drinking.On 7/14/26 at 2:30 p.m., in an interview, the DON said she was unable to locate any provider notifications for Resident #1 not eating or drinking on 6/26/26 and 6/27/26 until 6/27/26 at 9:00 p.m.

Based on record review, residents representatives and staff interviews, the facility failed to ensure the Residents funds were conveyed to the appropriate party within the required 30-day timeframe after death or discharge from the facility, for 3 (Residents #15, #26, #27) of 3 Residents reviewed.The findings included:Review of the facility policy Refund of Overpayments Policy #10410, effective date February 1, 2019, revised date [DATE] states, Refunds Due Resident: 2. Within thirty (30) days of death of a resident, the residents personal funds and final accounting of those funds will be made available to the residents representative or to the probate administering the residents care.1. Review of the clinical record for Resident #15 revealed an admission date of [DATE] and a discharge date of [DATE]. On [DATE] at 2:10p.m., in a telephone interview, Resident #15's Power of Attorney said that while his mother was in the facility she had about $1800.00 or more in her account. He said his mother died in [DATE]. A few weeks after his mother died, he went to the facility to see about getting his mother's funds recuperated. Resident #15's Power of Attorney said he went to the facility about 6 times and called about 20 times, but no one would talk to him. He said he finally got the refund around [DATE].On [DATE] at 9:18 a.m., in an interview, the Regional Director of Business Office Services said the refund of funds to a resident's family with a power of attorney on file is given within 30 days of a resident passing. She said that when Resident #15 expired on [DATE], she had a balance of $1826.15 in her account. She said that she did not have documentation that the facility reached out to the family to notify them of the refunds due. She said that the refund was issued to Resident #15's family on [DATE].2. Review of the clinical record for Resident #26 revealed a date of admission of [DATE] and a discharge date of [DATE].Review of the facility provided Resident Fund Statement revealed an ending balance of $116.46 as of [DATE]. On [DATE] at 3:18p.m., in an interview, the Regional Director of Business Office Services verified that Resident #26 was discharged from the facility on [DATE].She verified that the ending balance of Resident #26's account was $116.46. The Director of Business Office Services said that the facility has not yet issued a refund to the resident. She stated the expectation of the facility is that refunds for discharged Residents are completed within 30 days of discharge.3. Review of the clinical record for Resident #27 revealed an admission date of [DATE] and a discharge date of [DATE].Review of the facility provided Resident Fund Statement revealed an ending balance of $221.18 as of [DATE].On [DATE] at 9:38 a.m., in an interview, the Regional Director of Business Office Services verified that Resident #27 was discharged from the facility on [DATE] and that the resident's account balance as of today, [DATE] was $381.36. She confirmed that as of [DATE], the facility had not issued a refund to the resident.On [DATE] at 11:01a.m., in an interview, the Administrator said that her expectation was that once a Resident is discharged or expires, their account funds are refunded in accordance with facility policy of 30 days.

Based on observation, record review, residents and staff interviews, the facility failed to provide the necessary services to maintain personal hygiene for 3 (Residents #25, #68 and #12) of 4 dependent residents reviewed for activities of daily living (ADL). The findings included: The facility policy Activities of Daily Living (ADL's) implemented 11/3/20 (revised 11/29/22) documented Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Review of the clinical record revealed Resident #12 had a readmitted [DATE] with diagnoses including dementia, depression and anxiety. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 4/30/24 documented the resident required substantial to maximum staff assistance for personal hygiene. The MDS noted Resident #12's cognitive skills for daily decision making were severely impaired. Review of the care plan initiated 8/8/22 identified Resident #12 had an ADL self-care deficit due to confusion and dementia. The care plan instructed staff to check nail length and trim and clean on bath day every Monday and Thursday and as necessary and report any changes to the nurse. On 7/29/24 at 9:55 a.m., Resident #12 was observed in his room, seated in a wheelchair. His fingernails were noted be very long approximately 1/2 inch in length with a brown substance under the nail beds. His left thumb nail was thick, black and was approximately 1 inch in length. Resident #12 had a strong body odor of urine. On 7/29/24 at 11:51 a.m., Resident #12 was observed in the main dining room awaiting the noon meal. The Regional Nurse Consultant handed the resident a wet wipe to clean his hands and commented that his nails were very long. During random observations on 7/30/24 at 12:02 p.m., and 8/1/24 at 9:23 a.m., Resident #12 was observed with his fingernails in the same condition and not trimmed or cleaned. 2. Review of the clinical record revealed Resident #25 had a readmitted [DATE] with diagnoses including bi-polar disorder, depression, and anxiety. The Quarterly MDS dated [DATE] documented the resident required moderate staff assistance for personal hygiene. The MDS noted Resident #25's cognitive skills for daily decision making were moderately impaired. The care plan initiated on 9/4/22 identified Resident #25 had an ADL self-care performance deficit related to decreased ability to perform ADLS in grooming and personal hygiene. The goal for Resident #25 specified the resident will have bathing, grooming, toileting, and ADL needs met with assistance from staff. The care plan specified Resident #25's scheduled shower days were Tuesday and Friday on the 3:00 p.m., to 11:00 p.m., shift. The care plan instructed staff to check nail length and trim and clean on bath day and as necessary. On 7/29/24 at 10:07 a.m., Resident #25 was observed in his room in bed without clothing, wearing a disposable brief. He was unshaven with approximately 4 to 5 days growth of facial hair. His fingernails were long, approximately 1/2 inch in length with a brown and black substance under the nail beds. Resident #25 did not answer questions appropriately. On 7/29/24 at 3:26 p.m., Resident # 25 was observed in the television the South Unit room dressed in his own clothing. He remained unshaven, with long and dirty nails. On 7/30/24 at 8:33 a.m., Resident # 25 was observed in his room in bed wearing the same clothing as the previous day. He remained unshaven and his fingernails remained long and dirty. Resident # 25 did not respond when spoken to. On 7/31/24 at 11:23 a.m., in an interview CNA Staff C said Resident #25 required total care with his ADLS. He does refuse care sometimes. He likes to be showered at night and he will ask you to shower him. He asks to be shaved, if you try to do it when he does not want it, he will fight you. I try and talk him into it, asking him would he like me to shave him. We do nail care on shower days and as needed. Sometimes they don't want you to touch their nails. 3. Review of the clinical record revealed Resident #68 had an admitted [DATE] with diagnoses including hemiparesis and hemiplegia (loss of movement on one side of the body) affecting the left side. The Quarterly MDS dated [DATE] documented the resident required moderate staff assistance for personal hygiene. The MDS noted Resident #68's cognitive skills for daily decision making were intact. The care plan initiated 4/11/24 identified Resident #68 had an ADL self-care performance deficit related to recent cerebral vascular accident (stroke) with left sided weakness. The goal for Resident #68 was to have bathing, grooming, toileting, and ADL needs met with assistance from staff. On 7/29/24 at 11:13 a.m., Resident # 68 was observed in his room in bed. He said sometimes he gets his showers and other times he gets a bed bath. The residents fingernails on the left hand were very long , approximately 1/2 inch in length with a brown substance under the nail beds. He said his brother is supposed to come with a pair of clippers and cut them for him. He said he did not know why the staff don't trim and clean them. During random observations on 7/30/24 at 8:32 a.m., and 8/1/24 at 8:58 a.m., Resident # 68's left hand fingernails remained in the same condition. On 8/1/24 at 9:31 a.m., in an interview Certified Nursing Assistant (CNA) Staff C said nail care is usually done weekly at shower times. Sometimes activities will do the nails and sometimes if I have time, I will do nail care for the residents in the TV lounge. I am not assigned to this resident, but I can do his nail care if you want, I don't mind. On 8/1/24 at 10:21 a.m., in an interview the Director of Nursing said the expectation is for nail care to be done on shower days as part of the care. On 8/1/24 at 10:27 a.m., in an interview and observation the South Unit Manager Licensed Practical Nurse (LPN) Staff B was with Resident #25 and said I'm aware of the residents need for nail care. Resident #25 looked at the LPN and showed her his long fingernails and said, I really need someone to trim them, they are bad. Staff B said she is one who usually does the nail care but she had been off for 2 weeks. She said we can't do toenails, podiatry does them, but I will take care of the fingernails today for Residents #12, #25 and #68.

Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure medications were administered in accordance with professional standards of practice for 1 (Resident #63) of 7 residents reviewed by failing to follow physician's orders parameters for medication administration. The findings included: Review of facility policy titled Medication Administration dated 5/24/2023 showed, Policy Statement: Medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice. Policy Compliance Guidelines: 8. obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . Clinical record review revealed Resident #63's diagnoses included Essential (Primary) Hypertension (High Blood Pressure). Review of the physician's orders revealed Resident #63's medication regimen included: Amlodipine Besylate 10 mg (milligrams) one tablet by mouth one time a day related to Essential (Primary) Hypertension. Hydrochlorothiazide 25 mg one tablet by mouth one time a day related to localized edema (swelling caused by fluid buildup in the tissues). Lisinopril 40 mg one tablet by mouth one time a day related to Essential (Primary) Hypertension. The physician's orders for the Amlodipine, the Hydrochlorothiazide and the Lisinopril specified to hold the medications for the systolic (top number) blood pressure below 140. Review of the Medication Administration Record (MAR) for May 2024, June 2024 and July 2024 revealed: In May 2024, the Amlodipine, Hydrochlorothiazide and the Lisinopril were administered 17 times when the documented systolic blood pressure was below 140. In June 2024, the Amlodipine, Hydrochlorothiazide and the Lisinopril were administered 18 times when the documented systolic blood pressure was below 140. In July 2024, the Amlodipine, Hydrochlorothiazide and the Lisinopril were administered 11 times when the documented systolic blood pressure was below 140. On 7/31/24 at 10:58 a.m., in an interview Licensed Practical Nurse (LPN) Staff F said if the blood pressure is out of the specified parameter, the nurse should hold the medication and document in the electronic record the medication was held due to the blood pressure being out of parameter. Staff F said if a resident receives blood pressure medication the physicians are supposed to review the vital signs (blood pressure and pulse) when they come in. On 7/31/24 at 11:18 a.m., in an interview LPN Staff G said if a blood pressure medication has parameters, she would take the blood pressure before administering the medication. If the blood pressure was outside of the specified parameter, she would hold the medication and document the medication was held because the medication was outside of the specified parameters. On 7/31/24 at 11:45 a.m., in an interview the Director of Nursing (DON) said the expectation is for the nurses to hold the medication if the blood pressure is outside the specified parameters. The DON said the physicians are able to and should monitor the residents' blood pressure through the system and adjust the medications if needed. The DON reviewed Resident #63's MARs for July 2024 and verified 11 times Resident #63's systolic blood pressure was lower than 140 and the resident was administered the Amlodipine, Hydrochlorothiazide and Lisinopril. On 7/31/24 at 2:10 p.m., in an interview Resident #63's attending physician said he expects the nurses to follow his orders as written. He expects the nurses to call him if they have any questions or if there are any issues. The physician said he did not notice in July 2024 the nurses administered all three blood pressure medications on 11 different occasions when the resident's systolic blood pressure was below 140 and did not notice on 16 occasions the resident's systolic blood pressure was below 140 and all three blood pressure medications were held. On 7/31/24 at 3:04 p.m., in an interview the Consultant Pharmacist said the monthly medication regimen review includes reviewing the blood pressure medications, the blood pressure readings obtained to verify the parameters are being followed. The Consultant Pharmacist said during his reviews, he did not notice staff administered the three blood pressure medications 46 times to Resident #63 when the blood pressure was outside of the specified parameters in the past three months. He said he did not notice Resident #63's systolic blood pressure was below 140 in 16 occasions resulting in all three blood pressure medications being held. On 8/1/24 at 11:14 a.m., in an interview the Administrator said she expects the nurses to follow the physician ordered parameters for blood pressure medications. She expects the Consultant Pharmacist to notice and notify the facility in a timely manner of any issues related to medications being given outside of specified parameters or medications being held.

Based on clinical record review, review of facility's policies and procedures and staff interviews, the facility failed to ensure the medication regimen review identified medications administered without adequate monitoring for 1 (Resident #63) of 7 residents reviewed for unnecessary medications. The findings included: Review of the facility's policy and procedure titled, Medication Regimen Review with a date reviewed/revised of 1/2022 noted, The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart . Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications. The MMR includes: a. Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. b. Collaboration with other members of the interdisciplinary team . Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Clinical record review revealed Resident #63's diagnoses included Essential (Primary) Hypertension (High Blood Pressure). Review of the physician's orders revealed Resident #63's medication regimen included: Amlodipine Besylate 10 mg (milligrams) one tablet by mouth one time a day related to Essential (Primary) Hypertension. Hydrochlorothiazide 25 mg one tablet by mouth one time a day related to localized edema (swelling caused by fluid buildup in the tissues). Lisinopril 40 mg one tablet by mouth one time a day related to Essential (Primary) Hypertension. The physician's orders for the Amlodipine, the Hydrochlorothiazide and the Lisinopril specified to hold the medications for the systolic (top number) blood pressure below 140. Review of the Medication Regimen Review and the Medication Administration Record (MAR) for May 2024, June 2024 and July 2024 revealed: In May 2024, the MAR showed 29 times the resident's systolic blood pressure was below 140. The Amlodipine, Hydrochlorothiazide and the Lisinopril were administered 17 times when the documented systolic blood pressure was below 140. The Medication Regimen Review performed between 5/20/24 and 5/21/24 showed Resident #63 was included in the list of Patients with no irregularities noted. In June 2024, the MAR showed 28 times the resident's systolic blood pressure was below 140. The Amlodipine, Hydrochlorothiazide and the Lisinopril were administered 18 times when the documented systolic blood pressure was below 140. The Medication Regimen Review performed between 6/23/24 and 6/24/24 showed Resident #63 was included in the list of Patients with no irregularities noted. In July 2024, 27 times Resident #63's systolic blood pressure was below 140. The Amlodipine, Hydrochlorothiazide and the Lisinopril were administered 11 times when the documented systolic blood pressure was below 140. On 7/31/24 at 10:58 a.m., in an interview Licensed Practical Nurse (LPN) Staff F said if a resident receives blood pressure medication the physicians are supposed to review the vital signs (blood pressure and pulse) when they come in. On 7/31/24 at 11:45 a.m., in an interview the Director of Nursing (DON) said the expectation is for the nurses to hold the medication if the blood pressure is outside the specified parameters. The DON said the physicians are able to and should monitor the residents' blood pressure through the system and adjust the medications if needed. The DON reviewed Resident #63's MARs for July 2024 and verified 11 times Resident #63's systolic blood pressure was lower than 140 and the resident was administered the Amlodipine, Hydrochlorothiazide and Lisinopril. On 7/31/24 at 2:10 p.m., in an interview Resident #63's attending physician said he expects the nurses to follow his orders as written. He expects the nurses to call him if they have any questions or if there are any issues. The physician said he did not notice in July 2024 the nurses administered all three blood pressure medications on 11 different occasions when the resident's systolic blood pressure was below 140 and did not notice on 16 occasions the resident's systolic blood pressure was below 140 and all three medications were held. On 7/31/24 at 3:04 p.m., in an interview the Consultant Pharmacist said the monthly medication regimen review includes reviewing the blood pressure medications, the blood pressure readings obtained to verify the parameters are being followed. The Consultant Pharmacist said during his reviews, he did not notice staff administered the Amlodipine, Hydrochlorothiazide and the Lisinopril 46 times to Resident #63 when the blood pressure was outside of the specified parameters in the past three months. He said he did not notice Resident #63's systolic blood pressure was below 140 in 16 occasions resulting in all three medications being held. On 8/1/24 at 11:14 a.m., in an interview the Administrator said she expects the nurses to follow the physician ordered parameters for blood pressure medications. She expects the Consultant Pharmacist to notice and notify the facility in a timely manner of any issues related to medications being given outside of specified parameters or medications being held.

Based on record review and staff interview, the facility failed to issue in writing the Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 3 (Residents #17, #463, and #464) of 3 residents reviewed for advanced beneficiary notices. This had the potential for residents to not be aware of the right to appeal the facility decision to terminate Medicare services. The findings included: The facility policy Advanced Beneficiary Notices documented, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage . A Notice of Medicare Non-Coverage (NOMNC) Form shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization . The notice shall be written legibly in a language and or format that the resident/representative understands. Verbal explanations detailing the reasons for non-coverage shall be provided . If the notice cannot be hand-delivered, a telephone notice shall be made, followed up immediately with a mailed, emailed, faxed or hand-delivered notice. Documentation shall comply with form instructions regarding telephone notices. 1. Review of the clinical record for Resident #17 revealed a PPS (Prospective Payment System) Minimum Data Set (MDS) Part A discharge assessment with a target date of 12/15/23. The MDS noted the resident's most recent Medicare stay started on 10/2/23 and ended on 12/14/23. Resident #17 remained at the facility. On 2/20/24 at 3:40 p.m., the Skilled Nursing Facility (SNF) Beneficiary Notification Review form provided by the facility noted Medicare Part A Skilled Services Episode started on 10/2/23, and the last covered day was 12/15/23. The form noted the facility initiated the discharge from Medicare Part A services when the benefit days were not exhausted. The facility provided a SNFABN and a NOMNC form which noted Resident #17 was unable to sign the notice due to significant cognitive impairment and the information was conveyed to the resident's power of attorney via telephone on 12/13/23. She said she started employment at the facility on 11/2/23 and the information for the NOMNC was done verbally in a phone conversation. On 2/20/24 at 3:35 p.m., in an interview the Social Service Director (SSD) verified the clinical record contained no documentation the facility provided the required notice to the resident or representative in writing. 2. Review of the clinical record for Resident #463 revealed a Discharge MDS assessment with a target date of 11/4/23 for a planned discharge, return not anticipated. On 2/20/24 the SNF Beneficiary Notification Review form provided by the facility noted Medicare Part A Skilled Services start date was 10/2/23 and the last covered day of Part A services was 11/3/23. The form noted, Cannot determine from record if D/C (discharge) was self-initiated. On 2/20/24 at 3:55 p.m., the Social Service Director (SSD) said she could not locate documentation the facility provided Resident #463 with the required SNFABN or NOMNC form. 3. Review of the clinical record for Resident #464 revealed a Part A discharge MDS assessment with a target date of 9/14/23. The MDS noted the most recent Medicare Stay started on 9/1/23 and ended on 9/14/23. Resident #464 remained at the facility until 12/26/23. On 2/20/24 review of the SNF Beneficiary Notification Review form provided by the facility showed the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The form noted the SNFABN notice was not given. Under Other/Explain the facility noted, Unknown. Review of the NOMNC form showed the resident's guardian was notified via telephone on 9/11/23. On 2/20/24 at 3:55 p.m., in an interview the SSD verified the Notice of Medicare Non-Coverage was not given in writing to the resident's guardian.

Based on observation, review of the clinical record and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Residents #7, #12 and #461) of 3 residents reviewed for Activities of Daily Living (ADL). The findings included: The facility policy Activities of Daily Living (ADL's) (Revised 11/29/22) documented, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. Review of the clinical record revealed Resident #7 was had an admitted [DATE]. Diagnoses included Parkinson's disease, Huntington's disease, dementia, and schizoaffective disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date (ARD) of 12/7/23 documented Resident #7 was dependent on staff for all care. The MDS noted Resident #7's cognitive skills for daily decision making were severely impaired. On 2/19/24 at 9:56 a.m., Resident #7 was observed in the television (TV) room on the South Nursing Unit in a specialized reclining wheelchair. He was nonverbal and made no eye contact. The resident had a very strong odor of feces and had approximately 2-3 days growth of facial hair. Resident #7 appeared unkempt with greasy, uncombed hair. On 2/19/24 at 10:00 a.m., Certified Nursing Assistant (CNA) Staff E who was present during the observation verified Resident #7 had a very strong odor of feces, two to three days growth of facial hair, looked unkempt with greasy, uncombed hair. CNA Staff E did not remove Resident #7 from the television room. On 2/19/24 at 12:34 p.m., Resident #7 was observed in the main dining room for the noon meal. He remained with a strong odor of feces. On 2/20/24 during random observations at 10:03 a.m., 10:49 a.m., and 12:06 p.m., Resident #7 was observed in the day room. He had approximately three to four days of facial hair growth. Review of the CNA documentation revealed Resident #7 received personal hygiene assistance, was shaved on 2/19/24 and 2/20/24. On 2/21/24 at 9:07 a.m., in an interview and observation, the Assistant Director of Nursing (ADON), confirmed Resident #7 had approximately five days of facial hair growth. The ADON said, we are waiting for an electric razor to shave him and have asked the guardian to bring one for him. The ADON said it is hard to shave him because of the constant movements of his head and we don't want to hurt him. The clinical record showed no documentation of contact with Resident #7's representative to request an electric razor. Review of the CNA documentation for January 2024 revealed Resident #7's shower days were Tuesdays and Fridays on the 3:00 p.m., to 11:00 p.m., shift. The document showed on 1/2/24, 1/16/24, 1/26/24 and 1/30/24 Resident # 7 received a bed bath in lieu of the scheduled shower. Review of the CNA documentation from 2/1/24 to 2/20/24 revealed Resident #7 received a bed bath instead of the scheduled shower on 2/2/24, 2/9/24, 2/13/24 and 2/20/24. There was no documentation in the clinical record Resident #7 refused the scheduled showers. 2. Review of the clinical record revealed Resident #12 had an admitted [DATE]. Diagnoses included dementia, major depressive disorder, anxiety, and adjustment disorder. The Annual MDS with an ARD of 1/30/24 documented Resident #12 cognitive skills for daily decision making were severely impaired. Review of the care plan revealed Resident #12 required assistance from staff for toileting, bathing, and personal hygiene. On 2/19/24 at 9:20 a.m., Resident #12 was observed in the television room on the South Unit, across from the nursing desk sitting in a wheelchair. He was facing away from the television. Resident #12 had a strong urine smell, and an accumulation of a brown substance under his nails. Resident #12 had approximately three days of facial hair growth. On 2/19/24 form 11:00 a.m., to approximately 12:00 p.m., observation showed Resident #12 remained in the television room on the South Unit, across from the nursing desk sitting in a wheelchair, facing away from the television. Resident #12 had obvious sign of incontinence, and a strong urine smell. The resident's pants were wet with urine dripping on the floor forming a puddle under the resident's wheelchair. On 2/19/24 at approximately 12:00 p.m., Licensed Practical Nurse (LPN) Staff G entered the television room and stepped in the puddle of urine on the floor. LPN Staff G took the resident to his room and left him there. LPN Staff G was observed walking down the hall and calling for a CNA. On 2/20/24 at 9:00 a.m., to 11:00 a.m., Resident #12 was observed sitting in a wheelchair in the South Unit television room, facing the wall. No staff were observed in the television room. On 2/20/24 at 12:00 p.m., Resident #12 remained in the television room in his wheelchair, facing the wall. A staff member took the resident to the main dining room for lunch. On 2/20/24 at 2:41 p.m., in an interview CNA Staff D said, Residents are changed every two hours, some are offered to be changed or toileted more frequently if they request it of if you know they are heavy wetters. 3. Review of the clinical record revealed Resident #461 was admitted on [DATE]. Diagnoses included acute respiratory failure, complete small bowel obstruction, Myasthenia Gravis, anxiety, and need for assistance with personal care. The 5-day MDS dated [DATE] documented the resident required partial to moderate assistance with ADL's including showers. The MDS indicated Resident #461's cognitive skills for daily decision making were severely impaired. On 2/19/24 at 10:23 a.m., Resident #461 was observed in his room in his wheelchair. He had approximately two days of facial hair growth. The resident had an accumulation of brown substance under his nails. In an interview Resident #461 said he received one shower since his admission. On 2/20/24 at 8:47 a.m., Resident #461 was observed in his room in his wheelchair. Resident #461 had approximately three days of facial hair growth. The resident was wearing pajama pants and lifting his shirt. Resident #461 lifted his upper body clothing showing he was wearing five shirts. Review of the CNA documentation for February 2024 revealed the residents scheduled shower days were Tuesdays and Fridays on the day shift. The documentation from 2/8/24 to 2/20/24 revealed Resident #461 received one shower (2/20/24) since his admission on 2/7/24. The documentation showed he received a bed bath on 2/8/24, 2/9/24 and 2/16/24. On 2/13/24 the CNA documented N/A (not applicable). The clinical record showed no documentation Resident #461 had refused his scheduled showers. On 2/21/24 at 10:23 a.m., in an interview CNA Staff E said, men are shaved on shower days and at least every other day. Staff E explained the showers are located in the CNA assignment books; it goes by room numbers and there are 2 books. The shower list is also in the documentation we do on the computer. We also fill out a shower sheet, the CNA provided and demonstrated how she would mark any skin changes and if the resident refused the shower, you would write it on the sheet and in the electronic record.

Based on observations, review of the clinical records, review of facility policies and procedures, and staff interviews, the facility the facility failed to implement meaningful resident centered activities to meet the interest and wellbeing of 2 (Resident #7 and #12) of 2 residents reviewed for activities. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration. The findings included: The facility policy Activities implemented 11/2023 (revised 2/24) documented, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences. Facility sponsored group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. 1. Each resident's interest and needs will be assessed on a routine basis. The assessment shall include, but not limited to: b. Activity assessment to include residents interest, preferences and needed adaptations. 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging and usefulness. b. Create opportunities for each resident to have a meaningful life. 1. Review of the clinical record revealed Resident #7 was [AGE] years old with an admitted [DATE]. Diagnoses included Parkinson's disease, Huntington's disease, dementia, and schizoaffective disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date (ARD) of 12/7/23 documented Resident #7 was dependent on staff for all care. The MDS noted Resident #7's cognitive skills for daily decision making were severely impaired. On 2/19/24 at 9:55 a.m., Resident #7 was observed in the South Unit television room (TV) room across from the nurse's station. He was in a special reclining chair. The TV was on, and 4 other residents were in the room. Certified Nursing Assistant (CNA) Staff E said, the ones who can't talk or do much, we bring them in here and they watch TV. The resident does not speak, occasionally he might say a word and he is total care with everything. On 2/20/24 at 10:22 a.m., and 10:47 a.m., Resident #7 was observed in the TV room with 3 other residents sitting in a reclined position since 8:30 a.m. The resident had uncontrollable movements and was not able to watch the television. No staff was observed interacting with him. Review of the activity calendar specified at 9:30 a.m., coffee social and at 10:00 a.m., and Movin and Grooving. On 2/20/24 at 3:07 p.m., in an interview with Licensed Practical Nurse Staff C said the residents in the TV room are there to watch TV. It is not a fall or increased supervision room; it is just a TV room where they go to watch TV. During random observations on 2/21/24 at 8:51 a.m., and 9:47 a.m., Resident #7 was in a wheelchair in the TV room, the TV was on but he was not meaningfully engaged and was not looking in the direction of the TV. The activity calendar specified at 9:30 a.m., coffee social and Catholic mass at 10:00 a.m. The initial activity assessment dated [DATE] specified the resident enjoyed music, watching movies, going outside and exercise (active games) as appropriate. He enjoys most of all leisure activities but has cognitive and physical limitations where staff encouragement and support is needed for participation. He needs staff involvement daily to participate in leisure programs and needs staff to encourage and bring him to groups of interest. Review of the Activity documentation for January 2024 revealed Resident #7 had no one to one activities on the day shift on 1/1/24, 1/4/24, 1/5/24, 1/6/24, 1/7/24, 1/12/24, 1/14/24, 1/15/24, 1/17/24, 1/23/24, 1/26/24, 1/27/24, 1/28/24 and 1/31/34. On the 3-11 shift Resident #7 had one documented one to one activity on 1/14/24, and one group activity on 1/13/24. On 2/22/24 during random observations at 9:14 a.m., 9:40 a.m., and 10:12 a.m., Resident #7 was in the TV room but not watching the television. The calendar on the wall documented coffee social at 9:30 a.m. and moving and grooving at 10:00 a.m. 2. Review of the clinical record revealed Resident #12 had an admitted [DATE]. Diagnoses included dementia, major depressive disorder, anxiety, and adjustment disorder. The Annual MDS with an ARD of 1/30/24 documented Resident #12 cognitive skills for daily decision making were severely impaired. The initial activity assessment dated [DATE] documented the resident enjoys music, going outside, interacting with staff and others, watching TV (movies & shows). He was not very active in leisure pursuits prior to admission. Lead a sedentary leisure lifestyle at home. He is alert but confused. Needs staff and family assistance for any leisure involvement and needs cues to participate, eat or receive care. He verbalizes but most times not appropriate or accurate. On 2/19/24 at 10:00 a.m., Resident #12 was observed in the TV room on the South Unit sitting in a wheelchair, facing away from the television. Review of the activity calendar specified coffee social at 9:30 a.m., and trivia at 10:00 a.m. On 2/20/24 at 11:33 a.m., Resident #12 was observed in the TV room on the South Unit with three other residents. Resident #12 said he did not know what it was he was watching and did not know what was supposed to be on the TV. On 2/21/24 from 9:11 a.m., to 11:25 a.m., Resident #12 was observed in the TV room. The television was on, but he was not watching the television. The activity calendar specified coffee social at 9:30 a.m., and Catholic mass at 10:00 a.m. During observations on 2/22/24 at 9:18 a.m., and 9:41 a.m., Resident #12 was seated in his w/c in the TV room on the south unit. The TV was on. Resident #12 was in his wheelchair at the back of the room and looking around. No facility staff was in the television room interacting with the resident. The activity calendar specified coffee social at 9:30 a.m. Review of the Activity Documentation for January 2024 revealed Resident #12 attended no group activities on 1/1/24, 1/4/24, 1/5/24, 1/6/24, 1/7/24, 1/10/24, 1/11/24, 1/12/24, 1/13/24, 1/14/24, 1/15/24, 1/17/24, 1/18/24, 1/19/24, 1/20/24, 1/21/24, 1/22/24, 1/23/24, 1/24/24, 1/25/24, 1/26/24, 1/27/24, 1/28/24 and 1/31/24. There was no documentation Resident #12 participated in one to one activities on 1/1/24, 1/2/24, 1/5/24, 1/6/24, 1/7/24, 1/8/24, 1/9/24, 1/10/24, 1/12/24, 1/15/24, 1/16/24, 1/17/24, 1/20/24, 1/23/24, 1/26/24, 1/27/24, 1/28/24, 1/29/24, 1/30/24 and 1/30/24. Review of the February 2024 Activity Documentation revealed Resident #12 had no participation in group activities 2/1/24 through 2/7/24, on 2/10/24, 2/12/24, 2/15/24, 2/17/24 and 2/21/24. No one-to-one activities were documented on 2/1/24, 2/3/24, 2/4/24, 2/5/24, 2/9/24, 2/13/24, 2/14/24, 2/16/24, 1/17/24 and 2/21/24. On 2/20/24 at 3:08 p.m., in an interview the Activity Director said, The TV room is for the residents to watch TV. There is no special calendar for the residents who are not cognitively able to participate in the daily activities. The Activity Director said, we do take them to group activities so they can watch and be a part of things. Right now, I have only one assistant and we are short two activity aides. The Activity Director said she started employment at the facility a few weeks ago. She said she does sensory items like watching television, touch balls and different items for five to ten minutes daily. The Activity Director said she did not have a schedule for the sensory activities for the residents with impaired cognition.

Based on observations, record review and staff interviews, the facility failed to implement processes to ensure the residents' right to a safe and clean environment in that they failed to ensure an environment free of disease-causing pests. On 12/19/22 the facility became aware of rodent infestation in the building, including the kitchen. The facility consistently failed to implement the recommendations from the contracted pest control company to trim back over hanging trees next to the building to prevent wildlife from getting easier access to the building. The facility failed to identify and repair all rodent entry points. The failure to provide a safe and sanitary environment free of disease causing pests created a likelihood of spread of diseases through direct or indirect contact with infected rodents which could result in serious illness, or death, resulting in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. Rodents can also damage building structures and start fires by gnawing electrical wiring. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross reference to F600, F812, F835, F867, F880 and F925. The facility's Standard Precautions Infection Control policy (copyright 2023. The compliance Store LLC) noted, Care of the Environment: Policies and procedures have been established for routine and targeted cleaning of environmental surfaces as indicated by the level of resident contract and degree of soiling. Personnel are trained in the use of the procedures . The facility's Infection Prevention and Control Program (copyright 2023. The compliance Store LLC), noted, . Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside of their scope to the appropriate department . Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . Review of the Center for Disease Control (CDC) and Prevention document titled, How to Control Wild Rodent Infestations, last reviewed on January 3, 2023, noted, Rats and mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. Many diseases do not cause any apparent illness in rodents, so you cannot tell if a rodent is carrying a disease just by looking at it . Rodents, such as rats, mice . are known to carry many diseases. Diseases can spread to people directly and indirectly from rodents .'' The CDC document listed 17 Diseases that can be spread directly by rodents (depending on geographic region), including Hemorrhagic Fever with Renal Syndrome (The condition affects many organ systems of the body, damages the overall cardiovascular system, and reduces the body's ability to function on its own. Symptoms of this type often include bleeding and hemorrhaging. This can cause a severe life threatening disease), Monkeypox (Virus that affects rodents, and causes a painful rash, enlarged lymph nodes and fever in humans), and rat-bite fever (causes fever, vomiting, headache, muscle, and joint pain, and rash in humans). Certain diseases can spread from rodents to people through indirect contact. This can occur when people are bitten by ticks, mites, fleas, and mosquitos that have fed on infected rodents. Diseases can also spread to people from rodents through the consumption of an intermediate host (for example, beetles or cockroaches) . The CDC document lists 17 diseases spread indirectly by rodents (depending on geographic region), including Angiostrongylus (rat lungworm), a disease transmitted from rodents to humans through infected larvae that affects the brain and spinal cord in humans, and Powassan virus (transmitted by ticks, and causes brain infection in humans). The Center for Disease Control and Prevention recommendation to clean up rodent urine and droppings (last reviewed January 3, 2023) noted, Step 1: Put on rubber or plastic gloves. Step 2: Spray urine and droppings with bleach solution or an EPA-registered disinfectant until very wet. Let it soak for 5 minutes or according to instructions on the disinfectant label. Step 3: Use paper towels to wipe up the urine or droppings and cleaning product. Step 4: Throw the paper towels in a covered garbage can that is regularly emptied. Step 5: Mop or sponge the area with a disinfectant. o Clean all hard surfaces including floors, countertops, cabinets, and drawers. o Follow instructions below to clean and disinfect other types of surfaces. Step 6: Wash gloved hands with soap and water or a disinfectant before removing gloves. Step 7: Wash hands with soap and warm water after removing gloves or use a waterless alcohol-based hand rub when soap is not available, and hands are not visibly soiled. On 8/2/23 at 12:20 p.m., Licensed Practical Nurse (LPN) Staff NN said she has never seen a rat but has heard them running in the ceiling, and residents have complained about hearing rats in the ceiling. On 8/2/23 4:45 p.m., the Senior Regional Director of Culinary Services stated, I was told the rat trap in the kitchen was placed there as a preventative measure because there had been rat sightings in the past. On 8/3/23 at 9:25 a.m., LPN Staff I said, The rats are so bad. They have roaches and rats, but I'm more afraid of the rats. You hear them running across the ceiling. I'm so scared they are going to fall on me. They are out anytime of the day. You have to open the doors to the soiled utility room and the nourishment room really carefully because they run away from you and go into the holes in the cabinets. On 8/3/23 at 9:25 a.m., observation of the South Unit soiled utility room with LPN Staff I revealed a hole in the baseboard of the wall, with a missing tile. Photographic evidence obtained. There was hole at the lower left bottom of the storage cabinet. Photographic evidence obtained. There was a hole in the baseboard where two cabinets met. Photographic evidence obtained. LPN Staff I said, I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. LPN Staff I said she doesn't go in the soiled utility room because of the rats. She stands at the door and throws soiled linen and garbage into the bins. On 8/3/23 at 9:35 a.m., Registered Nurse (RN) Staff D said, The rats and roaches are disgusting and everywhere in the building. I have seen them in residents' rooms, the utility rooms and nourishment rooms. They run in the ceiling, you hear scratching, and you can hear them run around up there. If it fell on me, I would be screaming. I know I have reported it to the management staff, but the rats are still here. It doesn't matter what time of day, you will see them, but they are worse at night. On 8/3/23 at 9:45 a.m., Resident #89 reported he saw a rodent in his room approximately three weeks ago, and Maintenance filled the hole in the bathroom. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said about two weeks ago staff informed him they saw a rat in Resident #89's bathroom. He observed a hole in the wall, which he plugged at that time. There was no documentation the resident's room was disinfected after the sighting of the rat. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said, I don't know anything about it. I certainly have never seen any; this is the first I'm hearing about it. After reviewing the content of the reports of the contracted pest control company and the observation of rodent feces on the floor of the kitchen storage area with the Infection Preventionist, she said, I knew there were rats in the kitchen about six months ago when the former Administration was here, but I was told it was taken care of. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he has been employed with the company since September 2022, and had been the acting Maintenance Director at the facility since the beginning of July 2023. He said he became aware of possible rat problem after they started to replace the facility roof in February 2023 which was completed sometimes in June 2023. He said he started hearing from some of the facility staff about seeing rats and hearing rats in the ceiling during the roof construction. He said the first time he heard of rats in the kitchen was two weeks ago when a kitchen staff told him they saw a rat in the kitchen. He looked at the area where the kitchen staff said they saw the rat, and noted there was a hole in the wall. He said he has not had any meetings with the administrative staff related to the rats in the facility. He said as of this time no one from administration has asked him what interventions he had put into place to address the staff seeing rats in the facility. He said he conducted an informal meeting with the housekeeping director to remind her staff to ensure they were not leaving food which the rats might be eating, and remind them to do proper cleaning and disinfection in general. It was an informal meeting; he doesn't have any documentation related to the meeting. On 8/3/2023 at 12:08 p.m., Certified Nursing Assistant (CNA) Staff A said she has worked at the facility for over [AGE] years, and she can smell the rats. On 8/3/23 at 12:10 p.m., Certified Nursing Assistant (CNA) Staff K said she has seen rats in the facility, usually at night on the South Unit. The CNA said the rats are really bad on the secured memory unit. She said, I have seen roaches and the rats over there. It is an infestation there. On 8/3/23 at 12:20 p.m., CNA Staff E said, The roaches and the rats here are terrible, it is a problem. I have seen them both here in the facility, they know about it. On 8/3/2023 at 12:25 p.m., Resident #29 said he had seen rats in the front and back of the building and heard them in the ceiling. On 8/3/23 at 12:33 p.m., the Housekeeping Manager stated, There are pest issues at facility, they called the pest guy weekly. On 8/3/23 at 1:00 p.m., RN Staff KK stated, I have heard people saying they have seen rats mostly in the big dining room. On 8/3/23 review of the pest control logbook located at the front desk of the facility noted the following dietary staff entries: 11/3/22 at 6:00 a.m., rat, location found: Kitchen. 11/13/22 at 6:00 a.m., rats, location found: Kitchen. 11/23/22 at 6:30 p.m., rat, location found: Homestead dining room. 12/13/22 at 6:30 a.m., rat, location found: Kitchen. 2/16/23, (no time in the morning), rat, location found: Kitchen. 2/20/23 in the morning, rat, location found: Beverage station, department: Kitchen. 3/18/23 (no time indicated), rat, location found: Kitchen. 3/25/23 (no time indicated), rat, location found: North dining room. 4/6/23 at 6:15 a.m., rat, location found: Kitchen. 4/22/23 at 6:00 a.m., rat, location found: Kitchen. 4/25/23 at 6:15 a.m., 3 rats, location found: Kitchen. The North Unit Pest sighting log noted: 7/1/23 at 2:00 a.m., roach back hall nursing medication cart. An initial was placed next to the entry and dated 7/13/23. 7/24/23 at 1:30 a.m., Rats (2) in soiled utility. An initial was placed next to the entry and dated 7/28/23. 7/24/23 at 1:30 a.m., Roaches in med carts, on nurses station counters, on the floors. An initial was placed next to the entry and dated 7/28/23. The contracted Pest Control inspection report dated 7/28/23 noted, Checked all 3 logbooks and scanned them. Signed off on rodent issues after checking on them. Baited nurse main cart with roach gel for roach sightings. Lots more rodent activity this month. On 8/3/23 at 12:22 p.m., during a telephone interview, the technician from the contracted pest control company said two rodents were caught in the kitchen yesterday. He said he told the kitchen staff not to leave bread and other food items the rats can get into on the counters or where it would be accessible to the rats. He told them to put the bread in the refrigerator. On 8/3/23 at 12:30 p.m., the Administrator said the rat problem had been identified prior to her arrival to the facility. She said she has been employed at the facility since May 19, 2023. She did not know how long it has gone on. She said she knows the pest control company comes out weekly as needed. She said the Maintenance Director is in charge of pest control and has direct oversight over the building. She said she could provide a copy of the contract signed on 7/20/2023 addressing the rat problem. On 8/4/23 at 11:15 a.m., black smear marks, resembling rodent grease marks were observed along the baseboard of the South Unit soiled utility room. Dried yellow stains, and rodent feces were observed on the floor of the soiled utility room. On 7/31/23 at 9:46 a.m., Resident #88's shared bathroom had dried feces on the toilet tank, around the toilet base, and splattered on the wall. Photographic evidence obtained. On 8/1/23 at 9:28 a.m., Resident #88's shared bathroom remained with dried feces on the toilet tank, the toilet base, and on the wall. A used adult incontinent brief was observed on the floor underneath the sink in the bathroom. Photographic evidence obtained. On 8/1/23 at 3:03 p.m., Resident #88's shared bathroom remained with dried feces on the toilet tank, the toilet base, and on the wall. On 8/1/23 at 3:10 p.m., the Housekeeping manager stated all rooms are cleaned daily. The housekeepers spray and wipe all surfaces, empty trash can, dust, sweep and mop the floor, but do not clean up body fluids such as feces, urine, or emesis. The expectation is to get someone from nursing, have them dispose of the body fluids and then housekeeping will clean and sanitize the area. On 7/31/23 at 10:08 a.m., a trail of foul smelling watery stool of approximately 20 feet was noted on the hallway floor of the memory care unit between rooms 405, and 410. Photographic evidence obtained. Multiple staff members and residents were observed walking in the hallway. On 7/31/23 at approximately 10:15 a.m., a staff member was observed wiping, and smearing the watery stool in a circular motion. Housekeeping was not observed sanitizing the area once the stool was wiped. On 8/1/23 at 9:38 a.m., Resident #73's room was observed with a large amount of live white crawling bugs on the bedside table. Video documentation obtained. LPN Staff MM verified the observation of the bugs and said she had seen them in other rooms as well. Resident #73 said, Just brush them off on the floor. On 8/3/23 at 11:50 a.m., multiple ant-like insects were observed crawling on Resident #2's bed, and on the resident's wound dressings on both ankles. Photographic evidence obtained. The resident said the nurse who changed the dressings to her ankles this morning told her she had ants crawling in her bed, and on her legs. The resident said she requested to have her bed sheets changed since then to get rid of the ants and no one has come all morning. On 8/3/23 at 12:00 p.m., LPN Staff I was notified of the observation of the crawling insects on the resident's bed and her request to have her sheets changed and the pest removed. LPN Staff I said she would let the Certified Nursing Assistant know. On 8/3/23 at 3:30 p.m., Resident #2 said she felt, terrible, just terrible when the nurse told her she had ants in her bed. She said the ants were crawling in her dressings. She said, no one wants bugs in their bed. I told the nurse I wanted an aide to change my bed, but no one has come yet. On 8/3/23 at 3:45 p.m., Housekeeper Staff BB was observed cleaning Resident #2's mattress. Staff BB said there were ants in the resident's open bags of chips and in the resident's bed. On 8/3/23 at 4:00 p.m., the Director of Nursing said she was informed of the ants in Resident #2's bed and on her legs. She said she thought the ants were attracted to the Medi honey (medical grade honey) used to treat the resident's wounds. She said they will be changing the resident's wound treatment. 44307 On 7/31/23 at 10:00 a.m., the ceiling tiles in room [ROOM NUMBER] in the secured memory care unit had multiple brown stains. Photographic evidence obtained. On 7/31/23 at 10:25 a.m., room [ROOM NUMBER]'s floor had dirt, grime and food particles. The shared toilet was dirty with brown stains, the bathroom light was broken, and the dresser was broken with exposed wood. Photographic evidence obtained. On 7/31/23 at 10:45 a.m., room [ROOM NUMBER] had a broken bathroom light. The paint in the bathroom was chipped and the toilet was running continuously. Photographic evidence obtained. On 8/3/23 at 11:55 a.m., brown bugs were observed crawling in the shower room and in the clean utility room of the memory unit. On 8/3/23 at 12:20 p.m., CNA Staff FF, in the memory care unit said, I see a lot of roaches. The guy comes and sprays and it is not doing anything. I also see ants sometimes, but I see roaches every time I work. I have heard about the rats but not seen them. On 8/3/23 at 12:33 p.m., Housekeeping Manager Staff U said she would expect staff to report to her if they saw roaches or bugs. She said they have a book in the front of the facility where they write the concerns. The pest guy reviews the book and then treats the identified concerns. On 8/3/23 at 1:00 p.m., RN Staff KK said, Most of the time we see roaches at nurses' stations and residents' rooms, I haven't seen rats. I have heard people saying they have seen rats mostly in the big dining room. We have a binder at the nurses' station to document if we see anything. Review of the binder provided by RN Staff KK revealed: On 7/1/23 a roach in the back hall nursing cart. On 7/24/23 two rats in the soiled utility room, roaches in med carts, roaches on nurse's station counters and on floor. On 8/3/23 at 1:15 p.m., LPN Unit Manager Staff AA said, That is not the master binder. I would like to see the master binder which is kept in the front. She confirmed she was aware of rats in the soiled utility. She said, It was reported to me, and I believe maintenance. I don't know where it went from there. I don't meet with maintenance. We don't have a set person for this facility. Reviewed master binder, sightings were not documented in master binder. On 8/4/23 at 1:00 p.m., a follow up tour of the memory care unit to review concerns identified on 7/31/23 revealed: room [ROOM NUMBER] remained with the stained ceiling tiles. room [ROOM NUMBER] still had the light out in bathroom, the dresser remained with missing front piece exposing wood. room [ROOM NUMBER] remained with the bathroom light bulb out, chipped paint on the bathroom wall and the toilet continuously running. 25618 On 7/31/23 during the initial tour of the 300 and 400 hallways in the memory care unit, observation included multiple areas, on both hallway walls, were damaged, and repaired but the damaged walls which were repaired were not painted to match the rest of the walls. One of the handrails on the 400 hallway was missing the end cap. Two hallway electrical outlet cover plates in the 400 hallway and two of the electrical outlet cover plates in room [ROOM NUMBER] were warped causing the corners to protrude outward. Several ceiling tiles in rooms [ROOM NUMBERS] were observed to have had large brown stains. One ceiling tile in room [ROOM NUMBER] by the window was observed to have had a black fuzzy substance in the middle of the brown stain. The chair rail on the wall behind bed 318B was observed to be broken and missing sections. The baseboard across from 318B was observed to be damaged and coming off the wall. The bathroom bulbs in rooms [ROOM NUMBERS] were observed as not working. On 8/3/23 at 10:47 a.m., the Director of Plant Operations said the facility currently did not have a Maintenance Director since 7/5/23. He said he had been filling in as the facility's Maintenance Director since then until they were able to hire a new Maintenance Director for the facility. He said all staff were required when they observed and/or heard of any facility damage or equipment not working to place the information in their computer maintenance program called TELS as a work order (is a web-based software designed to help senior Living operators and maintenance tract and schedule maintenance anf fire safety task). He stated he reviewed the TELS system on a routine basis, completed all work orders in the TELS system, and marked them as completed in the TELS program when he had finished the repair and/or work order. On 8/4/23 at 3:00 p.m. after a tour of the 300 and 400 hallways, the Director of Plant Operations confirmed multiple damaged wall repairs in the 300 and 400 hallways which were not painted to match the walls as required. He confirmed the end cap on the handrail on the 400 hallway was missing, there were several brown stained ceiling tiles in rooms [ROOM NUMBERS], and 1 ceiling tile in room [ROOM NUMBER] which had a black fuzzy substance in the middle of the brown stain. He confirmed the light bulbs in the bathroom in 305 and 308 were not working. He confirmed 2 electrical outlets in the 400 hallway and two electrical outlets in room [ROOM NUMBER] were warped and protruding outward which could cause an injury to the residents on the memory care unit. He also confirmed the chair rail around 318B bed was broken and missing a section, and the baseboard across from 318B's bed was damaged and falling off the wall. The Director of Plant Operations, after reviewing the work orders in the TELS computer system, said the facility staff did not enter the rooms and hallway damages and damage/repairs observed during our tour of the memory care unit into the TELS system as work orders as required. He said since the facility staff did not enter the work orders into the TELS system, he was unaware of the repairs needing to be completed in the facility.

Based on observations, record review, review of the facility's policies and procedures and staff interviews, the facility failed to protect the residents' rights to be free from neglect in that they failed to adequately address ongoing presence of rats in the facility, including the kitchen. On 12/19/22 the facility became aware of the rodent infestation in the building, including the kitchen, and neglected to implement appropriate immediate actions to eradicate the rodent infestation. Certain diseases can spread from rodents to people from direct or indirect contact with infected rodents which could result in serious illness, or death. Rodents can also damage building structures and start fires by gnawing electrical wiring. The facility failed to consistently implement recommendations from the contracted pest control company, including trimming back over hanging trees next to the building to prevent wildlife easier access to the building. The facility failed to identify and repair all rodent entry points into the building. The facility failure to provide services to ensure a clean and safe environment, free from disease causing pests resulted in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross reference to F584, F812, F835, F867, F880 and F925. Facility policy titled Abuse, Neglect and Exploitation revised 11/29/22 noted it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit neglect. The facility policy defines neglect as, The failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy noted the facility will implement policies and procedures to prevent and prohibit all types of neglect and ensure the health and safety of each resident, addressing features of the physical environment that may make neglect more likely to occur. The facility's pest sighting logbooks located at the front desk included the following entries: 11/3/22 at 6:00 a.m., rat, location found: Kitchen. 11/13/22 at 6:00 a.m., rats, location found: Kitchen. 11/23/22 at 6:30 p.m., rat, location found: Homestead dining room. 12/13/22 at 6:30 a.m., rat, location found: Kitchen. 2/16/23, (no time in the morning), rat, location found: Kitchen. 2/20/23 in the morning, rat, location found: Beverage station, department: Kitchen. 3/18/23 (no time indicated), rat, location found: Kitchen. 3/25/23 (no time indicated), rat, location found: North dining room. 4/6/23 at 6:15 a.m., rat, location found: Kitchen. 4/22/23 at 6:00 a.m., rat, location found: Kitchen. 4/25/23 at 6:15 a.m., 3 rats, location found: Kitchen. The North Unit Pest sighting log noted: 7/1/23 at 2:00 a.m., roach back hall nursing medication cart. An initial was placed next to the entry and dated 7/13/23. 7/11/23, evening, rat, location found: room [ROOM NUMBER]. 7/24/23 at 1:30 a.m., Rats (2) in soiled utility. An initial was placed next to the entry and dated 7/28/23. 7/24/23 at 1:30 a.m., Roaches in med carts, on nurses station counters, on the floors. An initial was placed next to the entry and dated 7/28/23. Review of the contracted Pest Control company reports from 11/2022 through 7/28/23 revealed: 12/19/22: The facility has been given a quote for all other exclusions. Inspected several large rodent snap traps, previously placed in the Family Room and Kitchen areas. Four rodents were captured and removed. All traps were baited and reset, to monitor activity until mass trapping service and exclusion service are approved. 3/10/23: Couldn't find 3rd logbook at the 2nd nurse station. Inspected outside perimeter. Noticed multiple spots for wildlife to get in . 3/24/23: Overhanging trees next to building needs to be trimmed back for preventing ants and wildlife to getting easier access to building . 3/28/23: Caught a rat on glueboard [sic] underneath kitchen equipment. Replaced with 2 more glueboards. Dining room has roof rat activity. Set out 2 large glueboards in drawer. And 4 large glueboards on floor by cabinets. Inspected rest of dining room . 4/25/23: Inspected kitchen area, last nite [sic] 3 roof rats were caught and disposed of. Will be back this Friday with a follow-up to check on kitchen . 4/28/23: There is a lot of rodent activity feeding off bait. Spoke with head chef in the kitchen and we caught 2 more roof rats in kitchen on our large glueboards. Set out 8 more large glueboards in kitchen . 5/12/23: There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 6/2/23: There is moderate amount of rodent activity at this time. Spoke with front desk before leaving. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 6/8/23: The roof is repaired. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 6/15/23: Arrived on property and spoke with front desk. Spoke with kitchen staff. They had caught a large rat last nite [sic] . There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 6/29/23: Texting mrs.[sic] (name) info. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 7/28/23: Arrived on the property and spoke with acting director . Rodent activity in building. They know exclusion is being done . Signed off on rodent issues after checking on them . On 8/3/23 at 3:01 p.m., observation of the outside of the building revealed multiple overhanging branches over building that need to be trimmed back for preventing ants and wildlife easier access to building as per the multiple recommendations of the contracted pest control company. Photographic evidence obtained. On 8/3/23 at 3:10 p.m., the Administrator said since she has been employed at the facility in May 2023, the overhanging branches had not been trimmed. The Administrator provided a receipt dated 1/2/23 from an outside tree service company listing a different address from the facility that read, Canary palm + (plus) 1 Palm. She said the receipt was from an outside company for tree trimming at the facility. On 8/10/23 at 11:57 a.m., in a telephone interview, a representative from the outside tree service company said on 1/2/23 the company did not provide any tree trimming services at the facility. The address listed on the receipt was private residence. As of the exit date of 8/6/23, the facility failed to provide documentation the overhanging branches over building were trimmed back for preventing ants and wildlife easier access to building as per the multiple recommendations of the contracted pest control company on 3/24/23, 5/12/23, 6/2/23, 6/8/23, 6/15/23, and 6/29/23. On 8/3/23, the facility provided copies of email exchanges between the facility and the pest control company. On 4/18/23 the pest control company noted, The best option to rid the facility of this rodent issue is a multi-step process. First we will need to seal up any holes, openings, entry points, and areas where rodents access into the building. I found several openings such as roof returns, plumbing stacks, AC (air conditioning) chases, opening around wires, and around conduits entering into building. The next step is a full trapping program for 1 month. We will do a 3 day trapping where we place traps in drop down ceiling but not set the traps. This will get the rodents from being trap shy and allow for the best capture rate . I know this facility is undergoing roof repairs, but my recommendation is for us to start this exclusion right after the roofers have completed their service . On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he has been employed with the company since September 2022, and has been the acting Maintenance Director at the facility since the beginning of July 2023. He said he became aware of possible rat problem after they started to replace the facility roof in February 2023. The roof repair was completed several months later, sometime in June 2023. He said he started hearing from some of the facility staff about seeing rats and hearing rats in the ceiling during the roof construction. He said started emailing the pest control company in April 2023 about the rats in the facility, who gave him some recommendations about what they can do about stopping the rats from entering the facility. He said the pest control company told him the rats could not be fully removed from the facility until the new roof was completed and all entry points were sealed. The Regional Plant Operation Director said he got over a hundred rodent entry points sealed sometime in June 2023, and the pest control company signed an eradication agreement to remove all the rats in the facility on 7/20/23. The Regional Plant Operation Director toured the exterior of the facility and showed some possible rodent entry points he closed or covered to prevent the rats from entering the facility. He said the pest control company provides him with their findings for each visit, and he was aware of all the pest control recommendations the facility needed to implement to address the rats in the facility. He said he had not had an opportunity to trim back the trees overhanging branches the rats could use to get on the roof and enter the facility. On 8/3/23 at 9:25 a.m., Licensed practical Nurse (LPN) Staff I said, The rats are so bad. They have roaches and rats, but I'm more afraid of the rats. You hear them running across the ceiling. I'm so scared they are going to fall on me. They are out anytime of the day. You have to open the doors to the soiled utility room and the nourishment room really carefully because they run away from you and go into the holes in the cabinets. On 8/3/23 at 9:25 a.m., observation of the South Unit soiled utility room with LPN Staff I revealed a hole in the baseboard of the wall, with a missing tile. Photographic evidence obtained. There was hole at the lower left bottom of the storage cabinet. Photographic evidence obtained. There was a hole in the baseboard where two cabinets met. Photographic evidence obtained. LPN Staff I said, I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. On 8/4/23 at 11:15 a.m., black smear marks, resembling rodent grease marks, were observed along the baseboard of the South Unit soiled utility room. Dried yellow stains, and rodent feces were observed on the floor of the soiled utility room. On 8/3/23 at 9:45 a.m., Resident #89 reported he saw a rodent in his room approximately three weeks ago, and Maintenance filled the hole in the bathroom. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said about two weeks ago staff informed him they saw a rat in Resident #89's bathroom. He observed a hole in the wall, which he plugged at that time. On 8/3/23 at 10:04 a.m., during a follow up tour of the kitchen with the Director of Food and Nutrition Services and the Regional Hospitality director, rodent feces were noted on the floor beneath the canned goods cart and bread cart. The kitchen door leading to the outside had a visible gap at the bottom with outside daylight shining through the gap. The Director of Food and Nutrition Services and Regional Hospitality Director verified the observation of the rodent feces and stated they had swept there the day before. The Director of Food and Nutrition Services said a mouse ran across her foot last week in her office located in the kitchen. She said she noted the rodents chewed the tartar sauce packets. She cleaned them off and wiped the area with bleach. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said, I don't know anything about it. I certainly have never seen any; this is the first I'm hearing about it. After reviewing the content of the reports of the contracted pest control company, and the observation of rodent feces on the floor of the kitchen storage area with the Infection Preventionist, she said, I knew there were rats in the kitchen about six months ago when the former Administration was here, but I was told it was taken care of. She verified she was not aware of any plan to address the rodent infestation at the facility. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said the first time he heard of rats in the kitchen was two weeks ago when a kitchen staff told him they saw a rat in the kitchen. He looked at the area where the kitchen staff said they saw the rat, and noted there was a hole in the wall. He has not had any meetings with the administrative staff related to the reporting of rats in the facility. He said as of this time no one from administration has asked him what interventions he had put into place to address the staff seeing rats in the facility. On 8/3/23 at 12:10 p.m., Certified Nursing Assistant (CNA) Staff K, she said she has seen rats in the facility, usually at night on the South Unit. The CNA said the rats are really bad on the secured memory unit. She said, I have seen roaches and the rats over there. It is an infestation there. On 8/3/23 at 12:22 p.m., during a telephone interview, the technician from the contracted pest control company said two rodents were caught in the kitchen yesterday. He said he told the kitchen staff not to leave bread and other food items the rats can get into on the counters or where it would be accessible to rats. He told them to put the bread in the refrigerator. On 8/3/23 at 3:18 p.m., a follow up tour of the kitchen with the Senior Regional Director of Culinary Services revealed rodent feces on the floor throughout the kitchen food storage area. Photographic evidence obtained. Rodent feces were noted on canned good items, and metal shelving racks storing canned food. Photographic evidence obtained. Single service packages of mayonnaise stored in a basket in the kitchen were observed with visible rodent bite marks. Photographic evidence obtained. Multiple loaves of packaged bread were observed stored on shelves in the dry storage area where the rodent feces were observed on the floor. Photographic evidence obtained. The Senior Regional Director of Culinary Services verified the rodent feces throughout the kitchen storage area floor and metal shelves used to store food. He verified the bread, packets of mayonnaise and other food items were not stored in rodent proof containers as per the pest company recommendation. He stated there was no policy in place for additional cleaning precautions once rodent feces have been visualized. He stated, We have been cleaning and sanitizing being sure to change out the water, and rags to prevent cross-contamination. In regard to canned goods, we are especially sure to sanitize the can where it will connect with the opener. On 8/4/23 at 6:20 p.m., the technician from the contracted pest control company said rats were entering the building through the air conditioning pipes. On July 25, 2023, he closed that hole. He said he usually gets three rats every two days. On 8/3/23 at 11:50 a.m., multiple ant-like crawling insects were observed crawling on Resident #2's bed, and on the wound dressings on both ankles. Photographic evidence obtained. The resident said the nurse who changed the dressings to her ankles this morning told her she had ants crawling in her bed, and on her legs. The resident said she requested to have her bed sheets changed since then to get rid of the ants and no one has come all morning. On 8/3/23 at 12:00 p.m., LPN Staff I was notified of the observation of the crawling insects observed on the resident's bed and her request to have her sheets changed and the pest removed. LPN Staff I said she would let the Certified Nursing Assistant know. On 8/3/23 at 3:30 p.m., Resident #2 said she felt terrible, just terrible when the nurse told her she had ants in her bed. She said the ants were crawling in her dressings. She said, no one wants bugs in their bed. I told the nurse I wanted an aide to change my bed, but no one had come yet. On 8/3/23 at 3:45 p.m., three hours and forty five minutes after LPN Staff I was notified of the ants in the resident's bed, Housekeeper staff BB was observed cleaning Resident #2's mattress. Staff BB said there were ants in the resident's open bags of chips and in the resident's bed. On 8/3/23 at 4:55 p.m., the Administrator said the trees have not been trimmed since she's been employed at the facility on 5/19/23 for preventing ants and wildlife easier access to building . She said the facility did not have a PIP (Performance Improvement Plan) in place to address the pest control, including the rat infestation.

Based on observation, record review, and interview the facility failed to mitigate rodent infestation in the foodservice establishment and failed to take effective measures to protect packaged food, clean equipment, single service, and single use items from contamination from rodents. On 12/19/22 the facility became aware of rodent infestation in the kitchen and failed to take effective immediate actions to eradicate rodent infestation, store and prepare food in a manner to prevent contamination from disease causing rodents. This failure created a serious threat to residents health and safety due to the spread of certain diseases from rodents to people from cross contamination of food and equipment from infected rodent urine, feces, and saliva which could result in serious illness or death and resulted in the determination of Immediate Jeopardy at a scope and severity of pattern (K) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86 with 85 residents consuming an oral diet. The findings included: Cross reference to F584, F600, F835, F867, F880 and F925. The facility's NEXTLEVEL policy Food Storage-Dry Goods (policy 18), with an effective date of 10/2019, stated it is the center policy to ensure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code . The Dining Services Director or designees ensures that the storage area . shall not be subject to contamination by condensation, leakage, rodents, or vermin. The Dining services Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed. Review of the Center for Disease Control (CDC) and Prevention document titled, How to Control Wild Rodent Infestations, last reviewed on January 3, 2023, noted, Rats and mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. Many diseases do not cause any apparent illness in rodents, so you cannot tell if a rodent is carrying a disease just by looking at it . Rodents, such as rats, mice . are known to carry many diseases. Diseases can spread to people directly and indirectly from rodents .'' Rodents can transmit food pathogens, such as Salmonella, Escherichia coli, and Listeria monocytogenes. These pathogens can make nursing home residents seriously ill or die from foodborne illness, as they are a highly susceptible population. On 7/31/23 at 2:57 p.m., during a kitchen tour, a large wooden trigger snap rat trap was noted on the floor located behind an open storage shelf unit. Photographic evidence obtained. On 8/2/23 4:45 p.m., The Senior Regional Director of Culinary Services stated he was told the rat trap in the kitchen was placed there as a preventative measure because there had been rat sightings in the past. Review of the contracted pest control company reports from 11/2022 through 7/28/23 revealed: On 12/19/23 the company had given the facility a quote for all other exclusions. The report noted, Inspected several large rodent snap traps, previously placed in the Family Room and Kitchen areas. Four rodents were captured and removed. All traps were baited and reset, to monitor activity until mass trapping service and exclusion service are approved. On 3/24/23, Inspected with head chef in main kitchen for rodent issues. Set up and baited 1 rat trap under kitchen equipment. Set up 4 large rat glueboards under other side of main kitchen equipment. Roof is still under construction. Overhanging trees next to building needs to be trimmed back for preventing ants and wildlife to getting easier access to building. On 3/28/23, Arrived on property and spoke with front desk and head chef. Caught a rat on glueboard underneath kitchen equipment. Replaced with 2 more glueboards. Dining room has roofrat [sic] activity. Set out 2 large glueboards in drawer. And 4 large glueboards on floor by cabinets. On 4/25/23, Inspected kitchen area, last nite [sic] 3 roof rats were caught and disposed of. Will be back this Friday with a follow-up check on kitchen. On 4/28/23, Arrived on property and spoke with manager and front desk. There is a lot of rodent activity feeding off bait. Spoke with head chef in kitchen and we caught 2 more roof rats in kitchen on our large glueboards. Set out 8 more glueboards in kitchen. On 6/2/23, Inspected, cleaned, and rebaited rodent stations 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, rodent station 4 is missing. There is moderate amount of rodent activity at this time. Spoke with front desk before leaving. On 6/15/23, Spoke with kitchen staff. They caught a large rat last night. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building. On 6/29/23, Texting mrs.[sic] (name) info. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building. On 7/13/23, Spoke with (Maintenance Director) about adding more rodents stations. On 7/28/23, Checked all 3 logbooks and scanned them. Signed off on rodent issues after checking on them. Lots more rodent activity this month. Spoke with [name] before leaving. On 8/3/23 at 9:25 a.m., Licensed practical Nurse (LPN) Staff I said, The rats are so bad. They have roaches and rats, but I'm more afraid of the rats. You hear them running across the ceiling. I'm so scared they are going to fall on me. They are out anytime of the day. You have to open the doors to the soiled utility room and the nourishment room really carefully because they run away from you and go into the holes in the cabinets. I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. On 8/3/23 at 9:35 a.m., Registered Nurse (RN) Staff D, said, The rats and roaches are disgusting and everywhere in the building. I have seen them in the resident rooms, in the utility rooms and nourishment rooms. They run in the ceiling, you hear scratching, and you can hear them run around up there. If it fell on me, I would be screaming. I know I have reported it to the management staff, but the rats are still here. It doesn't matter what time of day, you will see them, but they are worse at night. On 8/3/23 at 10:04 a.m., during a follow up tour of the kitchen, rodent feces were noted on the floor beneath the canned goods cart and bread cart. The Director of Food and Nutrition Services, and Regional Hospitality Director verified the observation of the rodent feces and stated they had swept there the day before. There was no documentation the facility followed the CDC guidelines to clean up rodent urine and droppings. Review of the CDC document titled Clean up rodent urine and droppings with a review date of January 3, 2023 noted, Step 1: Put on rubber or plastic gloves. Step 2: Spray urine and droppings with bleach solution or an EPA-registered disinfectant until very wet. Let it soak for 5 minutes or according to instructions on the disinfectant label. Step 3: Use paper towels to wipe up the urine or droppings and cleaning product. Step 4: Throw the paper towels in a covered garbage can that is regularly emptied. Step 5: Mop or sponge the area with a disinfectant. Clean all hard surfaces including floors, countertops, cabinets, and drawers. Step 6: Wash gloved hands with soap and water or a disinfectant before removing gloves. Step 7: Wash hands with soap and warm water after removing gloves or use a waterless alcohol-based hand rub when soap is not available, and hands are not visibly soiled. https://www.cdc.gov/healthypets/pets/wildlife/clean-up.html The Director of Food and Nutrition Services stated she had a mouse run across her foot last week. She said she noted the rodents chewed the tartar sauce packets. She cleaned them off and wiped the area with bleach. She said the rats were very fond of the tartar sauce. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said, I don't know anything about it. I certainly have never seen any; this is the first I'm hearing about it. After reviewing the content of the reports of the contracted pest control company with the Infection Preventionist, and the observation of rodent feces on the floor of the kitchen storage area, she said, I knew there were rats in the kitchen about six months ago when the former Administration was here, but I was told it was taken care of. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he has been the acting Maintenance Director at the facility since the beginning of July 2023. He said the housekeeping nor kitchen director had informed him of seeing rodents/rats in the facility. He said he became aware of possible rat problem after they started to replace the facility roof in February 2023 which was completed sometimes in June 2023. He said he started hearing from some of the facility staff about seeing rats and hearing rats in the ceiling during the roof construction. He said the first time he heard of rats in the kitchen was two weeks ago when a kitchen staff told him they saw a rat in the kitchen. He looked at the area where the kitchen staff said they saw the rat, and noted there was a hole in the wall. He knows of two rodent traps in the facility located in the memory care dining room. On 8/3/23 review of the pest control logbook located at the front desk of the facility noted the following dietary staff entries: 12/13/22 at 6:30 a.m., rat, location: Kitchen. 2/16/23, (no time in the morning), rat, location: Kitchen. 2/20/23 in the morning, rat, Kitchen, beverage station. 3/18/23 (no time indicated), rat, location: Kitchen. 3/25/23 (no time indicated), rat, location: North dining room. 4/6/23 at 6:15 a.m., rat in the kitchen. 4/22/23 at 6:00 a.m., Dietary Staff Z documented rat, location: Kitchen. 4/25/23 at 6:15 a.m., Dietary Staff Z documented 3 rats, location: Kitchen. On 8/1/23 at 11:07 a.m., Dietary Staff Z said if he saw rodent activity, he would put it in the log/sighting book. On 8/3/23 at 12:22 p.m., during a telephone interview, the technician from the contracted pest control company said two rodents were caught in the kitchen yesterday. He said he told the kitchen staff not to leave bread and other food items the rats can get into on the counters or where it would be accessible to the rats. He told them to put the bread in the refrigerator. On 8/3/23 at 12:30 p.m., The Administrator said the rat problem had been identified prior to her arrival to the facility. She said she has been employed at the facility since May 19, 2023, and did not know how long the rodent problem has been going on. She said she knows pest control comes out weekly as needed. She said the Maintenance Director was in charge of pest control and had direct oversight over the building. She said the facility had a contract as of 7/20/23 with the pest control company to address the rat problem. On 8/3/23 at 1:00 p.m., Registered Nurse (RN) Staff KK stated I have heard people saying they have seen rats mostly in the big dining room, (The big dining room is located next to the kitchen). On 8/3/23 at 3:18 p.m., a follow up tour of the kitchen with the Senior Regional Director of Culinary Services revealed rodent feces on the floor throughout the kitchen food storage area. Photographic evidence obtained. Rodent feces were noted on canned good items, and metal shelving racks storing canned food. Photographic evidence obtained. Single service packages of mayonnaise stored in a basket in the kitchen were observed with visible rodent bite marks. Photographic evidence obtained. Multiple loaves of packaged bread were observed stored on shelves in the dry storage area where the rodent feces were observed on the floor. Photographic evidence obtained. The Senior Regional Director of Culinary Services verified the rodent feces throughout the kitchen storage area floor and metal shelves used to store food. He verified the bread; packets of mayonnaise and other food items were not stored in rodent proof containers. He stated there was no policy in place for additional cleaning precautions once rodent feces have been visualized. He stated, We have been cleaning and sanitizing being sure to change out the water, and rags to prevent cross-contamination. In regard to canned goods, we are especially sure to sanitize the can where it will connect with the opener. On 8/4/23 at 6:20 p.m., the technician from the contracted pest control company said rats were entering the building through the air conditioning pipes. On July 25, 2023, he closed that hole. He said he usually gets three rats every two days. The facility continued foodservice operations despite rodent infestation in the kitchen area. The facility failed to protect packaged foods, clean equipment and utensils and single-use items from being contaminated with rodent excrement and failed to discart rodent contaminated foods. On 8/4/23 at 2:00 p.m., the State Survey Agency mandated that the facility cease foodservice operations due to the rodent infestations.

Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect in that the Administration failed to ensure a safe and sanitary environment free from disease causing pests. On 12/19/22 the facility administration became aware of a rodent infestation. The facility Administration failed to take appropriate actions to eradicate the rodent infestation. Certain diseases can spread from rodents to people through direct or indirect contact with infected rodents which could result in serious illness, or death of residents. Rodents can also damage building structures and start fires by gnawing electrical wiring, the extent to which is not known at this time. On 7/31/23 through 8/3/23 multiple observations of rodent feces on the kitchen floor, and on the shelves of the dry storage food area used to store ready to eat food. Observation of ready to use packets of mayonnaise with visible rodent bite marks stored in a basket in the kitchen. The facility Administration failure to take immediate appropriate actions to address the ongoing rodent infestation resulted in the determination of Immediate Jeopardy at a scope and severity of pattern (K), starting on 12/19/22. On 8/4/23 at 7:27 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross Reference to F584, F600, F812, F867, F880, and F925. The Administrator's job description signed 2/24/2021 noted the duties and responsibilities included to verify that the building and grounds are maintained appropriately, and that equipment and work areas are clean, safe, and orderly, and any hazardous conditions are addressed. The Director of Nursing's job description signed on 3/24/23 noted, Summary: To manage the overall operations of the Nursing department in accordance with Company policies, standards of nursing practices and governmental regulations to maintain excellent care of all residents' needs. On 7/31/23 at 2:57 p.m., during a kitchen tour, a large wooden trigger snap rat trap was noted on the floor located behind an open storage shelf unit. On 8/2/23 at 12:20 p.m., Licensed Practical Nurse (LPN) Staff NN said she has heard rats running in the ceiling, and residents have complained about hearing rats in the ceiling. On 8/3/23 at 9:25 a.m., LPN Staff I said the rat problem was bad. She said they were out any time of the day. She said there were holes in the soiled utility room where the rats came in. She said she's reported the rat problem to the management all the time, and the pest control company technician who said the management would not pay to have the rats removed. On 8/3/23 at 9:25 a.m., the soiled utility room of the South Unit was observed with holes in the baseboard and the bottom of the cabinets where LPN Staff I said the rats come in. On 8/3/23 at 9:35 a.m., Registered Nurse Staff D said rats were everywhere in the building. She has seen them in residents' rooms, utility rooms and nourishment rooms. She said she has reported it to the management but the rats were still here. On 8/3/23 at 9:45 a.m., Resident #89 said he saw a rodent in his room approximately three weeks ago. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director verified approximately two weeks ago there was a rat in Resident #89's room and he plugged a hole in the wall at that time. He said he has been the Maintenance Director at the facility since the beginning of July 2023. On 8/3/23 at 10:04 a.m., the Director of Food and Nutrition Services said the week before she was in her office located in the kitchen and a mouse ran across her foot. On 8/3/23 at 10:04 a.m., during a tour of the kitchen, rodent feces were noted on the floor beneath the canned goods cart and bread cart in the kitchen dry storage area. The Director of Food and Nutrition Services verified the rodent feces on the floor beneath the canned goods cart and bread cart. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said about six months ago there were rats in the kitchen, but the former administration said it was taken care of. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he became aware of seeing rats and hearing rats during the roof construction in March 2023. He said no one from administration has asked him about interventions in place to address the rats in the building. On 8/3/23 review of the pest control logbook located at the front desk of the facility noted on 11/3/22, 11/13/22, 11/23/22, 12/13/22, 2/16/23, 2/20/23, 3/18/23, 3/25/23, 4/6/23, 4/22/23, 4/25/23, and 7/24/23, rats were observed in the facility, kitchen, or dining room. On 8/3/23 at 12:30 p.m., the Administrator said the rat problem had been identified prior to her arrival at the facility on May 19, 2023. She did not know how long it had been going on. She said the Maintenance Director was in charge of pest control and had direct oversight over the building. The pest control company was responsible to check the pest control sighting log and address it. The Administrator said on 7/20/23 the facility signed a contract with the pest control company addressing the rat problem. The Administrator said she did not know the extent of the rat infestation until 7/31/23 and developed a performance improvement plan. She said they have just changed the process and the pest control log will be reviewed by Administrator or designee daily. On 8/3/23 at 4:55 p.m., the Administrator said the trees have not been trimmed since she's been employed at the facility on 5/19/23. She said the facility did not have a PIP (Performance Improvement Plan) in place to address the pest control, including the rat infestation.

Based on record review, review of the facility's policies and procedures, and staff interviews, the facility failed to show effective communication and coordination to develop and implement adequate corrective actions related to pest control and rodent infestation to ensure a safe and sanitary environment free from disease causing pests, which could lead to the spread of diseases from direct and indirect contact with infected rodents. On 12/19/22 the facility administration became aware of a rodent infestation. On 7/31/23 through 8/3/23 multiple observations of rodent feces on the kitchen floor, and on the shelves of the dry storage food area used to store ready to eat food. Observation of single service packets of mayonnaise with visible rodent bite marks stored in a basket in the kitchen. The facility's lack of an effective ongoing QAPI (Quality Assurance and Performance Improvement) process to protect residents' health and safety created a likelihood of serious illness or death for the residents from direct or indirect contact with infected rodents resulted in the determination of Immediate Jeopardy starting on 12/19/22. On 8/4/23 at 7:27 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross Reference to F584, F600, F812, F835, F880, and F925. The Quality Assessment and Assurance Committee Policy implemented 11/2020 and last revised 8/8/2022 stated This facility will maintain a Quality Assessment and Assurance (QAA) Committee to identify issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. The Administrator's job description signed on 2/24/21 noted the Administrator is Responsible for the QA (Quality Assurance) program. Review of the contracted pest control company's reports from 12/19/2022 through 7/28/23 noted multiple incidents of rodent sightings on the Memory Care Unit, the kitchen, and South Nursing Unit. Rodent stations, live traps and glue sticks have been placed in the kitchen and throughout the building. Roaches and ants were also identified throughout the building. Review of the pest control logbook located at the front desk of the facility revealed multiple entries of rat sighting in the facility from 11/3/22 through 7/24/23 (11/3/22, 11/13/22, 11/23/22, 12/13/22, 2/16/23, 2/20/23, 3/18/23, 3/25/23, 4/6/23, 4/22/23, 4/25/23, 7/24/23). Review of an email from the contracted pest control company dated April 19, 2023, to the facility's corporate employees noted, The best option to rid the facility of this rodent issue is a multistep process. The process recommended was to seal up any holes, openings, entry points and areas where rodents access into the building . The next step is a full trapping program for one month . On 7/31/23 through 8/3/23 multiple observations were made of rodent feces on the floor and shelves used to store food items in the kitchen, and live crawling bugs in residents' rooms, shower room, soiled and clean utility rooms. Holes observed in walls and cabinets in the soiled utility room of the memory care units were identified by staff as entry points for the rats. Ant-like insects were observed crawling on a resident's bed and wound dressings. On 7/31/23 through 8/3/23 multiple staff interviews conducted with direct care staff and dietary staff revealed an ongoing concern with roaches and rat infestation in the facility, including the kitchen, dining room and residents' rooms. Staff reported they communicated the ongoing rat sightings to the facility administration without any sign of improvement. On 8/3/23 at 12:00 p.m., the Regional Plant Operation Director verified he was aware of the sightings of rats in the facility, including the kitchen. He said he has not had any meetings with the administrative staff related to the rats in the facility. He said as of this time no one from administration has asked him what interventions he had put into place to address the staff seeing rats in the facility. He said he conducted an informal meeting with the Housekeeping Director to remind her staff to ensure they were not leaving food which the rats might be eating and remind them to do proper cleaning and disinfection in general. It was an informal meeting; he doesn't have any documentation related to the meeting. He said he has not had time to trim the overhanging branches over the building as per the multiple recommendations of the contracted pest control company on 3/24/23, 5/12/23, 6/2/23, 6/8/23, 6/15/23, and 6/29/23 to prevent ants and wildlife easier access to the building. On 8/3/23 at 12:33 p.m., the Housekeeping Manager stated, There are pest issues at facility, they called the pest guy weekly. On 8/3/23 at 12:20 p.m., the technician from the pest control company reported in a telephone interview two rodents were caught in the kitchen yesterday. Review of the Quality Assurance and Performance Improvement (QAPI) meetings from May 2023 through June 2023 showed the QAPI committee met on 5/17/23 for QAPI plan updates, and 5/18/23. The facility provided documentation of QAPI- PIP (Performance Improvement Plan) dated 5/15/23 (updated 6/7/23 and 6/28/23), an Action Plan/PIP dated 5/16/23 (updated 6/6/23, and 6/28/23) and a QAPI-PIP Action Plan dated 6/27/23. There was no documentation of discussion of evaluation of the effectiveness of the pest control program, including eradication of rats. There was no discussion in the QAPI meetings about continued foodservice operations in light of rodent infestation and the high risk of food contamination from rodent excrement. On 8/4/2023 at 12:45 p.m., the Administrator verified the lack of documentation of evaluation of the actions implemented to ensure the eradication of pests, including rats in the facility. She said there was a noticed increase of rodent activities in 2022 and also a noticed need for new roof. The Administrator provided a typewritten timeline, and root cause analysis documenting the steps taken to address the rats and pests. The document read, Situation: Identified an ongoing concern related to pests. Most observations include insects; however, there have been a number of observations of rodents and or rodent droppings. Initially the facility experienced a level of pests (insects and rodents' activity) in 2022 that was addressed and viewed as corrected. At the time, the determination was the need for external rodent boxes. These were added and seemingly effective with low to no further rodent activity. It was recognized that the facility had need for a new roof. There was a correlation to the need for the new roof, leaking, etc. That this had an impact of pest concerns. Quotes were received late 2022, the new roof quote was selected . roof company had to apply for permits on March 14, 2023, and the room company initiated replacement on 3/27/23. The roof completion was on 5/12/23. Additional tree work was completed on 1/2/23, in preparation for roof replacement. The Administrator said, When I got here in May of 2023, there were no QAPI minutes before me. The rodent issue was first addressed in QAPI on 7/31/2023. She said there was no current PIP for the rodent issue. She said, the Process for approving expenditures above $1500.00 was put in an email to the Corporate Regional Director of Maintenance on 7/19/2023 for approval. On 7/19/2023, the contract was approved by Corporate Director of Plant Operations for rodent/pest control. The Administrator presented a timeline of actions implemented in a root cause analysis document which listed additional services as follows: 5/12/23 added rodent station boxes. 5/15/23 no activity, prevention remedies. 5/18/23 insect treatments. 5/26/23 inspected for spiders, wasps, baited for roaches. 6/2/23 insect monitor set for flying bugs, of 11 rodent stations, one is missing, moderate rodent activity. 6/8/23 treated exterior prevention for pests, rebaited rodent stations. 6/15/23 a rat was caught last evening, treated all areas for pest and roach control. 6/22/23 pest prevention. 6/29/23 low rodent activity, 2 rodent boxes missing and will be replaced. 7/13/23 exterior and interior areas treated for pest prevention, discussed adding more rodent stations, had rebaited 2 weeks ago, replaced missing boxes. The Administrator said the interdisciplinary team met and held an Ad-Hoc (impromptu) meeting on 8/3/23 to discuss the ongoing pest concern at the facility.

Based on observation, review of the clinical record, review of facility policy and resident and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the developement and transmission of zoonotic (animals) and vector-borne (e.g., mosquitoes, ticks, and fleas) disease and infections by rodent infestation. The facility failed to follow infection control practices and failed maintain urinary catheter drainage in a sanitary manner for 2 (Resident #4 and Resident #5) of 2 residents reviewed for urinary catheters. The facility failed to ensure staff followed infection prevention measures by failure to follow personal protective equipment (PPE) guidelines for residents on transmission based precautions for COVID-19, and failure to handle medications in a sanitary manner. The facility became aware on 12/19/22 of a rodent infestation in the building. On 7/31/23 through 8/3/23 multiple observations of rodent feces on the kitchen floor, and on the shelves of the dry storage food area used to store ready to eat food. Observation of ready to use packets of mayonnaise with visible rodent bite marks stored in a basket in the kitchen. The failure of the facility to implement systems with effective actions to eradicate rodent infestations created a serious threat to residents health and safety due to the spread of certain diseases from direct or indirect contact with rodents and resulted in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross reference to F584, F600, F812, F835, F867, F925. Review of the Center for Disease Control (CDC) and Prevention document titled, How to Control Wild Rodent Infestations, last reviewed on January 3, 2023, noted, Rats and mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. Many diseases do not cause any apparent illness in rodents, so you cannot tell if a rodent is carrying a disease just by looking at it . Rodents, such as rats, mice . are known to carry many diseases. Diseases can spread to people directly and indirectly from rodents . Diseases spread directly by rodents . Hantavirus, Hantavirus Pulmonary Syndrome, Hemorrhagic Fever with Renal Syndrome, [NAME] Fever, Leptospirosis, Lujo Hemorrhagic Fever, Lymphocytic Choriomeningitis (LCM), Monkeypox, Omsk Hemorrhagic Fever, Rat-Bite Fever, Salmonellosis, South American Arenaviruses ([NAME] hemorrhagic fever, Bolivian hemorrhagic fever, Chapare Hemorrhagic Fever, [NAME]-associated hemorrhagic fever, and Venezuelan hemorrhagic fever), Sylvatic Typhus, Tularemia . Diseases spread indirectly by rodents . Anaplasmosis, Angiostrongylus, Babesiosis, Borreliosis, Colorado tick fever, Cutaneous leishmaniasis, Flea-borne (Murine) Typhus, Hymenolepis diminuta, La [NAME] virus, Lyme disease, Moniliformis moniliformis, Plague, Powassan virus, Rickettsialpox, Scrub typhus, Tick-borne Relapsing Fever, Tularemia . These viral, bacterial, or parasitic 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 CDC website (https://www.cdc.gov/hantavirus/index.html) page last reviewed November 16, 2021, noted, Each hantavirus serotype has a specific rodent host species and is spread to people via aerosolized virus that is shed in urine, feces, and saliva, and less frequently by a bite from an infected host. (accessed on 8/10/23) The facility policy Pest Control Program implemented 1/2022 documented, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is identified as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). The facility's pest sighting logbooks located at the front desk included the following entries: 11/3/22 at 6:00 a.m., rat, location found: Kitchen. 11/13/22 at 6:00 a.m., rats, location found: Kitchen. 11/23/22 at 6:30 p.m., rat, location found: Homestead dining room. 12/13/22 at 6:30 a.m., rat, location found: Kitchen. 2/16/23, (no time in the morning), rat, location found: Kitchen. 2/20/23 in the morning, rat, location found: Beverage station, department: Kitchen. 3/18/23 (no time indicated), rat, location found: Kitchen. 3/25/23 (no time indicated), rat, location found: North dining room. 4/6/23 at 6:15 a.m., rat, location found: Kitchen. 4/22/23 at 6:00 a.m., rat, location found: Kitchen. 4/25/23 at 6:15 a.m., 3 rats, location found: Kitchen. The North Unit Pest sighting log noted: 7/1/23 at 2:00 a.m., roach back hall nursing medication cart. An initial was placed next to the entry and dated 7/13/23. 7/11/23, evening, rat, location found: room [ROOM NUMBER]. 7/24/23 at 1:30 a.m., Rats (2) in soiled utility. An initial was placed next to the entry and dated 7/28/23. 7/24/23 at 1:30 a.m., Roaches in med carts, on nurses station counters, on the floors. An initial was placed next to the entry and dated 7/28/23. Review of the contracted Pest Control company reports from 11/2022 through 7/28/23 revealed on 12/19/22 the contracted pest control company gave the facility a quote for mass rodent trapping. The contracted pest control company reports from 11/2022 through 7/28/23 noted multiple sightings of rats in the facility, including the kitchen. 3/28/23: Caught a rat on glueboard [sic] underneath kitchen equipment. Replaced with 2 more glueboards. Dining room has roof rat activity. Set out 2 large glueboards in drawer. And 4 large glueboards on floor by cabinets. Inspected rest of dining room. 4/25/23: Inspected kitchen area, last nite [sic] 3 roof rats were caught and disposed of. Will be back this Friday with a follow-up to check on kitchen. 4/28/23: There is a lot of rodent activity feeding off bait. Spoke with head chef in the kitchen and we caught 2 more roof rats in kitchen on our large glueboards. Set out 8 more large glueboards in kitchen. 6/2/23: There is moderate amount of rodent activity at this time. Spoke with front desk before leaving. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building. 6/15/23: Arrived on property and spoke with front desk. Spoke with kitchen staff. They had caught a large rat last nite [sic]. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building. 7/28/23: Arrived on the property and spoke with acting director . Rodent activity in building. They know exclusion is being done . Signed off on rodent issues after checking on them. There was no documentation of effective measures by the facility of ongoing measures to properly disinfect areas of rodent sightings to prevent cross contamination of food and possible spread of harmful bacteria and viruses generated from the rodent infestation in the kitchen and dry food storage area. There was no documentation in the pest control reports of inspection of the air ducts for the presence of rodent nesting, droppings, and urine. On 7/31/23 at 2:57 p.m., during a kitchen tour, a large wooden trigger snap rat trap was noted on the floor located behind an open storage shelf unit. Photographic evidence obtained. On 8/2/23 4:45 p.m., The Senior Regional Director of Culinary Services stated he was told the rat trap in the kitchen was placed there as a preventative measure because there had been rat sightings in the past. On 8/3/23 at 9:25 a.m., Licensed practical Nurse (LPN) Staff I said the facility had roaches and rats. They were out anytime of the day. They are in the soiled utility room and the nourishment rooms. She reports it all the time to management. On 8/3/23 at 9:35 a.m., Registered Nurse (RN) Staff D said the rats and roaches were everywhere in the building, the residents' rooms, the utility rooms, and nourishment rooms. She has reported it to the management staff, but the rats are still here. She sees them any time of the day, but they are worse at night. On 8/3/23 at 9:45 a.m., Resident #89 reported he saw a rodent in his room approximately three weeks ago, and Maintenance filled the hole in the bathroom. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said about two weeks ago staff informed him they saw a rat in Resident #89's bathroom. He observed a hole in the wall, which he plugged at that time. There was no documentation that the resident's room was disinfected after the sighting of the rat. On 8/3/23 at 10:04 a.m., rodent feces were noted on the floor beneath the canned goods cart and bread cart, in the kitchen dry storage area. The Regional Hospitality Director and the Director of Food and Nutrition services verified the observation of rodent feces. They said they had swept the floor the day before. The Director of Food and Nutrition Services said a mouse ran over her foot the week before in her office located within the kitchen. She said the rodents chewed the tartar sauce packets. She cleaned the packets and wiped off the area with bleach. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said two weeks ago a kitchen staff told him they saw a rat in the kitchen. He said he conducted an informal meeting with the Housekeeping Director to remind her staff to ensure they were not leaving food which the rats might be eating and remind them to do proper cleaning and disinfection in general. It was an informal meeting; he doesn't have any documentation related to the meeting. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said, I don't know anything about it. I certainly have never seen any; this is the first I'm hearing about it. After reviewing the content of the reports of the contracted pest control company with the Infection Preventionist, and the observation of rodent feces on the floor of the kitchen storage area, she said, I knew there were rats in the kitchen about six months ago when the former Administration was here, but I was told it was taken care of. On 8/4/23 at 11:55 a.m., in a telephone interview the Medical Director said the facility notified him on 8/3/23 of the rats in the kitchen and other areas. He said as long as the residents look and don't touch the rats, they are ok. He said there was no air spread of infection from the rats, It is not like years ago with the plague, that is not going to happen. The food is fine, as long as the rodent droppings don't go into the food. He said he had a meeting with the facility's team the day before and there were no rat droppings on the food, and the kitchen was cleaned the day before. When interviewed about rat droppings on food packaging the Medical Director said that was fine as long as the rodent droppings don't go into the food. He said again he met with the facility team yesterday and there were no rat droppings on the food. The plan is for the staff to write in the pest control book if they see any pests and the pest control will come. The physician said there was no chance the residents would get any infection as long as they did not touch the rats. The Medical Director said, I was told there were no rodent droppings anywhere in the kitchen. On 8/4/23 at 3:27 p.m., the Infection Preventionist said she spoke with the Medical Director today about the rat infestation. She said the Medical Director told her, There is nothing I need to do infection control wise for the rats. She repeated, He said it really wasn't necessary for me to do anything. The Center for Disease Control and Prevention recommendation to clean up rodent urine and droppings (last reviewed January 3, 2023) noted, Step 1: Put on rubber or plastic gloves. Step 2: Spray urine and droppings with bleach solution or an EPA-registered disinfectant until very wet. Let it soak for 5 minutes or according to instructions on the disinfectant label. Step 3: Use paper towels to wipe up the urine or droppings and cleaning product. Step 4: Throw the paper towels in a covered garbage can that is regularly emptied. Step 5: Mop or sponge the area with a disinfectant. o Clean all hard surfaces including floors, countertops, cabinets, and drawers. o Follow instructions below to clean and disinfect other types of surfaces. Step 6: Wash gloved hands with soap and water or a disinfectant before removing gloves. Step 7: Wash hands with soap and warm water after removing gloves or use a waterless alcohol-based hand rub when soap is not available, and hands are not visibly soiled. The facility continued foodservice operations despite rodent infestation in the kitchen area. The facility failed to protect packaged foods, clean equipment and utensils and single service and single-use items from being contaminated with rodent excrement and failed to discard rodent contaminated foods. On 8/3/23 at 11:50 a.m., multiple ant-like crawling insects were observed crawling on Resident #2's bed, and on the resident's wound dressings on both ankles. Photographic evidence obtained. The resident said the nurse who changed the dressings to her ankles this morning told her she had ants crawling in her bed, and on her legs. The resident said she requested to have her bed sheets changed since then to get rid of the ants and no one has come all morning. On 8/3/23 at 12:00 p.m., LPN Staff I was notified of the observation of the crawling insects observed on the resident's bed and her request to have her sheets changed and the pest removed. LPN Staff I said she would let the Certified Nursing Assistant know. On 8/3/23 at 3:30 p.m., Resident #2 said she felt, terrible, just terrible when the nurse told her she had ants in her bed. She said the ants were crawling in her dressing. She said, no one wants bugs in their bed. I told the nurse I wanted an aide to change my bed, but no one has come yet. On 8/3/23 at 3:45 p.m., Housekeeper Staff BB was observed cleaning Resident #2's mattress. Staff BB said there were ants in the resident's open bags of chips and in the resident's bed. On 8/3/23 at 4:00 p.m., the Director of Nursing said she was informed of the ants in Resident #2's bed and on her legs. She said she thought the ants were attracted to the Medi honey (medical grade honey) used to treat the resident's wounds. She said they will be changing the resident's wound treatment. The facility policy Catheter Care revised (1/6/23), documented It is the policy of this facility to ensure residents with indwelling catheters (tube inserted into the bladder to drain urine) receive appropriate catheter care and maintain their dignity and privacy. Catheter care will be performed every shift and as needed by nursing personnel. Empty drainage bags when bag is hall-full or every 2-3 hours. Review of the clinical record showed Resident #4 had an admitted [DATE] with diagnoses including neurogenic bladder caused by a cerebral vascular accident requiring an indwelling urinary catheter. Resident #4's care plan instructed staff to keep the catheter off the floor. On 7/31/23 at 9:39 a.m., Resident #4's urinary catheter drainage bag and tubing were observed on the floor. The drainage bag was completely full, and the urine was beginning to flow back into the tubing. The observation was verified by LPN Staff I. Photographic evidence obtained. Review of the clinical record showed Resident #5 had an admitted [DATE] with diagnoses including urinary tract infection and obstructive and reflux uropathy requiring an indwelling urinary catheter. Resident #5's care plan instructed staff to keep the catheter off the floor. On 7/31/23 at 9:32 a.m., Resident #5's urinary catheter drainage bag and tubing were observed on the floor. LPN Staff I confirmed the observation. Photographic evidence obtained. On 7/31/23 at 9:23 a.m., Housekeeping Staff G was observed entering the room of a resident on transmission-based precautions for Coronavirus Disease 2019 (COVID-19). The signage posted on the door instructed staff on the personal protective equipment (PPE) required to enter the room, including mask, gown, and gloves. Staff G had a KN95 mask on and no other PPE. Photographic evidence obtained. Staff G began emptying the garbage and cleaning the room. LPN Staff I was present during the observation. Housekeeper Staff G verified she failed to don the proper PPE before entering the resident's room. LPN Staff I was present during the observation. 44307 On 7/31/23 at 11:50 a.m., observed lunch tray service for the 300 hall. Observed Certified Nursing Assistant (CNA) Staff JJ, passing lunch trays. CNA, Staff JJ, entered a room to deliver lunch tray to resident #27 who was on transmission based precautions for Coronavirus disease 2019 (COVID-19). The signage posted on the resident's door indicating what Personal Protection Equipment (PPE) should be worn when entering room including eye protection. The CNA donned a gown and entered the room with the meal tray without wearing eye protection. Several minutes later the CNA came out of the room. The CNA did not remove the exposed gown, proceeded to the food service cart, and removed a meal tray for resident #71. The lunch cart contained eight meal trays when she removed the tray while wearing the exposed cover gown. The CNA returned to Resident #27's room, without wearing eye protection. CNA Staff JJ was also observed entering delivering a meal tray to Resident #84 who was on transmission based precautions for COVID-19 without wearing the posted required PPE including eye protection. On 7/31/23 at 12:05 p.m., observed CNA Staff P don PPE prior to entering Resident #65's room. The signage posted on the door clearly indicated gowns, gloves and eye protection were required for entrance. The CNA did not use eye protection and entered the resident's room. After providing set up for the resident CNA Staff P exited the room and went to lunch tray cart containing five other residents' lunch trays without changing isolation exposed gown. CNA Staff P retrieved a meal tray from the meal cart and took it to Resident #28's room who was on transmission based precautions for COVID-19 without eye protection. On 7/31/23 at 12:15 p.m., CNA Staff P said, I did not know I needed to wear them, I didn't notice the signage, when asked about wearing eye precautions to enter the room of residents on transmission based precautions for COVID-19. CNA Staff P verified she failed to change the isolation gown when going in and out of residents' rooms who were on transmission based precautions for COVID-19. CNA Staff P said, I was told that I did not need to change gowns between residents who are in the same room when they are both in isolation. On 7/31/23 at 12:30 p.m. CNA Staff JJ verified she did not wear eye precautions when going in residents' rooms who were on transmission based precautions for COVID-19 disease. She verified the rooms had the signage on the door clearly indicating to wear eye precautions. The CNA said, I was passing trays by myself. I looked in the cart for a face shield but there weren't any. So, I just did what I needed to do. When asked about leaving Resident #27's room with the contaminated gown and going to the lunch tray cart for the roommate's meal, the CNA replied, I can see now that it was wrong, I should have changed everything and washed my hands. On 8/2/23 at 10:00 a.m., observed LPN Staff I, administering medications to Resident #33. LPN Staff I placed six tablets of Vitamin D 25 mcg (micrograms) into the cap of the medication bottle. She said, I don't need all of them and placed her ungloved thumb on the pills and shook one back into the bottle. Upon interview, LPN Staff I said she shouldn't have touched the pills with her bare hands. She said, I shouldn't have done that. I know better.'' On 8/3/23 at 10:07 a.m., the observation of LPN Staff I touching the Vitamin D pills with her bare hands was shared with the DON. She said this was unacceptable and would be working with the staff for improvement.

Based on observation, interview and record review, the facility failed to ensure adequate pest control measures to eradicate an ongoing rodent infestation. On 12/19/22 the facility became aware of rodent infestation in the building, including the kitchen. The facility failed to consistently implement the recommendations from the contracted pest control company to trim back over hanging trees next to the building to prevent wildlife from getting easier access to the building. The facility failed to identify and repair all rodent entry points. The failure to implement adequate measures to eradicate and contain a rodent infestation created a serious threat to residents health and safety due to the spread of certain diseases from direct or indirect contact with rodents and resulted in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross reference to F600, F812, F835, F867, and F880. The facility policy titled Pest Control Program implemented 1/2022 stated it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. An effective pest control program is defined as measures to eradicate and contain common household pests, (bed buds, lice, roaches, ants, mosquitos, flies, mice, and rats). The facility will maintain a report system of issues that may arise in between scheduled visits with outside pest services and treat as indicated. Review of the pest control logbook located at the front of the facility noted on 12/13/22, 2/16/23, 2/20/23, 3/18/23, 3/25/23, 4/6/23, 4/22/23, 4/25/23, the dietary staff documented sightings of rats in the kitchen and/or the North Dining Room. The North Unit Pest sighting logbook noted on 7/11/23 a rat was observed in room [ROOM NUMBER], and on 7/24/23 two rats in the soiled utility room. The pest control company reports showed on 3/24/23, 5/12/23, 6/2/23, 6/8/23, 6/15/23, 6/29/23 the company recommended trimming back over hanging trees next to the building to prevent ants and wildlife from getting easier access to the building. On 8/3/23 at 3:01 p.m., observation of the outside of the building revealed multiple overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building as per the multiple recommendations of the contracted pest control company. Photographic evidence obtained. Pest control records from 12/19/2022 through 7/28/23 noted multiple incidents of rodent sightings on the Memory Care Unit, the kitchen, and South Nursing Unit. Rodent stations, live traps and glue sticks have been placed in the kitchen and throughout the building. Roaches and ants were also identified throughout the building. The contracted Pest Control inspection report dated 7/28/23 noted, Checked all 3 logbooks and scanned them. Signed off on rodent issues after checking on them. Baited nurse main cart with roach gel for roach sightings. Lots more rodent activity this month. Review of an email from the contracted pest control company dated April 19, 2023 to the Facility Plant operations and a facility corporate employee noted the pest control company representative stated he visited the facility today and saw several openings, activity and conditions leading to the rodent activity. The representative informed (name) the best option to rid the facility of this rodent issue is a multistep process. The process recommended was to seal up any holes, openings, entry points and areas where rodents access into the building . The next step is a full trapping program for one month . Lastly, I have included extra rodent bait stations around the facility for more control and better monitoring. My recommendation is to start this exclusion right after the roofers have completed their service. This program I am sure will take an entire day. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he has been employed with the company since September 2022, and has been the acting Maintenance Director at the facility since the beginning of July 2023. He said he became aware of possible rat problem after they started to replace the facility roof in February 2023. The roof repair was completed several months later, sometimes in June 2023. He said started emailing the pest control company in April 2023 about the rats in the facility, who gave him some recommendations about what they can do about stopping the rats from entering the facility. He said the pest control company told him the rats could not be fully removed from the facility until the new roof was completed and all entry points were sealed. The Regional Plant Operation Director said he got over a hundred rodent entry points sealed sometimes in June 2023, and the pest control company signed an eradication agreement to remove all the rats in the facility on 7/20/23. On 8/3/23 at 3:10 p.m., the Administrator said since she has been employed at the facility in May 19, 2023, the overhanging branches had not been trimmed. The facility did not complete a Pest Exclusion agreement until 7/20/23. This agreement allows the pest control company to inspect and seal all holes and cracks throughout the building to eliminate rodent points of entry even though the roof completion was on 5/12/23. On 7/31/23 at 2:57 p.m., during a kitchen tour, a large wooden trigger snap rat trap was noted on the floor located behind an open storage shelf unit. Photographic evidence obtained. On 8/2/23 4:45 p.m., The Senior Regional Director of Culinary Services stated he was told the rat trap in the kitchen was placed there as a preventative measure because there had been rat sightings in the past. On 8/3/23 at 9:25 a.m., Licensed practical Nurse (LPN) Staff I said, The rats are so bad. They have roaches and rats, but I'm more afraid of the rats. You hear them running across the ceiling. I'm so scared they are going to fall on me. They are out anytime of the day. You have to open the doors to the soiled utility room and the nourishment room really carefully because they run away from you and go into the holes in the cabinets. I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. On 8/3/23 at 9:25 a.m., observation of the South Unit soiled utility room with LPN Staff I revealed a hole in the baseboard of the wall, with a missing tile. Photographic evidence obtained. There was hole at the lower left bottom of the storage cabinet. Photographic evidence obtained. There was a hole in the baseboard where two cabinets met. Photographic evidence obtained. LPN Staff I said, I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. On 8/3/23 at 9:35 a.m., Registered Nurse (RN) Staff D, said, The rats and roaches are disgusting and everywhere in the building. I have seen them in the resident rooms, in the utility rooms and nourishment rooms. They run in the ceiling, you hear scratching, and you can hear them run around up there. If it fell on me, I would be screaming. I know I have reported it to the management staff, but the rats are still here. It doesn't matter what time of day, you will see them, but they are worse at night. On 8/3/23 at 10:04 a.m., during a follow up tour of the kitchen, rodent feces were noted on the floor beneath the canned goods cart and bread cart. The Director of Food and Nutrition Services, and Regional Hospitality Director verified the observation of the rodent feces and stated they had swept there the day before. The Director of Food and Nutrition Services stated she had a mouse run across her foot last week. On 8/3/23 at 11:50 a.m., multiple ant-like crawling insects were observed crawling on Resident #2's bed, and on the resident's wound dressings on both ankles. Photographic evidence obtained. The resident said the nurse who changed the dressings to her ankles this morning told her she had ants crawling in her bed, and on her legs. On 8/3/23 at 12:22 p.m., during a telephone interview, the technician from the contracted pest control company said two rodents were caught in the kitchen yesterday. He said he told the kitchen staff not to leave bread and other food items the rats can get into on the counters or where it would be accessible to the rats. He told them to put the bread in the refrigerator. On 8/3/23 at 12:30 p.m., the Administrator said the rat problem had been identified prior to her arrival to the facility on [DATE]. She said she knew the pest control came out weekly as needed. She said the Maintenance Director was in charge of pest control and had direct oversight over the building. She said she could provide a copy of the contract signed on 7/20/2023 addressing the rat problem. On 8/3/23 at 3:18 p.m., a follow up tour of the kitchen with the Senior Regional Director of Culinary Services revealed rodent feces on the floor throughout the kitchen food storage area. Rodent feces were noted on canned good items, and metal shelving racks storing canned food. Single service packages of mayonnaise stored in a basket in the kitchen were observed with visible rodent bite marks. Multiple loaves of packaged bread were observed stored on shelves in the dry storage area where the rodent feces were observed on the floor. The Senior Regional Director of Culinary Services verified the rodent feces throughout the kitchen storage area floor and metal shelves used to store food. He verified the bread; packets of mayonnaise and other food items were not stored in rodent proof containers. On 8/4/23 at 12:45 p.m., the Administrator provided a timeline, and root cause analysis documenting the steps taken to address the rats and pests. The document read, Situation: Identified an ongoing concern related to pests. Most observations include insects; however, there have been a number of observations of rodents and or rodent droppings. Initially the facility experienced a level of pests (insects and rodents' activity) in 2022 that was addressed and viewed as corrected. At the time, the determination was the need for external rodent boxes. These were added and seemingly effective with low to no further rodent activity. It was recognized that the facility had need for a new roof. There was a correlation to the need for the new roof, leaking, etc. That this had an impact of pest concerns. Quotes were received late 2022, the new roof quote was selected . roof company had to apply for permits on March 14, 2023, and the room company initiated replacement on 3/27/23. The roof completion was on 5/12/23. Additional tree work was completed on 1/2/23, in preparation for roof replacement. The root cause analysis document included a list of additional services as follows: 5/12/23 added rodent station boxes. 5/15/23 no activity, prevention remedies. 5/18/23 insect treatments. 5/26/23 inspected for spiders, wasps, baited for roaches. 6/2/23 insect monitor set for flying bugs, of 11 rodent stations, one is missing, moderate rodent activity. 6/8/23 treated exterior prevention for pests, rebaited rodent stations. 6/15/23 a rat was caught last evening, treated all areas for pest and roach control. 6/22/23 pest prevention. 6/29/23 low rodent activity, 2 rodent boxes missing and will be replaced. 7/13/23 exterior and interior areas treated for pest prevention, discussed adding more rodent stations, had rebaited 2 weeks ago, replaced missing boxes. 7/28/23 after start of exclusion, rodent activity reported, traps were not set and no rodent activity observed at this time interior. Rodent stations outside of building, lots of rodent activity, cleaned and rebaited rodent stations. The Administrator provided a receipt dated 1/2/23 from an outside tree service company listing a different address from the facility that read, Canary palm + (plus) 1 Palm. She said the receipt was from an outside company for tree trimming at the facility. On 8/10/23 at 11:57 a.m., in a telephone interview, a representative from the outside tree service company said on 1/2/23 the company did not provide any tree trimming services at the facility. The address listed on the receipt was private property. On 8/4/23 at 2:00 p.m., the State Survey Agency mandated that the facility cease foodservice operations due to the rodent infestations. On 8/4/23 at 6:20 p.m., the technician from the contracted pest control company said rats were entering the building through the air conditioning pipes. On July 25, 2023, he closed that hole. He said he usually gets three rats every two days. 44307 On 8/3/23 at 11:55 a.m., live crawling brown bugs were observed in the shower room and in the clean utility room in the memory unit. On 8/3/23 at 12:05 p.m., several brown crawling insects were observed in the memory care unit clean utility room in front of storage cabinet. On 8/3/23 at 12:20 p.m., CNA Staff FF, in the memory care unit said, I see a lot of roaches. The guy comes and sprays and it is not doing anything. I also see ants sometimes, but I see roaches every time I work. I have heard about the rats but not seen them. On 8/3/23 at 12:33 p.m., Housekeeping manager Staff U said she would expect staff to report to her if they saw roaches or bugs. She said they have a book in the front of the facility where they write the concerns. The pest guy reviews the book and then treats the identified concerns. On 8/3/23 at 1:00 p.m., RN Staff KK said, Most of the time we see roaches at nurses' stations and residents' rooms, I haven't seen rats. I have heard people saying they have seen rats mostly in the big dining room. We have a binder in the nurses' station to document if we see anything.

Based on observations, record review, resident and staff interviews the facility failed to ensure 2 (Resident #29 and Resident #88) of 2 residents reviewed experiencing mouth pain, received dental services to meet their needs. The findings included: The facility policy for Dental Services Implemented 1/2022 and last revised 5/2022 stated, it is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease/dental radiographs as needed, dental cleaning, fillings, minor partial or full denture adjustments, smoothing broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. On 8/01/23 at 11:45 a.m., Resident #29, he said he has been a resident at the facility for 16 months. He said he had pain when he ate due to broken teeth. The resident opened his mouth. Multiple broken teeth were observed worn down to the down to the gum line on his lower jaw. He said the facility offered to send him to a dentist when he was admitted but no one has mentioned it since. He said he told them he would have to be put to sleep to have the work done because he was scared of going to the dentist. He said he was afraid of the pain and would be unable to have dental work if he was awake. He said he would love to get his teeth fixed or get dentures. Resident #29 was admitted to the facility on [DATE]. His BIMS (Brief Interview for Mental Status) was a 15 of 15 which indicated the resident was cognitively intact. The Admission Record noted the primary payer to be Humana Medicaid. Resident # 29's Care Plan initiated on 4/27/2023 stated Resident #29 has 1 tooth, history of inflamed gums, but no complaints of anything new. The goal was for resident to be free of infection, pain, or bleeding in the oral cavity by review date. Interventions listed as initiated were coordinate arrangements for dental care, transportation as needed/as ordered . Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted . Monitor/document/report as needed any signs or symptoms of oral/dental problems needing attention: Pain, abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue inflamed, ulcers in mouth, lesions. There were no further interventions or documentation addressing Resident # 29 dental issues in the resident's care plan. Resident #29's oral evaluation completed on 4/20/2022 noted some missing teeth and, has very few teeth. The Minimum Data Set (MDS) for Oral/Dental Status dated 11/8/2022 and 7/24/2023 for Resident #29 reported no broken or loosely fitting full or partial denture and no mouth or facial pain, discomfort or difficulty with chewing. The Nutritional Risk Screen completed on 4/5/2023 for Resident #29 reported no chewing problems reported or observed. The diet upon admission to facility and the current diet ordered for Resident #29 was a Regular diet. On 8/2/2023 at 1:00 p.m., the Administrator and the Director of Nursing (DON) both said Resident #29 never wanted to see a dentist. They said it was offered but he refused. They denied having knowledge of the resident having pain when chewing. On 8/2/23 at 1:30 p.m., Resident #29 said he had no teeth to chew so there was pain every time he ate, he was just used to the pain. He said he would love to have teeth, but was so scared of the dentist. He denied saying he didn't want to go to the dentist, he just said he was afraid to go to the dentist. He said he had not seen a dentist since his admission to the facility. The DON provided an email from Medical Records dated 8/3/2023 stating that Resident #29 had refused dental services in the past. The email noted there was no documentation the resident had ever been seen by the dentist before. 46824 Record review revealed Resident #88 admitted on [DATE]. The Admission Record information noted the payor source was Medicaid. The Admission Minimum Data Set (MDS) assessment with a target date of 4/18/23 noted diagnoses of Alzheimers Dementia, and Anxiety. The Brief interview of Mental Status (BIMS) indicated Resident #88's cognition was moderately impaired with a score of 9. The MDS noted the resident had obvious or likely cavity or broken natural teeth. A physician order with an effective date of 6/22/23 noted Resident #88, may be seen and evaluated by dental. Resident #88's care plan with an effective date of 4/26/23 noted resident has a dental or oral problem related to chipped teeth to his upper ridge and edentulous (without teeth) to lower ridge. Interventions included to assist or complete mouth/oral care daily and as needed. On 8/2/23 at 1:48 p.m., Resident #88 stated his front teeth hurt. He stated, It's hard to chew and bite down, it hurts. Resident #88's upper front teeth were observed to be broken, and jagged. The resident stated he had not brushed his teeth. On 8/4/23 at 9:02 a.m., Resident #88 was observed eating breakfast, chewing on the side. He opened his mouth, and showed the DON his teeth. They were brown with debris along the gum line and between teeth. The DON verified his teeth looked bad and needed to see a dentist. The DON verified the resident did not have a toothbrush or toothpaste in his room, bathroom or drawers. On 8/4/23 at 9:24 a.m., Resident #88 stated his teeth were worse than they have ever been. On 8/4/23 at 9:32 a.m., the interim Social Service Director (SSD) stated the dental provider was in the building on 6/27/23 but there was no record of Resident #88 receiving dental services since admission. The SSD stated she was not aware resident had mouth pain. Record review revealed no documentation of a referral to the dentist for Resident #88. On 8/4/23 at 12:27 p.m., the Regional Nurse stated, we would ask the resident if they would like to see the dentist, and we would do a consult. That is the way it should be. The dental evaluation should be completed by Social Services and documented in the progress notes.

Based on observation, record review, and staff interview, the facility failed to ensure 7 (Residents #35, #40, #55, #67, #73, #194, #88) of 7 residents received medications in accordance with professional standards of practice by failing to order medications on a timely manner or failure to administer medications in accordance with the physician's orders. The findings included: Review of facility policy titled, Admission Orders, revised 5/2022 which states, A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and /or verbal orders for the residents' immediate care and needs. 1. The written and/or verbal orders should include at a minimum: (a) Dietary, (b) Medication orders if indicated; (c) Routine care orders. 2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. 3. The orders should provide information to maintain or improve the resident's functional abilities. Review of facility policy titled, Medication Administration, revised 5/3/2022 which states Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. Keep medication cart clean, organized and stocked with adequate supplies .11. Compare medication source with medication administration record (MAR) to verify resident name. form, dose, route and time. (b) Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician . 13. Remove medication from source, taking care not to touch medication with bare hand. Review of facility policy titled Controlled Substance Administration and Accountability, revised 7/19/22 which stated, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . 1.(j) The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify: i. Controlled substances that are destroyed are appropriately documented; and ii. Medications removed from either the automated dispensing system or medication cart/ cabinet have a documented physician order. Review of facility policy titled, Unavailable Medications, revised 2/9/2022 which states, If a resident misses a scheduled dose of a medication, staff shall follow procedures for medication errors, including physician/ family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. 1. On 8/2/23 at 8:04 a.m., observed Licensed Practical Nurse (LPN) Staff H administer scheduled medications to Resident #40. The physician's orders included Cyclobenzaprine HCl Tablet 10 milligrams (mg) one tablet by mouth three times a day related to chronic pain syndrome. LPN Staff H said the medication was not available to be given. There was none available in the medication cart and this medication was not included in the floor stock of prescription medications. On 8/2/23 at 8:15 a.m., LPN Staff H said, It does not happen that often, looks like someone did not request the reorder. She said she would reorder the Cyclobenzaprine now. 2. On 8/2/23 at 8:20 a.m., observed LPN Staff H, administering scheduled medications to Resident #55. LPN Staff H said the resident returned to the facility the previous afternoon into the evening. She noted her medications had not been ordered so she was unable to administer the medications as ordered. Medications unable to be administered included Dexamethasone 6 mg tablet once a day for two days for COVID-19; Famotidine tablet 10 mg once a day for indigestion; Labetalol HCl 100 mg tablet, 1 tablet twice a day for hypertension (high blood pressure); Incruse Ellipta 62.5 mcg (micrograms)/ACT inhaler 1 puff once a day for Chronic Obstructive Pulmonary Disease (COPD); Depakene Solution 250 mg/ml (milliliter) 10 ml 2 times a day for mood disorder. LPN Staff H said, I don't know why they did not order them. I got two of the medications from the medication room supply. I will have the rest later today. On 8/2/23 at 8:45 a.m., the Director of Nursing (DON) was interviewed about Resident #55's orders not sent to the pharmacy after readmission the previous evening 8/1/23 around 6:00 p.m. The DON reviewed the records and said, I don't know why the nurse did not get the medications from the pharmacy. That should not have happened. 3. On 8/2/23 at 5:30 p.m., RN Staff M was observed conducting a narcotic count with the Director of Nursing RN, Staff M, said, Let me get the book. I can't leave it on the cart because the residents will take it. RN, Staff M said, Wait let me fill in the medications I have already given. RN Staff M documented on the declining inventory of the narcotic log for six residents, #67, #73, #70, # 35, #194 and #88 as follows: Resident #35, administered lorazepam tablet 1 mg 8/2/23 at 2000 (8:00 p.m.) Resident #194, administered lorazepam tablet 0.5 mg at 2000 (8:00 p.m.) Resident #88, administered alprazolam (used to treat anxiety) 0.25 mg at 2000 (8:00p.m.) Resident #67, administered tramadol (opioid analgesic) HCL tablet 50 mg on 8/2/23 at 1800 (6:00p.m.) Resident #73, administered oxycodone/acetaminophen 5-325 mg (opioid analgesic) tablet 8/2/23 at 1800 (6:00 p.m.) Resident #70, administered lorazepam (antianxiety) tablet 0.5 mg 8/2/23 at 1800 (6:00 p.m.) RN Staff M verified he documented he administered the Lorazepam to Residents #35, and #194, and the alprazolam to Resident #88 approximately three hours before scheduled time. RN Staff M said, I know that you should do one hour before and one hour after. RN, Staff M said, You need to understand that these residents get very confused and sundown [confusion occurring in late afternoon]. They will have behaviors, so they need their medications early. Review of the clinical record with the DON for Resident #35 revealed a physician's order dated 6/9/23 to discontinue the lorazepam 1 mg. There was no documentation in the clinical record Resident #35 was experiencing anxiety, and the physician was contacted and had authorized the administration of the discontinued lorazepam to Resident #35. Review of the clinical record with the DON for Resident #194 revealed an active physician's order dated 7/12/23 to administer lorazepam 0.5 mg tablet twice a day for restlessness. The medication was scheduled to be administered every 12 hours, at 9:00 a.m., and 9:00 p.m. Staff M had administered the lorazepam to the resident four hours before the scheduled time. There was no documentation in the clinical record Resident #194 was experiencing any restlessness and the physician was contacted and authorized the administration of the lorazepam outside of the scheduled time. Review of the clinical record for Resident #88 with the DON revealed an active physician's order dated 7/1/23 for alprazolam once a day at bedtime for anxiety. The medication was scheduled to be administered every evening at 8:00 p.m. RN Staff M had administered the alprazolam to the resident three hours prior to the scheduled time. The clinical record lacked documentation of behavior to support the early administration. There was no documentation the physician was contacted and had authorized the early administration of the alprazolam. Review of the physician's orders with the DON for Resident #67 revealed to administer Tramadol HCl 50 mg twice a day for pain. The medication was scheduled to be administered every 12 hours at 9:00 a.m. and 9:00 p.m. RN Staff M had administered the Tramadol four hours prior to the scheduled time. There was no documentation in the clinical record, Resident #67 was experiencing any pain and the physician had authorized the administration of the Tramadol outside of the scheduled time. Review of the clinical record with the DON for Resident #73 revealed a physician's order for oxycodone/acetaminophen 5-325 mg which was discontinued on 7/3/23. Resident #73 did not have an active order for the oxycodone/acetaminophen 5/325 RN Staff M documented he administered on 8/2/23 at 6:00 p.m. There was no documentation in the clinical record Resident #73 was experiencing any pain and the physician had authorized the administration of the discontinued oxycodone/acetaminophen 5/325. On 8/2/23 at 6:30 p.m., the Administrator who is the risk manager, and the Regional Nurse Consultant said RN Staff M was suspended pending investigation. On 8/3/23 at 10:07 a.m., the DON said she could not explain why the narcotics were kept in the medications carts several weeks after they were discontinued. She said the discontinued narcotics would be brought to the DON for destruction. The DON said, I cannot control everything. Best practice we know they should not have been in the cart. It is an expectation that when medication is discontinued you bring to the DON. The DON verified she has been employed at the facility since April 2023 and she has not sought out discontinued narcotics but has waited for staff to bring them to her. The DON said, moving forward I will be going to those carts every day.

Based on staff interview and staff record review the facility failed to ensure 4 (Staff O, CC, DD, and FF) of 5 staff employee records had a performance review completed at least once every 12 months with in-service education based on the outcome of the performance reviews. The findings included: Review of the Facility Assessment Tool last updated on 5/19/23, noted documentation in the Staff Training/Education and Competencies section the nurse aides are required to have in-service training throughout the year. In-service training must . address areas of weakness as determined in nurse aides' performance reviews as noted in the Facility Assessment Tool and the training may address the special needs of residents as determined by the facility staff. On 8/3/23 a review of Staff O's employee file, a CNA (Certified Nursing Assistant), revealed a date of hire of 6/11/14. Further review of Staff O's employee file failed to reveal documentation of an annual performance review for 2022 nor 2023. On 8/3/23 a review of Staff CC's employee file a CNA, revealed a date of hire of 11/21/12. Further review of Staff CC's employee file revealed the employee did not have an annual performance review completed for 2022 or 2023. On 8/3/23 a review of Staff DD's employee file a CNA, revealed a date of hire of 8/9/17. Further review of Staff DD's employee file revealed the employee did not have an annual performance review completed for 2022 or 2023. On 8/4/23 at 12:43 p.m., in an interview with Staff FF, a CNA, she said she was hired over 6 years ago. She said she did not remember the last time the facility completed her annual performance review, but she knew her annual performance review was not conducted in 2022 or 2023. On 8/4/23 at 1:25 p.m., in an interview with the Administrator, she said all CNA/nurse aides were required to have a performance review completed every 12 months which should address the CNA/nurse aides' areas of weakness as noted in the facility's Facility Assessment Tool. She said she was told by the Human Resource (HR) Director several months ago during an employee file audit, the HR Director noted several of the CNA/nurse aides annual performance reviews were not completed as required. The Administrator confirmed Staff O, CC, DD, and FF's annual performance reviews were not completed as of 8/4/23. On 8/4/23 at 2:01 p.m., in an interview with the HR Director, during an employee file audit, she informed the Administrator several of the staff required annual performance reviews were not completed. The HR Director confirmed Staff (O, CC, DD, EE, and FF)'s annual performance reviews were not completed for 2022 and 2023 as of this time.

Based on observations, staff interviews, resident records review and facility policy review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals. The facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The findings included: Review of facility policy titled, Medication Administration, revised 5/3/2022 which states Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. Keep medication cart clean, organized and stocked with adequate supplies . 11. Compare medication source with medication administration record (MAR) to verify resident name. form, dose, route, and time. (b) Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician . 13. Remove medication from source, taking care not to touch medication with bare hand. Review of facility policy titled Controlled Substance Administration and Accountability, revised 7/19/22 which stated, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure . 1.(j) The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify i. Controlled substances that are destroyed are appropriately documented; and ii. Medications removed from either the automated dispensing system or medication cart/ cabinet have a documented physician order. Review of facility policy titled, Unavailable Medications, revised 2/9/2022 which states, If a resident misses a scheduled dose of a medication, staff shall follow procedures for medication errors, including physician/ family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. On 8/2/23 at 8:04 a.m., observed Licensed Practical Nurse (LPN), Staff H, administer scheduled medications to Resident #40. Resident was ordered to receive Cyclobenzaprine HCl Tablet 10 milligrams (mg) one tablet by mouth three times a day related to chronic pain syndrome. LPN Staff H said the medication was not available to be given. There was none available in the medication cart and this medication was not in the floor stock of prescription medications. On 8/2/23 at 8:15 a.m., LPN Staff H said, It does not happen that often, looks like someone did not request the reorder. She said she would reorder the Cyclobenzaprine now. On 8/2/23 at 8:20 a.m., observed LPN Staff H, attempting to administer scheduled medications to Resident #55. LPN Staff H said the resident returned to the facility the previous afternoon into evening. She noted her medications had not been ordered so she was unable to administer the medications as ordered. Medications unable to be administered included Dexamethasone 6 mg tablet once a day for two days for COVID-19; Famotidine tablet 10 mg once a day for indigestion; Labetalol HCl 100 mg tablet, 1 tablet twice a day for hypertension (high blood pressure); Incruse Ellipta 62.5 mcg (micrograms)/ACT inhaler 1 puff once a day for Chronic Obstructive Pulmonary Disease (COPD); Depakene Solution 250 mg/ml (milliliter) 10 ml 2 times a day for mood disorder. LPN Staff H said, I don't know why they did not order them. I got two of the medications from the medication room supply. I will have the rest later today. On 8/2/23 at 8:45 a.m., the Director of Nursing (DON) was interviewed about Resident #55's orders not sent to the pharmacy after readmission the previous evening 8/1/23 around 600 p.m. The DON reviewed the records and said, I don't know why the nurse did not get the medications from pharmacy. That should not have happened. On 8/2/23 at 5:10 p.m., observation of the North Back Hall medication cart with Registered Nurse (RN) Staff M revealed a personal coffee cup stored in the center of the medication drawer. RN Staff M verified personal cups should not be stored in the medication cart and said, I had to go into a room, and we can't leave anything on the cart. RN Staff M said, I can't lie, and I don't want anyone else to get into trouble. It is mine. 11 full loose pills and many partial pill pieces were found in the bottom of the drawer among the medication cards. A white, half pill was observed loose in the controlled substance (narcotic) drawer. The half pill appeared to be Ativan (antianxiety). RN Staff M could not explain who was responsible for ensuring the cart did not have any loose pills. When asked if he checks the cart when working, RN Staff M replied, I don't know. On 8/2/23 at 5:30 p.m., The DON said, we just checked the carts the other day. I don't know why there are so many loose pills. It is a nurse's responsibility to ensure the carts are clean and the counts are correct. The DON said it was unacceptable for a nurse to store his coffee cup inside the medication drawer and that there should not be loose unaccounted for medications in the bottom of the drawer. On 8/2/23 at 5:30 p.m., RN Staff M was observed conducting a narcotic count with the Director of Nursing (due to the loose half pill in the narcotic drawer which appeared to be Ativan. The narcotic book was at nurses' station not with cart. RN, Staff M, said, Let me get the book. I can't leave it on the cart because the residents will take it. RN, Staff M said, Wait let me fill in the medications I have already given. RN Staff M documented on the declining inventory of the narcotic log for six residents, #67, #73, #70, # 35, #194 and #88 as follows: Resident #67, administered tramadol (opioid analgesic) HCL tablet 50 mg on 8/2/23 at 1800 (6:00p.m.) Resident #73, administered oxycodone/acetaminophen 5-325 mg (opioid analgesic) tablet 8/2/23 at 1800 (6:00 p.m.) Resident #70, administered lorazepam (antianxiety) tablet 0.5 mg 8/2/23 at 1800 (6:00 p.m.) Resident #35, administered lorazepam tablet 1 mg 8/2/23 at 2000 (8:00 p.m.) Resident #194, administered lorazepam tablet 0.5 mg at 2000 (8:00 p.m.) Resident #88, administered alprazolam (used to treat anxiety) 0.25 mg at 2000 (8:00p.m.) RN Staff M verified he documented he administered the Lorazepam to Residents #35, and #194, and the alprazolam to Resident #88 approximately three hours before scheduled time. RN Staff M said, I know that you should do one hour before and 1 hour after. RN, Staff M said, You need to understand that these residents get very confused and sundown [confusion occurring in late afternoon]. They will have behaviors, so they need their medications early. Review of the physician's orders with the DON for Resident #67 revealed to administer Tramadol HCl 50 mg twice a day for pain. The medication was scheduled to be administered every 12 hours at 9:00 a.m. and 9:00 p.m. RN Staff M had administered the Tramadol four hours prior to the scheduled time. There was no documentation in the clinical record, Resident #67 was experiencing any pain and the physician had authorized the administration of the Tramadol outside of the scheduled time. Review of the clinical record with the DON for Resident #73 revealed a physician's order for oxycodone/acetaminophen 5-325 mg which was discontinued on 7/3/23. Resident #73 did not have an active order for the oxycodone/acetaminophen 5/325 RN Staff M documented he administered on 8/2/23 at 6:00 p.m. There was no documentation in the clinical record Resident #73 was experiencing any pain and the physician had authorized the administration of the discontinued oxycodone/acetaminophen 5/325. Review of the clinical record with the DON for Resident #35 revealed a physician's order dated 6/9/23 to discontinue the lorazepam 1 mg. There was no documentation in the clinical record Resident #35 was experiencing any anxiety, and the physician was contacted and had authorized the administration of the discontinued lorazepam to Resident #35. Review of the clinical record with the DON for Resident #194 revealed an active physician's order dated 7/12/23 to administer lorazepam 0.5 mg tablet twice a day for restlessness. The medication was scheduled to be administered every 12 hours, at 9:00 a.m., and 9:00 p.m. Staff M had administered the lorazepam to the resident four hours before the scheduled time. There was no documentation in the clinical record Resident #194 was experiencing any restlessness and the physician was contacted and authorized the administration of the lorazepam outside of the scheduled time. Review of the clinical record for Resident #88 revealed an active physician's order dated 7/1/23 for alprazolam once a day at bedtime for anxiety. The medication was scheduled to be administered every evening at 8:00 p.m. RN Staff M had administered the alprazolam to the resident three hours prior to the scheduled time. The clinical record lacked documentation of behavior to support the early administration. There was no documentation the physician was contacted and had authorized the early administration of the alprazolam. On 8/2/23 at 6:30 p.m., the Administrator who is the risk manager, and the Regional Nurse Consultant said RN Staff M, was suspended pending investigation. They said they were not sure if the situation was drug diversion or medicating without orders and had contacted the police. The administrator said she did not know why the discontinued controlled substances were still in the medication carts. On 8/3/23 at 10:07 a.m., the DON said she could not explain why the narcotics were kept in the medications carts several weeks after they were discontinued. She said the discontinued narcotics would be brought to the DON for destruction. The DON said, I cannot control everything. Best practice we know they should not have been in the cart. It is an expectation that when medication is discontinued you bring to the DON. The DON verified she has been employed at the facility since April 2023 and she has not sought out discontinued narcotics but has waited for staff to bring them to her. The DON said, moving forward I will be going to those carts every day. The DON confirmed when she receives discontinued narcotics, she places them with the declining inventory log paper into the double locked cabinet in her office. The DON said she did not know what was currently in her cabinet and had no means of reconciling if what was in the cabinet matched medications which had been discontinued at facility. On 8/3/23 10:55 a.m., during a telephone interview the consultant pharmacist said he comes to the facility every four to six weeks, but it was not a scheduled visit. The pharmacist said it was the responsibility of the nursing team to collect and secure discontinued narcotics until he is at the facility for destruction. The pharmacist and the pharmacy technicians do not remove discontinued medications from the medication carts.

Based on observations, staff interviews, resident records review and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Two nurses and 25 opportunities were observed. Six medication errors were identified, resulting in a 24% medication error rate. The findings included: Review of facility policy titled, Medication Administration, revised 5/3/2022 which states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 11. (b) Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. On 8/2/23 at 8:04 a.m., observed Licensed Practical Nurse (LPN), Staff H, administer seven different scheduled medications to Resident #40. The physician's orders included Cyclobenzaprine HCl Tablet 10 milligrams (mg) one tablet by mouth three times a day related to chronic pain syndrome. LPN Staff H did not administer the Cyclobenzaprine. She said the medication was not available, and she'll have to reorder it. On 8/2/23 at 8:20 a.m., LPN Staff H administering scheduled medications to Resident #55, including Aspiring 325 mg, one tablet; Citalopram Hydrobromide 20 mg, one tablet and Furosemide 20 mg, one tablet. Review of the clinical record revealed orders for Dexamethasone 6 mg tablet once a day for two days for COVID-19, Famotidine tablet 10 mg once a day for indigestion, Labetalol HCl 100 mg tablet, 1 tablet twice a day for hypertension (high blood pressure), Incruse Ellipta 62.5 mcg (micrograms)/ACT inhaler 1 puff once a day for Chronic Obstructive Pulmonary Disease (COPD), and Depakene Solution 250 mg/ml (milliliter) 10 ml 2 times a day for mood disorder. LPN Staff H said the resident returned to the facility the previous afternoon into evening. She said her medications had not been ordered so she was unable to administer all the ordered medications. On 8/3/23 at 10:07 a.m., the Director of Nursing said she would be working with the staff for improvement.

Based on observation, record review, and staff interviews, the facility failed to implement processes to ensure adequate supervision of 1 (Resident #800) of 51 cognitively impaired resident at risk for elopement to prevent unsafe wandering and elopement. The facility also failed to ensure adequate interventions to prevent fall with major injury for 1 (Resident #850) of 3 residents reviewed for falls. Resident #800 was a vulnerable [AGE] year-old female who resided on the secured unit (provides specialized care for people with memory issues) of the facility for increased supervision. On 11/27/22 (unknown time after 3:30 p.m.) Resident #800 who was ambulatory, walked out of the secured unit and the facility without staff knowledge. The resident was found by local law enforcement on 11/27/22 at 10:16 p.m., approximately 2.3 miles from the facility. Resident #800 traveled alone in the afternoon and evening along a busy six lanes highway and crossing busy intersections. Resident #800 was missing and wandering alone for approximately six and a half hours. Resident #800 had a likelihood for serious harm, injury, or death, due to risk for serious injury from a fall, being hit by a car from crossing busy streets with a speed limit of 35 miles per hour, getting lost or becoming the victim of a serious crime. The failure to ensure adequate supervision to protect vulnerable residents from unsafe wandering and elopement resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on 11/27/22. The Administrator was notified of the Immediate Jeopardy of 1/24/23 at 5:18 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. There were 57 other residents the facility identified at risk for elopement. The findings included: Cross reference to F835 and F867. 1. The facility's Elopements and Wandering Residents policy with a date implemented of 11/27/22, and reviewed/revised of 1/11/23 noted, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents and elopement. Staff to confirm doors are secure and no additional individuals exited behind them when exiting secured units. Review of the clinical record revealed Resident #800 was a vulnerable [AGE] year-old female admitted to the secured unit of the facility on 7/29/22. Diagnoses included Dementia, Bipolar disorder (Mood swings ranging from depressive lows to manic highs), and Schizophrenia (Mental health condition that affects how someone thinks, feels and behaves). On 7/29/22, the facility completed and elopement evaluation which noted the resident had a medical diagnosis of dementia and cognitive impairment, a history of wandering in the past three months, but has not had exit seeking behaviors in the past month. The subsequent elopement assessments, dated 9/11/22, and 10/29/22 noted Resident #800 has had exit seeking behaviors in the past month (tailgating, packing belongings, and/or actively exit seeking). The assessments noted the resident was ambulatory. The Admission Minimum Data Set (MDS) assessment with a reference date 8/5/22 noted Resident #800 required supervision with set up assistance to ambulate on the unit. The admission noted the resident's cognition was severely impaired. The care plan initiated on 9/11/22 noted Resident #800 was at risk for elopement/Exit seeking, aimless wandering due to cognition, and had the potential to approach exit doors. The goal was for the resident not leave the facility unattended. The interventions included to monitor the resident for tailgating when visitors are in the building, and for active exit seeking behavior each shift. The care plan did not describe the process to alert staff of visitors on the unit to monitor the resident for tailgating. Review of the progress notes revealed a late entry dated 11/27/22 at 8:36 p.m., noting the attending physician was notified Resident #800 had eloped. Review of the facility's investigation dated 12/13/22 revealed a Certified Nursing Assistant (CNA) last observed Resident #800 on 11/17/22 at approximately 3:30 p.m., to 3:40 p.m., standing in front of her door. On 11/27/22 between 4:45 p.m., and 5:00 p.m., the CNA and the nurse were not able to locate Resident #800 on the unit for dinner or her afternoon medications. The facility activated their elopement policy and procedure, notified the Administrator, the Director of Nursing and local law enforcement. The investigation noted local law enforcement returned the resident to the facility unharmed on 11/27/22 at approximately 10:30 p.m. The resident was dressed in blue jeggings (looks like a pair of skinny jeans), a three quarter length shirt and foot coverings. The investigation did not describe foot covering. Resident #800 had some discomfort in her feet and some edema (swelling). The progress note dated 11/27/22 at 10:45 p.m. noted Resident #800's feet were swollen and pink. The resident had an open area under the ball of her right foot which was not new. On 11/27/22 Registered Nurse Staff Y documented on a statement Resident #800 returned to the facility at approximately 10:30 p.m., escorted by two police officers. The resident was wearing yellow gripper socks. The facility's investigation noted, Based on review of facility visitor log the facility had more than the usual number of visitors on 11/27/22 due to the holiday weekend . Signs were present on the doors to the unit advising staff and visitors to ensure doors were securely shut behind them . As a result of the investigation facility concludes [Resident #800] likely tailgated a visitor off the unit and through the front entrance of the facility . The facility's investigation did not address the lack of adequate supervision to prevent the unsafe wandering and elopement. Review of the visitors' log from 11/20/22 through 11/27/22 did not show documentation of increased visitors on the secured unit. On 11/20/22, and 1/22/22, one visitor was documented on the log for the secured unit. On 11/21/22, and 11/24/22: 12 visitors were documented on the log. On 11/23/22, nine visitors were documented on the log. On 11/27/22, four visitors were documented on the log. The corrective actions noted on the investigation dated 12/13/22 included: The use of a Visitor tag to identify visitors in the facility. Visitors directed to return tag prior to leaving the facility when signing out on visitor's log. Staff was educated not to provide the door codes to visitors. On 1/18/23 at 9:50 a.m., the receptionist said on 11/27/22 he had to leave the facility at 2:00 p.m. and notified the nurse supervisor who instructed him to leave the key fob (opens the door remotely) on the counter at the reception. The receptionist said when he returned an hour later, the reception desk was unattended, and the key fob was on the counter. He said Resident #998 used the key fob to let him back in the building. On 1/23/23 at 1:40 p.m., Resident #998 said he was at the front desk area on 11/27/22 when he saw the receptionist outside. The key fob was unattended on the counter, and he used it to let the receptionist in the building. He said there was no staff attending the front door of the facility when he used the key fob to let the receptionist in. On 1/18/23 at 2:13 p.m., in a telephone interview, former Resident #920 said on 11/27/22 when Resident #800 went missing, he used the key fob left unattended at the reception to let his visitor out. He sat outside for a few minutes and put the key fob back on the desk. He said he did not see the receptionist at any time when he had the key fob or returned it. Resident #920 said it was early evening. On 1/18/23 at 4:32 p.m., in a telephone interview the nurse supervisor said on 11/27/22 the receptionist told her he had to leave. She could not remember the exact time. She told him she would be right up. She said she could not remember telling him to leave the key fob unattended. She sat at the reception for approximately 15 to 20 minutes then left to help a resident. When she came back, the receptionist was already back. He was gone for maybe an hour. On 1/19/23 at 3:40 p.m., the Administrator said as part of the corrective actions, staff was to make sure each visitor is provided a visitor sticker. He said staff was to make sure all visitors sign out before letting them out of the door. The Administrator said Resident #800 tailgated a visitor out of the facility when the front desk was attended. He said Resident #800 did not elope when the key fob was left unattended on the counter hence the implementation of the visitors' stickers, and making sure all visitors sign out to ensure no resident tailgate visitors. Review of the facility's visitor's log with the Administrator from 11/28/22 through 1/19/23 revealed approximately 364 visitors signed in but did not sign out when leaving the facility. The Administrator verified staff did not ensure each visitor signed out of the facility as per their corrective actions. On 1/23/23 at 11:05 a.m., the Nursing Home Administrator (NHA) said, I never counted the number of visitors coming into the building during the investigation to determine if there was an actual increase of visitors. I just reached the conclusion based on the observation of more traffic in the facility that day. 30599 2. Resident #850 was a [AGE] year-old- male admitted to the facility on [DATE] from an acute care hospital. The Admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #850 had no pain and was not receiving any pain medications. The resident required extensive physical assistance of two persons for bed mobility, transfer. The resident was not stable moving from seated to standing position. Resident #850's care plan initiated on 10/24/22 read, At high risk for falls and fall related injury r/t [related to] Difficulty in walking, history of falls, impaired mobility, weakness, A-Fib [Atrial Fibrillation], HTN [Hypertension], Anemia, Alcohol Dependence withdrawal, Wernicke's Encephalopathy (Degenerative brain disorder). The interventions as of 10/24/22 included to ensure the call light was within reach and encourage the resident to use the call light for assistance with standing, transferring and ambulation; Needs a safe environment with even floors free from spills and/or clutter, a working and reachable call light, bed in low position. Upon the initial Therapy evaluation on 10/6/22, Resident #850 complained of pain and was not able to bear weight on his right lower extremity. Resident #850 continued to complain of pain with therapy sessions from 10/6/22 through 10/23/22. On 10/24/22, an X-ray of the right hip showed Resident #850 had a right subcapital (neck) fracture of the femur of indeterminate age. Resident #850 was transferred to the hospital and underwent a surgical repair of the fracture. Review of the facility's incident reports revealed on 11/14/22 at 4:20 a.m., Nurse walked by room and noted the resident [Resident #850] on the floor on the right back at the foot of residents[sic] bed in room [Room #]. The room had adequate lighting but there was liquid on the floor and the resident's brief was on the floor near resident. Resident was able to move extremities, but later began to c/o [complain of] increased pain to right hip. Resident states desire to go to hospital. Dr. notified Resident unable to give description. The incident report documented Resident #850 was alert and oriented to person, place, and time. Predisposing factors to the fall was documented as Wet floor. Predisposing Physiological Factors were documented as, Incontinent and Recent change in condition. Predisposing Situation Factors were documented as, Ambulating without assistance. On 1/20/23 at 1:10 p.m., Resident #850 was observed in his room. The resident was hard of hearing. All questions had to be written on a note pad. Resident #850 read the questions out loud and answered. Resident #850 verified he fell on ce since his admission. He said he was trying to get up to go to the bathroom when he fell . The resident said the call light was too far, he could not reach it to call for assistance. On 1/20/23 at approximately 2:00 p.m., the Director of Nursing (DON) said the interdisciplinary team determined the root cause of Resident #850's fall was he did not use his call light. The DON said other than the progress notes and the communication form he had no other documentation pertaining to an investigation of the resident's fall. The DON verified he had no documentation to show the resident's call light was within reach at the time of the fall. Resident #850 was admitted to the hospital on 11/14/22 and underwent a second surgery to his right hip. The Orthopedic Surgeon Documented on 11/15/22, . [AGE] year-old, Caucasian male recently had surgery for a femoral neck fracture with myself. He did well in the immediate postoperative period; however, he fell at his assisted living facility and sustained a periprosthetic fracture immediately below my hip replacement . I recommended removing the loose arthroplasty [joint replacement], which was now loose after the fracture .

Based on record review, review of the facility's policies and procedures, resident, and staff interviews the facility failed to monitor and evaluate the effectiveness of corrective actions implemented related to adequate supervision of cognitively impaired residents at risk for elopement and exit seeking behaviors. Resident #800 was a vulnerable [AGE] year-old female who resided on the secured unit (provides specialized care for people with memory issues) of the facility for increased supervision. On 11/27/22 (unknown time after 3:30 p.m.) Resident #800 who was ambulatory, walked out of the secured unit and the facility without staff knowledge. The resident was found by local law enforcement on 11/27/22 at 10:16 p.m., approximately 2.3 miles from the facility. Resident #800 traveled alone in the afternoon and evening along a busy six lanes highway and crossing busy intersections. Resident #800 was missing and wandering alone for approximately six and a half hours. Resident #800 had a likelihood for serious harm, injury, or death, due to risk for serious injury from a fall, being hit by a car from crossing busy streets with a speed limit of 35 miles per hour, getting lost or becoming the victim of a serious crime. On 11/28/22 the facility developed a performance improvement plan with action steps to prevent further unsafe wandering and elopement of residents identified at risk for elopement with exit seeking behavior. The facility failed to fully implement and monitor the corrective actions to determine the effectiveness of the process implemented to prevent further unsafe wandering and elopements. The failure to have an effective Quality Assurance and Performance Improvement (QAPI) program resulted in a determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 11/27/22. The Administrator was notified of the Immediate Jeopardy on 1/24/23 at 5:18 p.m. and provided the IJ templates. There were 57 other residents the facility identified at risk for elopement. The findings included: Cross reference to F689 and F835. The facility's 2022 Quality Assurance & Performance Improvement (QAPI) Plan stated: The QAPI plan . is designed to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility. Address gaps in systems or processes . Establish clear expectations around safety, quality, rights, choice and respect. Systematic Analysis and Systemic Action. The QAA (Quality Assessment and Assurance) Committee monitors progress to ensure that interventions or actions are implemented and effective in making and sustaining improvements . The facility's Quality Assurance and Performance Improvement (QAPI) policy (no implementation date) stated, Program Systematic Analysis and Systemic Action. The facility takes actions aimed at performance improvement as documented in QAA committee meeting minutes and action plans. Performance/success of the actions will be monitored and documented in subsequent QAA Committee or sub-committee meetings . The facility's Administrator job description signed on 6/20/22 noted the Administrator is responsible for the QA (Quality Assurance) program. Review of the facility's incidents, and investigations revealed on 11/27/22 sometimes after 3:30 p.m., to 3:40 p.m., Resident #800 who was cognitively impaired, and ambulatory walked out of the secured unit and the facility without staff knowledge. The resident was found by local law enforcement on 11/27/22 at 10:16 p.m. Resident #800 was 2.3 miles from the facility and traveled alone in the afternoon and evening along a busy six lanes highway and crossed busy intersections. The facility completed an investigation and determined Resident #800 tailgated a visitor through the front door on 11/27/22 due to an increased number of visitors during the holiday weekend. On 11/28/22 the Quality Assurance and Performance Improvement (QAPI) team, including the Director of Nursing, and Administrator participated in an ad hoc (unplanned) meeting to discuss Resident #800's elopement. The QAPI team developed a plan that included to assure residents safety with focused areas to include residents at risk for elopement. The action steps included initiation and continued staff education on elopement policy and drills. New process implemented for visitors to be provided visitor name tag. On 1/18/23 at 9:50 a.m., the receptionist said on 11/27/22 he had to leave the facility at 2:00 p.m. and notified the nurse supervisor who instructed him to leave the key fob (opens the door remotely) on the counter at the reception. The receptionist said when he returned an hour later, the reception desk was unattended, and the key fob was on the counter. He said Resident #998 used the key fob to let him back in the building. On 1/18/23 at 2:13 p.m., in a telephone interview, former Resident #920 said on 11/27/22 when Resident #800 went missing, he used the key fob left unattended at the reception to let his visitor out. He sat outside for a few minutes and put the key fob back on the desk. He said he did not see the receptionist at any time when he had the key fob or returned it. Resident #920 said it was early evening. On 1/18/23 at 4:32 p.m., in a telephone interview the nurse supervisor said on 11/27/22 the receptionist told her he had to leave. She could not remember the exact time. She told him she would be right up. She said she could not remember telling him to leave the key fob unattended. She sat at the reception for approximately 15 to 20 minutes then left to help a resident. When she came back, the receptionist was already back. He was gone for maybe an hour. On 1/19/23 at 2:00 p.m., the Assistant Director of Nursing said she was responsible to ensure all staff were educated on the corrective actions after Resident #800's elopement. She provided 20 in-service education sign-in sheets from 11/28/22 through 1/16/23. Two of the 20 sign-in sheets dated 12/8/22 did not document a topic for the in-service. One of the in-service education sheets only noted the participants were educated on Abuse, Neglect, and exploitation. Six of the sign-in sheets noted the topic was elopement policy/drills/abuse and neglect/Door codes not to be given to visitors. The in-services did not address the new process implemented for visitors to be provided with visitor name tag and ensure visitors sign-in and out. The Assistant Director of Nursing (ADON) said the facility utilizes agency nurses and Certified Nursing Assistants (CNAs). She said she educated the agency staff on the new process during the general orientation but did not document. On 1/19/23 at 3:40 p.m., during a review of the QAPI program, the Administrator said as part of the corrective actions, staff was to make sure each visitor is provided a visitor sticker. He said staff was to make sure all visitors sign out before letting them out of the door. The Administrator said Resident #800 tailgated a visitor out of the facility when the front desk was attended. He said Resident #800 did not elope when the key fob was left unattended on the counter hence the implementation of the visitors' stickers, and making sure all visitors sign out to ensure no resident tailgate visitors. Review of the facility's visitor's log with the Administrator from 11/28/22 through 1/19/23 revealed approximately 364 visitors signed in but did not sign out when leaving the facility. The Administrator verified staff did not ensure each visitor signed out of the facility as per their corrective actions. On 1/19/23 at 3:00 p.m., review of the visitors' log from 11/20/22 through 11/27/22 did not show documentation of increased visitors on the secured unit. On 11/20/22, and 1/22/22, one visitor was documented on the log for the secured unit. On 11/21/22, and 11/24/22: 12 visitors were documented on the log. On 11/23/22, nine visitors were documented on the log. On 11/27/22, four visitors were documented on the log. The Administrator said the QAPI team met again on 12/21/22 to discuss the results of audits and corrective actions. He could not provide documentation of tracking and evaluation of interventions implemented to determine if corrective actions were successful to prevent further unsafe wandering and elopement. There was no audit of the visitor's log to ensure staff followed the process to prevent the unsafe wandering of the facility for residents at risk for elopement and exit seeking. The Administrator said, We have had no other elopement. If you're asking if our plan has worked, no one had gotten out. On 1/19/23 at 5:10 p.m., the Regional Director of operations said the facility did not have an analysis of the information collected from the audits to determine if the process in place had achieved 100 % compliance. On 1/23/23 at 11:05 a.m., the Administrator said he determined Resident #800 tailgated a visitor out of the facility due to the increased number of visitors during the holiday weekend. He said, I never counted the number of visitors coming into the building during the investigation to determine if there was an actual increase of visitors. I just reached the conclusion based on the observation of more traffic in the facility that day.

Based on review of the facility's policies and procedures, record review and staff interview, the facility failed to implement their policy and honor the resident's right to receive cardiopulmonary resuscitation (CPR) in the event of cardiac and/or respiratory arrest for 1 (Resident #1) of 3 residents reviewed for care at the end of life. On [DATE] shortly after midnight, Resident #1 was found without a pulse or respiration. The facility failed to initiate CPR despite the resident's Power of Attorney directive to do everything that can be done. Resuscitation efforts, if successful, may have prolonged Resident #1's life. On [DATE] at 3:40 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. Cross reference: F678 and F835. The findings included: The facility's policy regarding Treatment and Advance Directives, revised ,d+[DATE] noted, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Closed record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of schizophrenia, dementia, coronary artery disease, emphysema, and atrial fibrillation. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 0 which meant Resident #1 was rarely/never understood. A valid Power of Attorney (POA) for healthcare decision was executed appointing Resident #1's sister as the POA on [DATE]. On [DATE] in a discussion with the facility social worker, the POA stated, Do everything that can be done, meaning full code status (initiate cardiopulmonary resuscitation (CPR) in the event of cardiac and/or respiratory arrest). Closed record review revealed a physician's order for full code was written on [DATE] and a care plan initiated on [DATE] which noted Resident #1 had an established CPR (Full code) order in place. Closed record review revealed on [DATE], a little after 12:00 a.m., Certified Nursing Assistant (CNA) Staff C entered Resident #1's room and he did not seem to be breathing. The CNA asked Licensed Practical Nurse (LPN) Staff A to come to his room. LPN Staff A nurse entered the room, checked pulse and respirations, and determined Resident #1 was not breathing and did not have a pulse. This occurred at 12:20 a.m. LPN Staff A exited the room and returned to the nursing station. She did not check for code status, start CPR or call [DATE]. LPN Staff A asked LPN Staff B to contact the physician and family to let them know the resident had expired. Review of the facility investigation revealed a witness statement from LPN Staff A dated [DATE] noting: Resident expired after midnight. During rounds I found the resident to be deceased . He still had the oxygen on, but he was not breathing there was no pulse . Once I saw he was deceased , I came to the desk at the nurse's station and notified the family and the MD (Physician). I didn't check to see that he was a full code. I didn't initiate CPR. The resident was mottled (patchy, irregular colors), and his extremities were cold, but his body was warm. I made a mistake. On [DATE] at 9:30 a.m., the Administrator and Director of Nursing (DON) confirmed LPN Staff A did not follow Resident #1's Power of Attorney's expressed advance directive for a full code and did not initiate CPR. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after verification of an acceptable removal plan, and the scope and severity reduced to D (No actual harm with potential for more than minimal harm that is not immediate jeopardy). The removal plan submitted by the facility and verified by the survey team included: [DATE] - The Licensed Nurse who did not perform CPR on the full code status resident was suspended pending investigation. The DON or designee initiated education with the licensed nurses on the facility's policy and procedure for responding to a medical emergency, validating code status, resident rights regarding advanced directives, and abuse and neglect. By end of day, education was completed with 23 of 65 facility licensed nurses and CNAs (35% completion). An ad hoc (unplanned) QAPI (Quality Assurance Performance Improvement) Committee meeting was held with the Medical Director in attendance. Root Cause Analysis was performed. A Performance Improvement Project (PIP) was implemented. DON/designee conducted a quality review of residents who coded in the last 6 months to ensure advanced directives were followed as ordered by the physician. In addition to Resident #1, 2 of 19 residents reviewed were full code, CPR was performed, and emergency medical personnel was contacted. The DON or designee initiated quality review of advanced directive orders for current residents residing in the facility. Physician orders for advance directives were confirmed present. For residents with DNR (Do Not Resuscitate) orders in place, the Florida DNR form was confirmed to be present in the medical records and care plans related to advanced directives were reviewed/updated accordingly. HR (Human Resources) or designee initiated audit of licensed nurses' CPR certification. DON or designee conducted Code Blue drills with licensed nursing staff. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. By end of day, 21 of 65 licensed nursing staff participated in drills (33% completion). [DATE] - Employment terminated with licensed nurse who did not initiate CPR on the full code resident (Resident #1). Nurse license reported to Florida Department of Health. HR or designee completed audit of licensed nurses' CPR certification. CPR certification current for 19 of 19 licensed nurses consisting of 8 RNs (Registered Nurses) and 11 LPNs (100% validated). The DON or designee initiated education with licensed nurses on the facility's policy and procedure for responding to a medical emergency, validating code status, resident rights regarding advanced directives, and abuse and neglect. By end of day, education completed with 64 of 65 facility licensed nurses and CNAs (98% completion). 1 CNA not yet educated will not be permitted to work until education has been received. Any new hires will receive education prior to providing resident care. The DON or designee completed the quality review of advanced directive orders for current residents residing in the facility. Physician orders for advance directive were confirmed present. For residents with DNR orders in place, the Florida DNR form was confirmed to be present in the medical records. Care plans related to advanced directives were reviewed/updated accordingly. DON or designee conducted Code Blue drills with licensed nursing staff. By end of day, 47 of 65 licensed nursing staff had successfully participated in Code Blue drills (72% completion). Licensed nursing staff will not be permitted to provide direct care to residents until he/she has participated in a code blue drill and has shown competency in implementing the emergency medical response policy. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. Ongoing monitoring to ensure compliant practice remains in place: DON or designee to conduct Code Blue drills weekly on each shift for four weeks, then 2 times monthly on each shift for 2 months to ensure licensed nursing staff respond as per federal regulation and facility policy and procedure. DON or designee to conduct competencies with 10 licensed nursing staff weekly for 3 months regarding following advanced directives and responding to medical emergencies to include identifying when CPR should be performed, and emergency medical personnel contacted. Findings will be reported at monthly QAPI committee meeting. Findings will be reported to QAPI committee monthly. Ongoing quality review schedule may be modified based on findings to ensure compliance practice remains in place.

Based on staff interview and clinical record review, the facility failed to provide cardiopulmonary resuscitation (CPR) in accordance with the resident's documented wishes and physician's order for 1 (Resident #1) of 3 sampled residents reviewed for emergency care. Resident #1 had a full code status effective [DATE]. On [DATE] shortly after midnight, the resident was unresponsive and had no pulse or respiration. The staff nurse on duty did not perform CPR or call [DATE]. Resident #1 expired at the facility without receiving CPR as per expressed wishes and physician's order. The facility's failure to initiate CPR in accordance with the resident's expressed wishes and physician's order resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on [DATE]. On [DATE] at 3:40 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after implementation of an acceptable removal plan was verified, and the scope and severity was reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). There were 59 residents with full code status at the time of the event. Cross reference: F578 and F835. The findings included: A Center for Clinical Standards and Quality/Survey & Certification (S&C) letter on Cardiopulmonary Resuscitation (CPR) in Nursing Home: ,d+[DATE]-NH, revised [DATE] includes the following: The American Heart Association (AHA) has established evidenced-based decision-making guidelines for initiating CPR when cardiac arrest occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place. 2) obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. Facility policy should specifically direct staff to initiate CPR when cardiac arrest occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines. Review of the facility policy Medical Emergency Response revised ,d+[DATE] noted, The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 0 which meant Resident #1 was rarely/never understood and had severe cognitive impairment. A valid Power of Attorney (POA) for healthcare decision was executed appointing Resident #1's sister as the POA on [DATE]. On [DATE] in a discussion with the facility social worker, the POA stated, Do everything that can be done meaning full code Status. Closed record review revealed a physician's order for full code was written on [DATE]. A care plan noting Resident #1 has an established CPR (full code) order in place was initiated on [DATE]. Closed record review revealed on [DATE], a little after 12:00 a.m., Certified Nursing Assistant (CNA) Staff C entered Resident #1's room and he did not seem to be breathing. The CNA asked LPN Staff A to come to the resident's room. LPN Staff A nurse entered the room, checked pulse and respirations, and determined Resident #1 was not breathing and did not have a pulse. This occurred at 12:20 a.m. LPN Staff A exited the room and returned to the nursing station. She did not check for code status, did not start CPR, and did not call [DATE]. LPN Staff A asked LPN Staff B to contact the physician and family to let them know the resident had expired. Review of the facility investigation revealed a witness statement from LPN Staff A dated [DATE] noting: Resident expired after midnight. During rounds I found the resident to be deceased . He still had the oxygen on, but he was not breathing there was no pulse . Once I saw he was deceased , I came to the desk at the nurse's station and notified the family and the MD (Physician). I didn't check to see that he was a full code. I didn't initiate CPR. The resident was mottled (patchy, irregular colors), and his extremities were cold, but his body was warm. I made a mistake. Review of the facility generated report submitted to the Florida Agency for Healthcare Administration on [DATE] noted Resident #1 was a long-term resident admitted to the facility on [DATE]. On [DATE] staff nurse observed Resident #1 unresponsive and without a pulse. The nurse did not verify the code status and CPR was not initiated. The facility completed a thorough investigation including, but not limited to resident interviews, staff interviews and medical record review. The facility substantiated the allegation of neglect and noted in the conclusion based on the facility investigative findings, it had been validated that the LPN did not initiate CPR when Resident #1 was observed without a pulse or respiration on [DATE]. The resident's care plan and physician orders for advanced directives were not followed. On [DATE] at 9:30 a.m., in an interview with the Administrator and Director of Nursing (DON), they confirmed LPN Staff A did not follow Resident #1's Power of Attorney's expressed advance directive for a full code and did not initiate CPR. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after verification of an acceptable removal plan, and the scope and severity reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). The removal plan submitted by the facility and verified by the survey team included: [DATE] - The Licensed Nurse who did not perform CPR on the full code status resident (Resident #1) was suspended pending investigation. The DON or designee initiated education with the licensed nurses on the facility's policy and procedure for responding to a medical emergency, validating code status, resident rights regarding advanced directives, and abuse and neglect. By end of day, education was completed with 23 of 65 facility licensed nurses and CNAs (35% completion). An ad hoc (unplanned) QAPI (Quality Assurance Performance Improvement) Committee meeting was held with the Medical Director in attendance. Root Cause Analysis was performed. A Performance Improvement Project (PIP) was implemented. DON/designee conducted a quality review of residents who coded in the last 6 months to ensure advanced directives were followed as ordered by the physician. In addition to Resident #1, 2 of 19 residents reviewed were full codes and CPR was performed and emergency medical personnel was contacted. The DON or designee initiated quality review of advanced directive orders for current residents residing in the facility. Physician orders for advance directives were confirmed present. For residents with DNR (Do Not Resuscitate) orders in place, the Florida DNR form was confirmed to be present in the medical records and care plans related to advanced directives were reviewed/updated accordingly. HR (Human Resources) or designee initiated audit of licensed nurses' CPR certification. DON or designee conducted Code Blue drills with licensed nursing staff. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. By end of day, 21 of 65 licensed nursing staff participated in drills (33% completion). [DATE] - Employment terminated with licensed nurse who did not initiate CPR on the full code resident (Resident #1). Nurse license reported to Florida Department of Health. HR or designee completed audit of licensed nurses' CPR certification. CPR certification current for 19 of 19 licensed nurses consisting of 8 RNs (Registered Nurses) and 11 LPNs (100% validated). The DON or designee initiated education with licensed nurses on the facility's policy and procedure for responding to a medical emergency, validating code status, resident rights regarding advanced directives, and abuse and neglect. By end of day, education was completed with 64 of 65 facility licensed nurses and CNAs (98% completion). 1 CNA not yet educated will not be permitted to work until education has been received. Any new hires will receive education prior providing resident care. The DON or designee completed the quality review of advanced directive orders for current residents residing in the facility. Physician orders for advance directive were confirmed present. For residents with DNR orders in place, the Florida DNR form was confirmed to be present in the medical records. Care plans related to advanced directives were reviewed/updated accordingly. DON or designee conducted Code Blue drills with licensed nursing staff. By end of day, 47 of 65 licensed nursing staff had successfully participated in Code Blue drills (72% completion). Licensed nursing staff will not be permitted to provide direct care to residents until he/she has participated in a code blue drill and has shown competency in implementing the emergency medical response policy. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. Ongoing monitoring to ensure compliant practice remains in place: DON or designee to conduct Code Blue drills weekly on each shift for four weeks, then 2 times monthly on each shift for 2 months to ensure licensed nursing staff respond as per federal regulation and facility policy and procedure. DON or designee to conduct competencies with 10 licensed nursing staff weekly for 3 months regarding following advanced directives and responding to medical emergencies to include identifying when CPR should be performed, and emergency medical personnel contacted. Findings will be reported to QAPI committee monthly. Findings will be reported at monthly QAPI committee meeting. Ongoing quality review schedule may be modified based on findings to ensure compliance practice remains in place.

Based on record review and staff interview, the facility administration failed to utilize its resources effectively to ensure licensed staff were competent to perform emergency response and provide life saving measures, including cardiopulmonary resuscitation for residents requiring such emergency care. This has the potential to negatively impact all 59 residents in the facility who may require emergency services. Resident #1 had a full code status effective [DATE]. On [DATE] shortly after midnight, the resident was unresponsive and had no pulse or respiration. The staff nurse on duty did not perform CPR or call [DATE]. Resident #1 expired at the facility without receiving CPR as per expressed wishes and physician's order. The failure of the facility's administration to ensure staff training and competency for emergency response resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on [DATE] when the licensed nurse failed to initiate CPR when Resident #1, who had a full code status, was found without a pulse or respiration. On [DATE] at 3:40 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after implementation of an acceptable removal plan was verified, and the scope and severity reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). Cross reference: F578 and F678. The findings included: The Administrator's job description which he signed on [DATE] revealed, Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents. The Director of Nursing's job description which she signed on [DATE] included, To manage the overall operations of the Nursing Department in accordance with company policies, standards of nursing practices and governmental regulations to maintain excellent care of all residents' needs. Review of the facility policy Residents' Rights Regarding Treatment and Advance Directives revised ,d+[DATE] noted, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Review of the Medical Emergency Response revised ,d+[DATE] noted, The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate . Review of the closed clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of schizophrenia, dementia, atrial fibrillation, emphysema, and coronary heart disease. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 0 which meant Resident #1 was rarely/never understood. A valid Power of Attorney (POA) for healthcare decision was executed appointing Resident #1's sister as the POA on [DATE]. On [DATE] in a discussion with the facility social worker, the POA stated, Do everything that can be done meaning full code Status. Closed record review revealed a physician's order for full code was written on [DATE] and a care plan noting Resident #1 had an established CPR (full code) order was initiated on [DATE]. Review of the closed clinical record revealed on [DATE], shortly after midnight, Resident #1 was unresponsive and had no pulse or respiration. Resident #1 expired at the facility without receiving CPR as per expressed wishes and physician's order. Licensed Practical Nurse (LPN) Staff A, the staff nurse on duty, did not perform CPR or call [DATE]. LPN Staff A asked LPN Staff B to contact the physician and family to let them know the resident had expired. Review of the facility investigation revealed a witness statement from LPN Staff A dated [DATE] noting she did not check the code status and did not initiate CPR. LPN Staff A documented in the statement, I made a mistake . Closed record review revealed no evidence LPN Staff A had been assessed for competency in medical emergency response or trained in resident's rights regarding treatment and advance directives. On [DATE] at 9:30 a.m., the Administrator and Director of Nursing confirmed LPN Staff A did not follow Resident #1's expressed advance directive for a full code and did not initiate CPR. On [DATE] at 2:10 p.m., the Director of Clinical Services provided documentation of training dated [DATE] to 17 licensed nurses. The training consisted of a 25-page presentation with two lines that included the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. The Director of Clinical Services also provided proof of training related to residents' rights dated [DATE] for LPN Staff B. She said the facility did not have documentation of assessment of clinical competencies for all 19 licensed nurses related to emergency response. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after verification of an acceptable removal plan, and the scope and severity reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). The removal plan submitted by the facility and verified by the survey team included: By [DATE], the facility DON or designee conducted Code Blue drills with licensed nursing staff to include 4 CNAs who had not yet participated in a code blue drill and prior to providing direct patient care. By the end of day, 51 of 65 licensed nursing staff had participated in Code Blue drills (78% completion). Licensed nursing staff will not be permitted to provide direct care to residents until he/she has participated in a code blue drill and has shown competency in implementing the emergency medical response policy. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. Ongoing monitoring to ensure compliant practice remains in place: DON or designee to conduct Code Blue drills weekly on each shift for four weeks, then 2 times monthly on each shift for 2 months to ensure licensed nursing staff respond as per federal regulation and facility policy and procedure. DON or designee to conduct competencies with 10 licensed nursing staff weekly for 3 months regarding following advanced directives and responding to medical emergencies to include identifying when CPR should be performed, and emergency medical personnel contacted. Regional Operations and/or Clinical Consultants to review education and competencies on emergency medical response policy and advanced directives that has been completed with facility staff to include newly hired licensed nurses and CNAs every other week for 4 weeks, then a minimum of monthly to ensure administration is effective in ensuring staff implement their emergency response policy. Chart reviews will be conducted by the DON/designee within 24 hours of a resident coding within the facility to verify the emergency response policy was implemented and advanced directives followed as per their wishes. Findings will be presented to QAPI (Quality Assurance and Performance Improvement) committee monthly. Ongoing quality review schedule may be modified based on findings to ensure to ensure compliance practice remains in place.

Based on record review, staff and family members interview, the facility failed to protect vulnerable residents' rights to be free from abuse. The facility failed to adequately supervise 1 (Resident #29) of 1 sampled resident with known behaviors with a likelihood to result in physical and sexual abuse. On 6/2/21 in the evening, a Certified Nursing Assistant (CNA) reported witnessing Resident #29 having inappropriate sexual contact with his roommate, Resident #11. The facility allowed the perpetrator (Resident #29) to remain in the same room with the alleged victim (Resident #11) until the evening of 6/7/21. Resident #29 was allowed to wander about the facility unsupervised and exposed his penis to Resident #68. Resident #29 also attempted to enter Resident #62's room, verbalizing the desire to commit a sexual act toward Resident #62. The facility failure to follow their policy and procedure and protect residents after an allegation of inappropriate sexual contact placed Resident #11 and other vulnerable residents at risk for further abuse. Residents #11, #62, and #68 have severe cognitive impairment and could not consent to sexual activities. Applying the reasonable person concept, Resident #11 would likely suffer serious psychosocial harm, not yet realized, because he was not able to consent to sexual activity which diminished his self-worth and self-respect. Survivors of sexual abuse may develop depression, anxiety, post-traumatic stress, personality disruptions, attachment issues and addiction. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. The Administrator was notified of the Immediate Jeopardy on 8/6/21 at 7:27 p.m. and provided the IJ templates. The findings included: Cross Reference to F607, F609, F610 and F835. The Facility's Abuse, Neglect, and Exploitation policy and procedure with a reviewed/revised date of 7/14/21, defines Sexual Abuse as non-consensual sexual contact of any type with a resident. An immediate investigation is warranted when suspicion or reports of abuse, neglect or exploitation occur. Under section VI. Protection of Resident- the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; and room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator. In an interview on 8/3/21 at 9:30 a.m., Resident #11's spouse said she was informed a couple of months ago a CNA found her husband's roommate (Resident #29) to have his hands down her husband's pants. She said they told her his roommate was moved out of his room into another room and the facility was going to investigate the incident. On 8/4/21, the facility's abuse investigation and federal immediate report was reviewed. The facility reported on 6/8/21 during the evening after dinner (no date) CNA Staff O saw Resident #29 at the foot of his roommate's bed (Resident #11). The CNA observed resident #29 with his hand in the top part resident #11's brief. CNA Staff O's written statement dated 6/8/21 was reviewed. The CNA noted at approximately 9:35 p.m. (no date), he observed Resident #29 in the dining room facing Resident #68. He heard Resident #68 say put it away. At that time, he observed Resident #29 had his penis out and said to Resident #29, You want it and Resident #68 began to curse at Resident #29. He then took Resident #29 to the unit and informed the nurse of his observation. CNA Staff O noted there was another incident that occurred before the weekend during the evening, after dinner. He saw Resident #29 in his room with his hand inside of Resident #11's brief. His statement noted he informed Registered Nurse (RN) Staff S at the time of the incident. In an interview on 8/5/21 at 2:36 p.m., CNA Staff O said there were 2 incidents involving Resident #29. The first was when he found him at the bedside of roommate Resident #11 with his hands down the front of Resident #11's brief. The next incident occurred about a week later when he came through the dining room and Resident #29 was exposing his penis to Resident #68. Right after this incident, Resident #29 was moved out of the room he shared with resident #11 into a different room. The CNA said he notified RN Staff S after the first incident. The facility's staffing schedule was reviewed and indicated both RN Staff S and CNA Staff O were working on the evening of 6/2/21. Resident #29's clinical record review revealed he is a cognitively impaired [AGE] year-old male with an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29's most recent comprehensive annual assessment, dated 3/8/21, revealed no coding for behaviors or wandering. His most recent quarterly assessment, dated 6/8/21, revealed no coding for behaviors or wandering. The quarterly assessment coded Resident #29 as requiring supervision for locomotion on unit. The care plan initiated on 4/20/20 noted Resident #29 had episodes of asking for sexual favors and/or making sexual inappropriate comments to other residents, verbal aggression, taunting. The interventions included to redirect resident gently but firmly from unacceptable behaviors (sexual inappropriate comments). The clinical record lacked documentation the care plan was updated to include additional supervision for Resident #29 on 6/3/21. In a progress note the Advanced Practice Registered Nurse(APRN) noted on 6/3/21 at 10:13 a.m., staff requested she evaluate Resident #29's sexually inappropriate behavior. Staff reported Resident #29 had been approaching men in the building (staff and residents) and requesting sexual favors. He was redirected by staff when this behavior occurred; He just laughed and left the situation. On 6/3/21 at 10:44 a.m., the facility's Social Services Director (SSD) noted, today Resident #29's representative was informed about this resident's sexually inappropriate behavior. On 6/8/21 at 6:40 a.m., Licensed Practical Nurse (LPN) Staff G noted Resident #29 entered Resident #62's room during care. The CNA asked Resident #29 to leave the room and the resident responded No. The CNA asked the resident why is he going into Resident #62's room, and he responded, I wanna [sic] chew his balls off . Resident #29 was observed previously at 5:24 a.m., and 6:01 a.m., attempting to enter Resident #62's room. Resident #11's clinical record review revealed a [AGE] year-old male with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's most recent quarterly Minimum Data Set (MDS) assessment, dated 5/4/21 revealed the resident was severely cognitively impaired. The resident was coded for rejection of care 1 to 3 days per week during the assessment period. There were no other behaviors noted. Resident #11 activities of daily living assistance ranged from extensive assistance to total dependence. There was no documentation Resident #11 was examined for evidence of physical or psychological harm until 6/8/21, 6 days after Resident #29 was observed with his hands down his pants. Resident #11 was not interviewable. On 8/6/21 at 5:15 p.m., in a second interview Resident #11's wife stated her husband would feel violated if he was able to express how he felt about the incident with Resident #29. Resident #68's clinical record review revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62's clinical record review revealed he is a [AGE] year-old male with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was noted to be unable to state or express needs. Resident #62 was observed to be in a private room and in bed all days of survey. The resident was non-responsive to attempts to be interviewed on 8/2/21. In an interview on 8/5/21 at 1:29 p.m., the Director of Nursing (DON) said there was no report of the incident involving Resident #29 inappropriately touching Resident #11, and she was not aware this had occurred until the morning of 6/8/21. The Administrator at the time had directed staff to move the resident to a different room on the night of 6/7/21. Resident #29 was sent out to the hospital that morning and one to one supervision (1:1) was started upon his return. In an interview on 8/5/21 at 3:49 p.m., the Administrator said he started employment at the facility on 6/25/21 and was not here at time of incident. He revealed the facility did not follow its abuse policy and did not protect Resident #11 from further abuse by allowing the alleged perpetrator to continue to share a room for 5 days. Facility documentation review revealed the APRN, and SSD were also aware of the inappropriate sexual contact on 6/3/21 but no indication of any action taken to prevent Resident #29 from having further contact with Resident #11. On 6/7/21, Resident #29 was relocated to a different room, but several entries were made by LPN Staff G of resident being seen trying to enter the room of another vulnerable resident's (#62) room. There was no evidence of the resident being on a 1:1 supervision during this time. The Administrator said he would look to see if there was any documentation of this being done. On 8/6/21 at 10:38 a.m., in an interview the APRN said on 6/3/21 a nurse notified her about the episodes with Resident #29 and Resident #11. She was told staff walked into their shared room to give care to Resident #11, Resident #29 had his hand inside of Resident #11's brief. She said Resident #29 was very mobile in his wheelchair and all over the facility. The APRN said she thought the episode may have happened the day before, on 6/2/21. She did not realize Resident #29 was still in the room with Resident #11 as she usually saw him outside of the room. On 8/6/21 at 12:27 p.m., in an interview the SSD said the nursing team informed her someone had seen Resident #29 with his hand in Resident #11's brief. She wrote the note on 6/3/21 after she heard of it. The SSD said they also discussed it in morning meeting and were putting Resident #29 on one-to-one supervision. All the department heads including the Administrator were in the meeting. She notified Resident #29's family. The SSD said they talked about a room change, and the 1:1 supervision was to be 24 hours a day. She was told about the incident involving Resident #68 and talked to him about it on 6/8/21. She said Resident #68 was offended by the incident and said Resident #29 was nasty. The SSD could not explain how the incident occurred if Resident #29 was on one-to-one supervision. On 8/6/21 at 12:50 p.m., in an interview the Administrator said he was unable to provide any evidence of one-to-one supervision for Resident #29 from 6/3/21 to 6/8/21 and upon his return from the hospital from 6/10/21 to 6/12/21. The facility provided evidence of some monitoring for the evening of 6/12/21 but lacked consistent documentation for the evening and night shifts when Resident #29 was more likely to exhibit these behaviors. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team, included the following: On 6/7/21 Resident #29 was placed in a room by himself. On 6/8/21 Resident #29 was placed on one-to-one supervision and Baker Act initiated. On 6/8/21 the facility initiated a thorough investigation, interviewed all interview able residents for any concern regarding any unwanted sexual advances. On 6/8/21 a full skin assessment was completed on Resident #11. On 6/8/21 Resident #11 was assessed by the APRN, no evidence of injuries noted. On 6/8/21 interview with Resident #68 was conducted. Resident showed no fear or anxiety towards interviewer. Mood unchanged and thorough investigation conducted. Interviewed all interviewable residents for any concerns regarding any unwanted sexual advances. No concerns noted. On 6/10/21 Resident #29 returned to the facility and was placed on every 30 minutes monitoring and placed in a private room. On 6/12/21 Resident #29 was placed on one-to-one supervision. On 7/14/21 The Abuse, Neglect and Exploitation / Reporting Alleged Violations policies were reviewed during Monthly Quality Assurance and Performance Improvement (QAPI) meeting. On 7/22/21 Resident #29 moved to a different room related to positive cases in the building and remained on one-to-one monitoring. On 8/5/21 Resident #29 was placed in a room by himself and placed on one-to-one supervision. On 8/7/21 Residents #29, #11 and #68 were evaluated by psychiatry services. The psychiatrist conducted a psychological evaluation of Resident #29 and medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . No concerns noted for Resident #11 and #68. The Interdisciplinary Team (IDT) reviewed and revised Resident #29's care plan to better identify patterns in resident's behavior and implement interventions. Care Plan revisions and interventions communicated to front line staff caring for resident. On 8/7/21 The Interdisciplinary Team reviewed residents with behaviors that could result in any abuse behaviors. They were identified and care plans personalized to reflect residents' preferences and the Kardex updated to assist with redirection to prevent other residents from suffering further physical abuse, sexual abuse, or any type of abuse. On 8/6/21, Federal Immediate report for abuse was filed to the Agency for Resident #11, Adult Protective Services was notified. On 8/6/21, a facility investigation was initiated by the Administrator in conjunction with the Director of Nurses. The IDT team has concluded the root cause analysis of this concern was lack of education related to identifying abuse, neglect policy and procedures including compliance with reporting allegations of Abuse/Neglect/Exploitation. On 8/6/21, the facility initiated a Quality Monitor audit review for current residents residing in the facility with a Brief Interview of Mental Status (BIMS) of 9 or above, interviewing and assessing for potential abuse. On 8/6/21, the facility initiated a Quality Monitor audit to review non-interview able residents by interviewing staff and resident families. The Administrator, DON, designee will complete a Quality Monitor to identify any resident with sexual behaviors with likelihood to result in physical and sexual abuse. On 8/6/21 and 8/7/2021 re-education initiated for Facility Staff by Administrator, DON, and Designee on: Abuse, neglect, exploitation with emphasis on abuse prevention and reporting investigation. In the event of any future resident-to-resident sexual abuse, the perpetrating resident will immediately be placed on one-to-one supervision until physician, and psych evaluation can be completed and reviewed by IDT. Outcomes of these evaluations will result in one-to-one supervision or the initiation of discharge planning to a facility with a focus on behavior management. Abuse/Neglect/Exploitation and Reporting allegations posters were placed at each nursing station, employee breakrooms, and by the time clock. Targeted Ad Hoc education completed to attain and maintain compliance. On 8/6/21, the Regional Director of Operations re-educated the Administrator and Director of Nursing as it relates to Federal Regulation F 600, Freedom from Abuse, Neglect and Exploitation and oversight of care and services. On 8/6/21, an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review a Performance Improvement Plan (PIP) inclusive of Abuse, Neglect and Exploitation ([NAME]). The Medical Director was also Involved in the QAPI review. On 8/7/21 an Ad-Hoc QAPI meeting was held to review any concerns identified on the quality monitoring tools along with any PIP inclusive of [NAME]. Abuse, Neglect and Exploitation, Reporting Alleged Violations policies have been reviewed by the committee. The committee also updated the Facility assessment. Ad-Hoc Quality Assurance meetings will be held after Morning Meeting to review the PIP and Quality Monitoring. Facility Staff will not be permitted to work until education completed. Newly hired staff members will receive education and training during the orientation period upon hire, by the Director of Nursing or designee.

Based on record review, policy review, and staff interview, the facility failed to operationalize their policy and procedure and failed to protect vulnerable residents' rights to be free from resident-to-resident incidents of sexual abuse. The facility failed to adequately supervise 1 (Resident #29) of 2 sampled residents with known behaviors with a likelihood to result in physical and sexual abuse. Resident #29 had a care plan for sexually inappropriate behavior since April 2020. The facility failed to implement adequate supervision and protection of vulnerable residents resulting in Resident #29 displaying sexually inappropriate behaviors toward Resident #11 and #68. On 6/2/21 in the evening, a Certified Nursing Assistant (CNA) reported witnessing Resident #29 having inappropriate sexual contact with his roommate, Resident #11. The facility allowed the perpetrator (Resident #29) to remain in the same room with the alleged victim (Resident #11) until the evening of 6/7/21. Resident #29 was allowed to wander about the facility unsupervised and exposed his penis to Resident #68. Resident #29 also attempted to enter Resident #62's room, verbalizing the desire to commit a sexual act toward Resident #62. The facility failure to follow their policy and procedure and protect residents after an allegation of inappropriate sexual contact placed Resident #11 and other vulnerable residents at risk for further abuse. Residents #11, #62, and #68 have severe cognitive impairment and could not consent to sexual activities. Applying the reasonable person concept, Resident #11 would likely suffer serious psychosocial harm, not yet realized, because he was not able to consent to sexual activity which diminished his self-worth and self-respect. Survivors of sexual abuse may develop depression, anxiety, post-traumatic stress, personality disruptions, attachment issues and addiction. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. The Administrator was notified of the Immediate Jeopardy on 8/6/21 at 7:27 p.m. and provided the IJ templates. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on 8/8/21 at 6:30 p.m. and the scope and severity were reduced to a D. The findings included: Cross Reference to F600, F609, F610 and F835. The facility Abuse, Neglect, and Exploitation policy and procedure with a reviewed/revised date 7/14/21, defines Sexual Abuse as non-consensual sexual contact of any type with a resident. Under Section V. Investigation-An immediate investigation is warranted when suspicion or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. Under section VI. Protection of Resident- the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include: responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; and room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator. On 8/3/21 at 9:30 a.m., in an interview Resident #11's spouse said she was informed a couple of months ago a CNA found her husband's roommate (Resident # 29) to have his hands down her husband's pants. She said they told her his roommate was moved out of his room into another room and the facility was going to investigate the incident. Resident #29's clinical record review revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on 4/20/20 noted Resident #29 had episodes of asking for sexual favors and/or making sexual inappropriate comments to other residents, verbal aggression, taunting. The interventions included to redirect the resident gently but firmly from unacceptable behaviors (sexual inappropriate comments). On 8/4/21, the facility's abuse investigation and federal immediate report was reviewed. The facility reported on 6/8/21 during the evening after dinner (no date) a CNA Staff O saw Resident #29 in his room at the foot of his roommate's bed (#11). The CNA observed resident #29 with his hand in the top part of the resident's brief. CNA Staff O's written statement dated 6/8/21 was reviewed. The CNA noted at approximately 9:35 p.m., he observed Resident #29 in the dining room facing Resident #68. He heard Resident #68 say put it away. At that time, he observed Resident #29 had his penis out and said to Resident #29, You want it and Resident #68 began to curse at Resident #29. He then took Resident #29 to the unit and informed the nurse what he observed. Staff O noted there was another incident that occurred before the weekend during the evening, after dinner. He saw Resident #29 in his room with his hand inside of Resident #11's brief. His statement noted he informed Registered Nurse (RN) Staff S at the time of the incident. There was no statement by RN Staff S found in the facility's investigation. On 8/5/21 at 2:36 p.m., in an interview CNA Staff O said there were 2 incidents involving Resident #29. The first was when he found him at the bedside of his roommate Resident #11 with his hands down the front of Resident #11's brief. The next incident occurred about a week later when he came through the dining room and Resident #29 was exposing his penis to Resident #68. Right after this incident, Resident #29 was moved out of the room he shared with resident #11 into a different room. The CNA said he notified RN Staff S after the first incident. In a progress note the Advanced Practice Registered Nurse (APRN) noted on 6/3/21 at 10:13 a.m., in Resident #29's clinical record staff requested she evaluated the resident's sexually inappropriate behavior. Staff reported Resident #29 had been approaching men in the building (staff and residents) and requesting sexual favors. He was redirected by staff when this behavior occurred; He just laughed and left the situation. On 6/3/21 at 10:44 a.m. the facility's Social Services Director (SSD) noted: today Resident #29's representative was informed about this resident's sexually inappropriate behavior. On 6/8/21 at 6:40 a.m., Licensed Practical Nurse (LPN) Staff G noted Resident #29 entered Resident #62's room during care, The CNA asked the resident to leave the room and the resident responded No. The CNA asked the resident why was he going into Resident #62's room, and he responded I wanna [sic] chew his balls off . Resident #29 was observed previously at 5:24 a.m., and 6:01 a.m., attempting to enter Resident #62's room. Resident #11's clinical record review revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/5/21 at 1:29 p.m., in an interview the Director of Nursing (DON) said there was no report of the incident involving Resident #29 inappropriately touching Resident #11, and she was not aware this had occurred until the morning of 6/8/21. The Administrator at the time had directed staff to move the resident to a different room on the night of 6/7/21. Resident #29 was sent out to the hospital that same morning. On 8/5/21 at 3:49 p.m., in an interview the Administrator said he started employment at the facility on 6/25/21 and was not here at time of incident. He revealed the facility did not follow its abuse policy, did not conduct a thorough investigation, and did not protect Resident #11 from further abuse by allowing the alleged perpetrator to continue to share a room for 5 days. Record review revealed documentation the APRN, and SSD were also aware of the inappropriate sexual contact on 6/3/21 but no indication of any action taken to report the incident or prevent the resident from having further contact with Resident #11. On 6/7/21, Resident #29 was relocated to a different room, but LPN Staff G made several entries of Resident #29 seen trying to enter the room of another vulnerable resident's (#62) room. There was no evidence of the resident being on a close supervision during this time. The Administrator said he would look to see if there was any documentation of this being done. On 8/6/21 at 10:38 a.m., in an interview the APRN said on 6/3/21 a nurse notified her about the episode with Resident #29 and Resident #11. She was told staff walked into their shared room to give care to Resident #11 and Resident #29 had his hand inside of Resident #11's brief. She said Resident #29 was very mobile in his wheelchair and all over the facility. The APRN said she thought the episode may have happened the day before, on 6/2/21. She did not realize Resident #29 was still in the room with Resident #11 as she usually saw him outside of the room. On 8/6/21 at 12:27 p.m., in an interview the SSD said she was informed through the nursing team someone had seen Resident #29 with his hand in Resident #11's brief. She wrote the note on 6/3/21 after she heard of it. The SSD said they also discussed it in morning meeting and were putting Resident #29 on one-to-one supervision. All the department heads including the Administrator were in the meeting. The Administrator and DON were to do the reporting to the state agency, and she assumed this was taken care of. She notified Resident #29's family. The SSD said they talked about a room change, and the one-to-one supervision was to be 24 hours a day. She was told about the incident involving Resident #68 and talked to him about it on 6/8/21. She said Resident #68 was offended by the incident and said Resident #29 was nasty. The SSD could not explain how that would occur if Resident #29 was on one-to-one supervision. On 8/6/21 at 12:50 p.m., in an interview the Administrator said he was unable to provide any evidence of Resident #29 being on one-to-one supervision after the incident on 6/3/21 to 6/8/21 before he left the facility. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team, included the following: On 6/7/21 Resident #29 was placed in a room by himself. On 6/8/21 Resident #29 was placed on one-to-one supervision and Baker Act (Invuluntary Psychiatric Evaluation) initiated. On 6/8/21 the facility initiated a thorough investigation, interviewed all interview able residents for any concerns regarding any unwanted sexual advances. On 6/8/21 a full skin assessment was completed on Resident #11. On 6/8/21 Resident #11 was assessed by the Advanced Practice Registered Nurse (APRN). The Resident showed no fear when approached by APRN. The Mood was unchanged from previous baseline. No anxiety noted. On 6/8/21 interview with Resident #68 was conducted. The Resident showed no fear or anxiety towards interviewer. The Mood unchanged and thorough investigation conducted. Interviewed all interviewable residents for any concerns regarding any unwanted sexual advances. No concerns noted. On 6/10/21 Resident #29 returned to the facility and was placed on every 30 minutes monitoring and placed in a private room. On 6/12/21 Resident #29 was placed on one-to-one supervision. On 7/14/21 the Abuse, Neglect and Exploitation, Reporting Alleged Violations policies were reviewed during our Monthly Quality Assurance Performance Improvement (QAPI) meeting. On 7/22/21 Resident #29 moved to a different room related to positive cases in the building and one-to-one monitoring continued. On 8/5/21 Resident #29 was placed in a private room and placed on one-to-one supervision. On 8/7/2021 Residents #29, #11 and #68 were evaluated by psychiatry services. The Psychiatrist conducted a psychological evaluation of Resident #29 and medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . No concerns noted for Residents #11 and #68. The Interdisciplinary Team reviewed and revised Resident #29 care plan to better identify patterns in resident behavior and implement interventions. Care Plan revisions and interventions communicated to front line staff caring for resident. On 8/6/21, a Federal Immediate report for abuse was filed to the Agency for Resident #11 and Adult Protective Services (API) was notified. On 8/6/21, a facility investigation was initiated by the Administrator in conjunction with the Director of Nurses. The Interdisciplinary Team (IDT) concluded the root cause analysis of this concern was lack of education related to identifying abuse, neglect policy and procedures including compliance with reporting allegations of Abuse/Neglect/Exploitation. On 8/6/21, the facility initiated a Quality Monitor audit review for current residents residing in the facility with a Brief Interview for Mental Status (BIMS) of 9 or above, interviewing/assessing for potential abuse. Any Concerns identified will be investigated immediately with state and Federal reporting as indicated. On 8/6/21, the facility initiated a Quality Monitor audit to review non-interview able residents by interviewing staff and resident' families. Any concerns identified will be investigated immediately. On 8/6/21 and 8/7/21 re-education initiated by Administrator/DON/Designee on for Facility Staff on: Abuse, Neglect and Exploitation with emphasis on abuse prevention and reporting investigation. In the event of any future resident-to-resident sexual abuse, the perpetrating resident will immediately be placed on one-to-one supervision until physician, and psych evaluations can be completed and reviewed by IDT. Outcomes of these evaluations will result in one-to- one supervision or the initiate of discharge planning to a facility with a focus on behavior management. Abuse/Neglect/Exploitation and Reporting allegations posters were placed at each nursing station, employee breakrooms, and by the time clock. Targeted Ad Hoc education completed as indicated to attain and maintain compliance. On 8/6/21, the Regional Director of Operations re-educated the Administrator and Director of Nursing as it relates to Federal Regulation F607. On 8/6/21, an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review a Performance Improvement Plan (PIP) inclusive of Abuse, Neglect and Exploitation ([NAME]). On 8/7/21 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review any concerns identified on the quality monitoring tools along with any PIP inclusive of [NAME]. Abuse, Neglect and Exploitation, Reporting Alleged Violations policies have been reviewed by the committee. The Facility assessment has been updated by the Committee. Ad-Hoc Quality Assurance meetings to be held after Morning Meeting to review the Plan of Correction (PIP) and Quality Monitoring. Facility Staff are not permitted to work until education completed. Newly hired staff members will receive education and training during the orientation period upon hire, by the Director of Nursing or designee.

Based on record review, policy review, and staff interviews, the facility failed to immediately report an alleged violation involving abuse to the appropriate officials, including to the State survey and certification agency, and adult protective services in accordance with State law. The facility failed to report the incident to the appropriate officials as soon as they became aware of the incident resident to resident sexual abuse involving Resident #29 and Resident #11. The facility's administration was made aware of the allegation on 6/3/21 and allowed Resident #11 to remain in the same room with the perpetrator until the evening of 6/7/21. Resident #29 was also allowed to wander about the facility unsupervised resulting in him exposing his penis to Resident #68, and attempting to enter Resident #62's room, verbalizing the desire to commit a sexual act toward the resident. The facility failed to take immediate action to protect Resident #11 and other residents from further sexual abuse inflicted by Resident #29. Residents #11, #62, and #68 have severe cognitive impairment and could not consent to sexual activities. Applying the reasonable person concept, Resident #11 would likely suffer serious psychosocial harm, not yet realized, because he was not able to consent to sexual activity which diminished his self-worth and self-respect. Survivors of sexual abuse may develop depression, anxiety, post-traumatic stress, personality disruptions, attachment issues and addiction. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. The failure to immediately report and appropriately intervene for sexually inappropriate behaviors of Resident #29 toward other residents resulted in noncompliance at the Immediate Jeopardy level starting on 6/3/21. The Administrator was notified of the Immediate Jeopardy on 8/6/21 at 7:27 p.m. and provided the IJ template. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on 8/8/21 at 6:30 p.m., and the scope and severity were reduced to D. The findings included: Cross Reference to F600, F 607, F610, and F835. The facility's Reporting Alleged Violations policy dated January 2021, revised date of July 12. 2021; included purpose is to assure that all alleged violations are reported immediately to the facility administrator and other officials. Under the section Response and Reporting of alleged violations: anyone in the facility can report an alleged violation. When an alleged violation is suspected, the Licensed Nurse should respond to the needs of the resident and protect them from further incident. Notify the Director of Nursing and Administrator. Complete an incident report and initiate an investigation immediately. Notify the attending physician, resident's family/legal representative and Medical Director. Obtain statements from direct care staff. Document actions taken in the medical record. The Administrator should follow-up with government agencies, during business hours, to confirm the report was received and to report the results of the investigation when final, as required by state agencies. In an interview on 8/3/21 at 9:30 a.m., Resident #11's family member said she was informed a couple of months ago that her husband's roommate (Resident # 29) was found by a CNA to have his hands down her husband's pants. She said they told her his roommate was moved out of his room into another room and the facility was going to investigate the incident. On 8/4/21, the facility's abuse investigation and federal immediate report was reviewed. On 6/8/21 the facility reported during the evening after dinner (no date) a CNA Staff O saw Resident #29 in his room at the foot of his roommate's bed (#11). The CNA observed resident #29 with his hand in the top part of the resident's brief. CNA Staff O's written statement dated 6/8/21 was reviewed. The CNA noted at approximately 9:35 p.m., he observed Resident #29 in the dining room facing Resident #68. He heard Resident #68 say put it away. At that time, he observed Resident #29 had his penis out and said to Resident #68, You want it and Resident #68 began to curse at Resident #29. He then took Resident #29 to the unit and informed the nurse what he observed. Staff O noted there was another incident that occurred before the weekend during the evening, after dinner. He saw Resident #29 in his room with his hand inside of Resident #11's brief. His statement noted he informed Registered Nurse (RN) Staff S at the time of the incident. In an interview on 8/5/21 at 2:36 p.m., CNA Staff O said there were 2 incidents involving Resident #29. The first was when he found him at bedside of roommate Resident #11 with his hands down the front of Resident #11's brief. The next incident occurred about a week later when he came through the dining room and Resident #29 was exposing his penis to Resident #68. Right after this incident, Resident #29 was moved out of the room he shared with resident #11 into a different room. The CNA said he notified RN Staff S after the first incident. The facility's staffing schedule was reviewed and indicated both RN Staff S and CNA Staff O were working on the evening of 6/2/21. Resident #29's clinical record was reviewed and revealed a history of sexually inappropriate behavior. In a progress note the Advanced Registered Nurse Practitioner (APRN) noted on 6/3/21 at 10:13 a.m., staff requested she evaluate the resident's sexually inappropriate behavior. Staff reports Resident #29 has been approaching the men in the building (staff and residents) and requesting sexual favors. He was redirected by staff when this behavior occurred; He just laughed and left the situation. On 6/3/21 at 10:44 a.m., the facility's Social Services Director (SSD) noted: today Resident #29's representative was informed about this resident's sexually inappropriate behavior. On 6/8/21 at 6:40 a.m., Licensed Practical Nurse (LPN) Staff G noted Resident #29 entered Resident #62's room during care, The CNA asked the resident to leave the room and the resident responded No. The CNA asked the resident why is he going into Resident #62's room, and he responded I wanna chew his balls off . Resident #29 was observed previously at 5:24 a.m., and 6:01 a.m., attempting to enter Resident #62's room. In an interview on 8/5/21 at 1:29 p.m., the Director of Nursing (DON) said there was no report of the incident involving Resident #29 inappropriately touching Resident #11, and she was not aware this had occurred until the morning of 6/8/21. The Administrator at the time had directed staff to move the resident to a different room on the night of 6/7/21 and reported the incident to the state agency. In an interview on 8/5/21 at 3:49 p.m., the Administrator said he did not start employment at the facility until 6/25/21 and was not here at time of incident. He revealed the facility did not follow its abuse policy, did not immediately report the allegation, and did not protect Resident #11 from further abuse by allowing the alleged perpetrator to continue to share a room for 5 days. Record review revealed documentation the APRN, and SSD were also aware of the inappropriate sexual contact on 6/3/21 but no indication of any action taken to report the incident, or prevent the resident from having further contact with Resident #11. On 6/7/21, Resident #29 was relocated to a different room, but several entries were made by LPN Staff G of resident being seen trying to enter the room of another vulnerable resident's (#62) room. There was no evidence of the resident being on one-to-one supervision during this time. In an interview on 8/6/21 at 10:38 a.m., the APRN said on 6/3/21 she was notified by a nurse about the episode with Resident #29 and Resident #11. Was told staff walked into their shared room to give care to Resident #11 and Resident #29 had his hand inside of Resident #11's brief. She said Resident #29 was very mobile in his wheelchair and all over the facility. The APRN said she thinks the episode may have happened the day before, on 6/2/21. She did not realize he was still in the room with Resident #11 as she usually saw him outside of the room. The APRN said she is a mandatory reporter, but the facility's social worker was also aware and thought she would have filed a report. In an interview on 8/6/21 at 12:27 p.m., the SSD said she was informed through nursing team that someone had seen Resident #29 with his hand in Resident #11's brief. She wrote the note on 6/3/21 after she heard of it. The SSD said they also discussed it in morning meeting and were putting Resident #29 on 1:1 supervision. All the department heads including the Administrator were in the meeting. The Administrator and DON were to do the reporting to the state agency and assumed this was taken care of. She did notify the family of Resident #29. On 8/8/21 the facility submitted an acceptable removal plan. Verified implementation of removal plan through record review of staff Inservice records and staff interviews. Administration was re-educated on regulatory requirements of reporting abuse/neglect. Resident #29 was observed on 1:1 observation. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team, included the following: On 8/6/21, a Federal Immediate report for abuse was filed to the State Agency for Resident #11, and Adult Protective Services (API) was notified. On 8/6/21, the facility initiated a Quality Monitor audit review for current residents residing in the facility with a Brief Interview for Mental Status (BIMS) of 9 or above, interviewing/assessing for potential abuse. Any Concerns identified will be investigated immediately with state and Federal reporting as indicated. On 8/6/21, the facility initiated a Quality Monitor audit to review non-interview able residents by interviewing staff and resident families. Any concerns identified will be investigated immediately with State and Federal reporting as indicated. On 8/6/21 and 8/7/21 re-education initiated by Administrator/DON/Designee on for Facility Staff on: Abuse, Neglect, Exploitation with emphasis on abuse prevention and reporting investigation. On 8/6/21 the Regional Director of Operations reeducated the Administrator and Director of Nursing as it relates to Federal Regulation F 609. On 8/6/21, an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review a Performance Improvement Plan (PIP) inclusive of Abuse, Neglect and Exploitation ([NAME]). On 8/7/21 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review any concerns identified on the quality monitoring tools along with any PIP inclusive of [NAME]. Ad-Hoc Quality Assurance meetings to be held after Morning Meeting to review Plan of Correction (PIP and Quality Monitoring). Facility Staff are not permitted to work until education completed. Newly hired staff members will receive education and training during the orientation period upon hire, by the Director of Nursing or designee.

Based on record review, policy review, and staff interview, the facility failed to have evidence of a thorough investigation after an allegation of inappropriate sexual contact and potential abuse was reported for 1 (Resident #29) of 1 resident sampled with sexual inappropriate behaviors. The allegation was reported on the evening of 6/2/21 and there was no investigation into the potential sexual abuse until 6/8/21. This failure to investigate and operationalize the abuse policy led to the alleged victim (Resident #11) remaining in the same room with the perpetrator (Resident #29) until the evening of 6/7/21. Resident #29 was also allowed to wander about the facility unsupervised resulting in him exposing his penis to Resident #68, and attempting to enter Resident #62's room, verbalizing the desire to commit a sexual act. The failure to not investigate the allegation of potential sexual abuse placed Resident #11 and other vulnerable residents at risk for further abuse. Applying the reasonable person concept, Resident #11 would likely suffer serious psychosocial harm, not yet realized, because he was not able to consent to sexual activity which diminished his self-worth and self-respect. Survivors of sexual abuse may develop depression, anxiety, post-traumatic stress, personality disruptions, attachment issues and addiction. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. The noncompliance resulted in Immediate Jeopardy starting on 6/3/21. The Administrator was notified of the Immediate Jeopardy on 8/6/21 at 7:27 p.m. and provided the IJ template. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on 8/8/21 at 6:30 p.m., and the scope and severity were reduced to D. The findings included: Cross Reference to F600, F607, F609, and F835. The facility's Abuse, Neglect, and Exploitation policy and procedure with a reviewed/revised date 7/14/21, defines Sexual Abuse as non-consensual sexual contact of any type with a resident. Under Section V. Investigation-An immediate investigation is warranted when suspicion or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. Under section VI. Protection of Resident- the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include: responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; and room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator. In an interview on 8/3/21 at 9:30 a.m., Resident #11's family member said she was informed a couple of months ago that her husband's roommate (Resident # 29) was found by a CNA to have his hands down her husband's pants. She said they told her his roommate was moved out of his room into another room and the facility was going to investigate the incident. On 8/4/21, the facility's abuse investigation and federal immediate report was reviewed. On 6/8/21 the facility reported during the evening after dinner (no date) a CNA Staff O saw Resident #29 in his room at the foot of his roommate's bed (#11). The CNA observed resident #29 with his hand in the top part of the resident's brief. CNA Staff O's written statement dated 6/8/21 was reviewed. The CNA noted at approximately 9:35 p.m., he observed Resident #29 in the dining room facing Resident #68. He heard Resident #68 say put it away. At that time, he observed Resident #29 had his penis out and said to Resident #68, You want it and Resident #68 began to curse at Resident #29. He then took Resident #29 to the unit and informed the nurse what he observed. Staff O noted there was another incident that occurred before the weekend during the evening, after dinner. He saw Resident #29 in his room with his hand inside of Resident #11's brief. His statement noted he informed Registered Nurse (RN) Staff S at the time of the incident. There was no statement by RN Staff S found in the facility's investigation. In an interview on 8/5/21 at 2:36 p.m., CNA Staff O said there were 2 incidents involving Resident #29. The first was when he found him at bedside of roommate Resident #11 with his hands down the front of Resident #11's brief. The next incident occurred about a week later when he came through the dining room and Resident #29 was exposing his penis to Resident #68. Right after this incident, Resident #29 was moved out of the room he shared with resident #11 into a different room. The CNA said he notified RN Staff S after the first incident Resident #29's clinical record was reviewed and revealed he is a [AGE] year-old male with a history of sexually inappropriate behavior. In a progress note the Advanced Practice Registered Nurse (APRN) noted on 6/3/21 at 10:13 a.m., staff requested she evaluate the resident's sexually inappropriate behavior. Staff reports Resident #29 has been approaching the men in the building (staff and residents) and requesting sexual favors. He is redirected by staff when this behavior occurs; He just laughs and leaves the situation. On 6/3/21 at 10:44 a.m. the facility's Social Services Director (SSD) noted: today Resident #29's representative was informed about this resident's sexually inappropriate behavior. On 6/8/21 at 6:40 a.m., Licensed Practical Nurse (LPN) Staff G noted Resident #29 entered Resident #62's room during care, The CNA asked the resident to leave the room and the resident responded No. The CNA asked the resident why is he going into Resident #62's room, and he responded I wanna [sic]chew his balls off . Resident #29 was observed previously at 5:24 a.m., and 6:01 a.m., attempting to enter Resident #62's room. In an interview on 8/5/21 at 1:29 p.m., the Director of Nursing (DON) said there was no report of the incident involving Resident #29 inappropriately touching Resident #11, and she was not aware this had occurred until the morning of 6/8/21. The Administrator at the time had directed staff to move the resident to a different room on the night of 6/7/21. Resident #29 was sent out to the hospital that same morning. The facility's staffing schedule was reviewed and indicated both RN Staff S and CNA Staff O were working on the evening of 6/2/21. CNA Staff O was not on duty 6/3/21. In an interview on 8/5/21 at 2:06 p.m., the DON said she had determined the date of the incident occurred on 6/3/21 as that was last day RN Staff S worked. She confirmed she had not interviewed RN staff S regarding the incident. The DON said she was not aware CNA Staff O was not even on duty that day. The DON did not identify and interview all staff members who were on duty 6/2/21 or may have had knowledge of the incident. In an interview on 8/5/21 at 3:49 p.m., the Administrator said he did not start until 6/25/21 and was not here at time of incident. He revealed the facility did not follow its abuse policy, did not conduct a thorough investigation, and did not protect Resident #11 from further abuse by allowing the alleged perpetrator to continue to share a room for 5 days. Record review revealed documentation the APRN, and SSD were also aware of the inappropriate sexual contact on 6/3/21 but no indication of any action taken to report the incident or prevent the resident from having further contact with Resident #11. On 6/7/21, Resident #29 was relocated to a different room, but several entries were made by LPN Staff G of resident being seen trying to enter the room of another vulnerable resident's (#62) room. There was no evidence of the resident being on a one-to-one supervision during this time. The Administrator said he would look to see if there was any documentation of this being done. In an interview on 8/6/21 at 10:38 a.m., the APRN said on 6/3/21 she was notified by a nurse about the episode with Resident #29 and Resident #11. Was told staff walked into their shared room to give care to Resident #11 and Resident #29 had his hand inside of Resident #11's brief. She said Resident #29 was very mobile in his wheelchair and all over the facility. The APRN said she thinks the episode may have happened the day before, on 6/2/21. In an interview on 8/6/21 at 11:06 a.m., the DON said she is now the Risk Manager, but the previous Administrator was the Risk Manager at the time of the incident. The root cause of this incident is a lack of education and understanding as to the seriousness of the issue. She did a disciplinary action with RN Staff S last night until she can further investigate her involvement. In an interview on 8/6/21 at 12:50 p.m., the Administrator said he was unable to provide any evidence of Resident #29 being on one-to-one supervision after the incident on 6/3/21 to 6/8/21 when he left the facility. On 8/8/21 the facility submitted an acceptable removal plan. Verified implementation of removal plan through record review of staff Inservice records and staff interviews. Administration was re-educated on investigation of abuse/neglect. Resident #29 was observed on 1:1 observation. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team, included the following: On 6/7/21 Resident #29 was placed in a room by himself. On 6/8/21 Resident #29 was placed on one-to-one supervision and Baker Act initiated. On 6/8/21 the facility initiated a thorough investigation, interviewed all interview able residents for any concern regarding any unwanted sexual advances. On 6/8/21 a full skin assessment was completed on Resident #11. On 6/8/21 Resident #11 was assessed by the APRN, no evidence of injuries noted. On 6/8/21 interview with Resident #68 was conducted. Resident showed no fear or anxiety towards interviewer. Mood unchanged and thorough investigation conducted. Interviewed all interviewable residents for any concerns regarding any unwanted sexual advances. No concerns noted. On 6/10/21 Resident #29 returned to the facility and was placed on every 30 minutes monitoring and placed in a private room. On 6/12/21 Resident #29 was placed on one-to-one supervision. On 7/14/21 The Abuse, Neglect and Exploitation / Reporting Alleged Violations policies were reviewed during Monthly Quality Assurance and Performance Improvement (QAPI) meeting. On 7/22/21 Resident #29 moved to a different room related to positive cases in the building and remained on one-to-one monitoring. On 8/5/21 Resident #29 was placed in a room by himself and placed on one-to-one supervision. On 8/7/21 Residents #29, #11 and #68 were evaluated by psychiatry services. The psychiatrist conducted a psychological evaluation of Resident #29 and medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . No concerns noted for Resident #11 and #68. The Interdisciplinary Team (IDT) reviewed and revised Resident #29's care plan to better identify patterns in resident's behavior and implement interventions. Care Plan revisions and interventions communicated to front line staff caring for resident. On 8/7/21 The Interdisciplinary Team reviewed residents with behaviors that could result in any abuse behaviors. They were identified and care plans personalized to reflect residents' preferences and the Kardex updated to assist with redirection to prevent other residents from suffering further physical abuse, sexual abuse, or any type of abuse. On 8/6/21, Federal Immediate report for abuse was filed to the Agency for Resident #11, Adult Protective Services was notified. On 8/6/21, a facility investigation was initiated by the Administrator in conjunction with the Director of Nurses. The IDT team has concluded the root cause analysis of this concern was lack of education related to identifying abuse, neglect policy and procedures including compliance with reporting allegations of Abuse/Neglect/Exploitation. On 8/6/21, the facility initiated a Quality Monitor audit review for current residents residing in the facility with a Brief Interview of Mental Status (BIMS) of 9 or above, interviewing and assessing for potential abuse. On 8/6/21, the facility initiated a Quality Monitor audit to review non-interview able residents by interviewing staff and resident families. The Administrator, DON, designee will complete a Quality Monitor to identify any resident with sexual behaviors with likelihood to result in physical and sexual abuse. On 8/6/21 and 8/7/2021 re-education initiated for Facility Staff by Administrator, DON, and Designee on: Abuse, neglect, exploitation with emphasis on abuse prevention and reporting investigation. In the event of any future resident-to-resident sexual abuse, the perpetrating resident will immediately be placed on one-to-one supervision until physician, and psych evaluation can be completed and reviewed by IDT. Outcomes of these evaluations will result in one-to-one supervision or the initiation of discharge planning to a facility with a focus on behavior management. Abuse/Neglect/Exploitation and Reporting allegations posters were placed at each nursing station, employee breakrooms, and by the time clock. Targeted Ad Hoc education completed to attain and maintain compliance. On 8/6/21, the Regional Director of Operations re-educated the Administrator and Director of Nursing as it relates to Federal Regulation F 610, Investigating, preventing and correction of alleged violations. On 8/6/21, an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review a Performance Improvement Plan (PIP) inclusive of Abuse, Neglect and Exploitation ([NAME]). The Medical Director was also Involved in the QAPI review. On 8/7/21 an Ad-Hoc QAPI meeting was held to review any concerns identified on the quality monitoring tools along with any PIP inclusive of [NAME]. Abuse, Neglect and Exploitation, Reporting Alleged Violations policies have been reviewed by the committee. The committee also updated the Facility assessment. Ad-Hoc Quality Assurance meetings will be held after Morning Meeting to review the PIP and Quality Monitoring. Facility Staff will not be permitted to work until education completed. Newly hired staff members will receive education and training during the orientation period upon hire, by the Director of Nursing or designee.

Based on record review and staff interviews, the facility's Administration failed to use resources effectively to ensure the facility's abuse policy and procedures was implemented to prevent, report, protect, and investigate sexual abuse for vulnerable residents (#11, #62, and #68,) Residents #11, #62, and #68 have severe cognitive impairment. Applying the reasonable person concept, Resident #11 would likely suffer serious psychosocial harm, not yet realized, because he was not able to consent to sexual activity which diminished his self-worth and self-respect. Survivors of sexual abuse may develop depression, anxiety, post-traumatic stress, personality disruptions, attachment issues and addiction. There is a chance of passing sexually transmitted infections during unprotected sexual activities, which can lead to further health complications and death. The failure of the Administration to implement their abuse policies created a likelihood that put Resident #11 at risk for further potential sexual abuse, as well as other vulnerable residents at risk for abuse. The noncompliance resulted in Immediate Jeopardy starting on 6/3/21. The Administrator was notified of the Immediate Jeopardy on 8/6/21 at 7:27 p.m. and provided the IJ template. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on 8/8/21 at 6:30 p.m., and the scope and severity were reduced to D. The findings included: Cross Reference to F600, F607, F609, and F610. Review of the Administrator job description dated April 2020 stated in the Summary section the Administrator was to lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents. Review of The Director of Nursing job description, signed on 2/19/21, stated in the Summary section to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs. The facility's Abuse, Neglect, and Exploitation policy and procedure with a reviewed/revised date of 7/14/21, defines Sexual Abuse as non-consensual sexual contact of any type with a resident. An immediate investigation is warranted when suspicion or reports of abuse, neglect or exploitation occur. Under section VI. Protection of Resident- the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include: responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; and room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator. In an interview on 8/3/21 at 9:30 a.m., Resident #11's family member said she was informed a couple of months ago that her husband's roommate (Resident # 29) was found by a Certified Nursing Assistant (CNA) to have his hands down her husband's pants. She said they told her his roommate was moved out of his room into another room and the facility was going to investigate the incident. On 8/4/21, the facility's abuse investigation and federal immediate report was reviewed. On 6/8/21 the facility reported during the evening after dinner (no date) a CNA Staff O saw Resident #29 in his room at the foot of his roommate's bed (#11). The CNA observed resident #29 with his hand in the top part of the resident's brief. CNA Staff O's written statement dated 6/8/21 was reviewed. The CNA noted at approximately 9:35 p.m., he observed Resident #29 in the dining room facing Resident #68. He heard Resident #68 say put it away. At that time, he observed Resident #29 had his penis out and said to Resident #68, You want it and Resident #68 began to curse at Resident #29. He then took Resident #29 to the unit and informed the nurse what he observed. Staff O noted there was another incident that occurred before the weekend during the evening, after dinner. He saw Resident #29 in his room with his hand inside of Resident #11's brief. His statement noted he informed Registered Nurse (RN) Staff S at the time of the incident. In an interview on 8/5/21 at 2:36 p.m., CNA Staff O said there were 2 incidents involving Resident #29. The first was when he found him at bedside of roommate Resident #11 with his hands down the front of Resident #11's brief. The next incident occurred about a week later when he came through the dining room and Resident #29 was exposing his penis to Resident #68. Right after this incident, Resident #29 was moved out of the room he shared with resident #11 into a different room. The CNA said he notified RN Staff S after the first incident. The facility's staffing schedule was reviewed and indicated both RN Staff S and CNA Staff O were working on the evening of 6/2/21. Resident #11's clinical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of the resident having been examined for any evidence of physical or psychological harm until 6/8/21, 6 days after the incident occurred. The resident was not interviewable. On 8/6/21 at 5:15 p.m., a second interview was conducted with Resident #11's wife. She stated her husband would feel violated if he was able to express how he felt about the incident with Resident #29. Resident #68's clinical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/5/21 at 11:10 a.m. Resident #68 was interviewed, and he denied any incident occurred with Resident #29. Resident #29's clinical record was reviewed and revealed a history of sexually inappropriate behavior. In a progress note the Advanced Practice Registered Nurse (APRN) noted on 6/3/21 at 10:13 a.m., staff requested she evaluate the resident's sexually inappropriate behavior. Staff reports Resident #29 has been approaching the men in the building (staff and residents) and requesting sexual favors. He is redirected when this behavior occurs by staff; He just laughs and leaves the situation. On 6/3/21 at 10:44 a.m. the facility's Social Services Director (SSD) noted: today Resident #29's representative was informed about this resident's sexually inappropriate behavior. On 6/8/21 at 6:40 a.m., Licensed Practical Nurse (LPN) Staff G noted Resident #29 entered Resident #62's room during care, The CNA asked the resident to leave the room and the resident responded No . The CNA asked the resident why is he going into Resident #62's room, and he responded I wanna [sic] chew his balls off . Resident #29 was observed previously at 5:24 a.m., and 6:01 a.m., attempting to enter Resident #62's room. Resident #62's clinical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was noted to be unable to state or express needs. Resident #62 was observed to be in a private room and in bed all days of survey. The resident was did not respond to attempts to be interviewed on 8/2/21. In an interview on 8/5/21 at 1:29 p.m., the Director of Nursing (DON) said there was no report of the incident involving Resident #29 inappropriately touching Resident #11, and she was not aware this had occurred until the morning of 6/8/21. The Administrator at the time had directed staff to move the resident to a different room on the night of 6/7/21. Resident #29 was sent out to the hospital that morning and one-to-one supervision was started upon his return. In an interview on 8/5/21 at 3:49 p.m., the Administrator said he did not start employment until 6/25/21 and was not here at time of incident. He revealed the facility did not follow its abuse policy, did not conduct a thorough investigation, and did not protect Resident #11 from further abuse by allowing the alleged perpetrator to continue to share a room for 5 days. Record review revealed documentation the APRN, and SSD were also aware of the inappropriate sexual contact on 6/3/21 but no indication of any action taken to report the incident or prevent the resident from having further contact with Resident #11. On 6/7/21, Resident #29 was relocated to a different room, but several entries were made by LPN Staff G of resident being seen trying to enter the room of another vulnerable resident's (#62) room. There was no evidence of the resident being on one-to-one supervision during this time. The Administrator said he would look to see if there was any documentation of this being done. In an interview on 8/6/21 at 10:38 a.m., the APRN said on 6/3/21 she was notified by a nurse about the episode with Resident #29 and Resident #11. Was told staff walked into their shared room to give care to Resident #11 and Resident #29 had his hand inside of Resident #11's brief. She said Resident #29 was very mobile in his wheelchair and all over the facility. The APRN said she thinks the episode may have happened the day before, on 6/2/21. She did not realize he was still in the room with Resident #11 as she usually saw him outside of the room. In an interview on 8/6/21 at 12:27 p.m., the SSD said she was informed through nursing team that someone had seen Resident #29 with his hand in Resident #11's brief. She wrote the note on 6/3/21 after she heard of it. The SSD said they also discussed it in morning meeting and were putting Resident #29 on one-to-one supervision. All the department heads including the Administrator were in the meeting. The Administrator and DON were to do the reporting to the state agency and assumed this was taken care of. She did notify the family of Resident #29. The SSD said they talked about a room change, and the one-to-one supervision was to be 24 hours a day. She was told about the incident involving Resident #68 and did talk to him about it on 6/8/21. She said the resident was offended by the incident and said Resident #29 was nasty. The SSD could not explain how that would occur if Resident #29 was on one-to-one supervision. In an interview on 8/6/21 at 12:50 p.m., the Administrator said he was unable to provide any evidence of Resident #29 being on one-to-one supervision from 6/3 to 6/8/21 and upon his return from 6/10 to 6/12/21. The facility provided evidence of some monitoring for the evening of 6/12/21 but lacked consistent documentation for the evening and night shifts when the resident was more likely to exhibit these behaviors. The immediate actions implemented by the facility according to their Immediate Jeopardy removal plan and verified by the survey team, included the following: On 8/6/21 education was completed by the Regional with the Administrator and Director of Nursing on their job descriptions. Beginning 8/6/21, the Administrator will hold Quality Assurance/Performance Improvement meetings daily until removal of immediacy is achieved. The facility will then move to weekly until compliance has been determined. On 8/6/21, the Regional educated the Administrator and the Director of Nursing on the components of regulations: F600 Free from Abuse and Neglect; F609 Reporting of Abuse and Neglect; F610 Investigation of Abuse and Neglect; F607 Operationalize Policy and Procedure to protect; F835 Administration. Targeted Ad Hoc education completed as indicated to attain and maintain compliance. The facility Administrator/designee and the Director of Nursing/designee will conduct a daily Monitoring of quality monitoring related to abuse and reporting of alleged violations until removal of immediacy. The facility will then move to weekly then monthly to ensure compliance maintained. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines compliance has been met and recommends moving to monthly monitoring by the Regional Director of Clinical Operations when completing their systems review. The Regional Director of Operations and or Regional Resource Nurse to perform quality Monitoring during visits for compliance with F 600, F609, F610, F607 and F 835. On 8/7/21, an Ad hoc Quality Assurance Performance Improvement (QAPI) Meeting was convened to review the removal plan as written. An Ad-Hoc Quality Assurance meetings to be held after Morning Meeting to review Plan of Correction (PIP) and Quality Monitoring.

Based on observation, interview, and record review, the facility failed to coordinate care to ensure the highest practicable medical needs of 3 (Residents #30, #59, and #101) of 26 residents sampled. The facility failed to provide incontinence care and skin assessment for the prevention of skin breakdown for Resident #30 and #59. This resulted two residents to develop further skin breakdown due to lack of assessment and treatment. The facility failed to provide care for the [MEDICAL TREATMENT] for Resident #101. This has the potential for the resident's [MEDICAL TREATMENT] access to fail. The findings included: 1. Resident # 30 was admitted on [DATE]. Review of Resident #30's Admission Nursing assessment dated [DATE] revealed integumentary (skin) section included the following documentation of pressure ulcer areas: sacrum, posterior left thigh, left lower shin. Review of MDS dated [DATE]; the skin conditions section documented pressure ulcers as present on admission: one unhealed pressure ulcer stage I or greater and, two stage II pressure ulcers, one stage III pressure ulcer, one unstageable/suspected deep tissue injury, and resident was at risk for pressure ulcers. Change in condition assessment dated [DATE] noted integumentary section has been documented as assessed, no symptoms noted (meaning no change). Review of Resident #30's care plan documented a need for care including skin breakdown related to limited mobility. The goal was resident's wound would heal as evidenced by decrease in size, absence of drainage and presence of granulation. The following interventions dated 10/31/16 were: evaluate wound care daily including surrounding tissue and presence or absence of drainage/infection and or new wound pain and report to Medical Doctor (MD) as indicated, observe skin condition daily with activities of daily living care and report abnormalities, weekly skin assessment by licensed nurse, weekly wound assessment to include measurements and description of wound status. On 12/6/16 at 2:00 p.m., Unit Manager RN Staff J said Resident #30 had an appointment on 11/17/16 with the Veteran's Administration (VA) wound care clinic. She said the resident lift at the VA was broken so the appointment was rescheduled for 12/1/16. RN Staff J said the VA social worker canceled the appointment because the VA could not arrange transportation. RN Staff J said another appointment has not been scheduled; she would have to do that. On the following day, RN Staff J said she had not made his appointment yet, but would do it today. By the end of the day 12/8/16, Staff J had not made the appointment. On 12/9/16 at 8:25 a.m., observations with the ADON and RN Staff J included Resident #30's pressure ulcers that were not documented (beyond the 6 documented wounds) on the Wound Record: A right buttock wound measured 0.5 centimeter (cm) by 0.4 cm and depth unable to determine (UTD); it was reddened around the edges and open with a necrotic spot in center. A pressure ulcer to the bottom of right foot, under 5th digit measuring 0.8 cm by 0.9 cm and depth UTD; there was a small amount of necrotic tissue in it. A pressure ulcer to the left ankle without a dressing and measuring 0.8 cm by 0.7 cm and depth UTD; the pressure ulcer had 100% slough. A wound on the left lower shin measured shin measured 2.5 cm by 1.2 cm and was red and blanchable. A wound right posterior lower leg measuring 2.0 cm by 0.7 cm and depth UTD with 80% slough in the wound bed; there was no dressing in place. On 12/9/16 at 9:17 a.m., Unit Manager RN Staff J stated Resident #30 came in with all of these pressure ulcers, none of them developed here. On 12/9/16 at 11:45 a.m., the DON confirmed the facility was not aware of the undocumented wounds that were observed. On 12/9/16 at 12:24 p.m., the Administrator said the facility had identified issues with wound care in October of 2016. She they had identified inconsistencies in care, of measurements, and assessments of wounds. She said the facility had identified turning and position was not being performed. The Administrator verified there were currently two residents in the facility that had pressure ulcers which included Resident #30. 2. Resident #59 was admitted to the facility on [DATE]. The Minimum (MDS) data set [DATE] showed Resident #59 is under hospice care. She was observed to be aphasic and unable to communicate her needs. Resident #59 was care-planned as incontinent of both bowel and bladder. Resident #59 was also care-planned for an unstageable pressure ulcer on her left heel. Resident #59 was observed to be totally dependent on staff to provide wound and incontinence care. The Minimum Data Set ((MDS) dated [DATE] showed Resident #59 was at risk for pressure ulcers. On 12/7/16 at 7:55 a.m., Resident #59 was observed reclining on her backside in a Broda chair near the south nursing station. At 9:00 a.m., the resident was reclining in the same position in the activity room near the south nursing station. At 10:00 a.m., the resident was reclining in the same place in the same position. At 11:00 a.m., the resident was reclining in the same position in the same place. Review of the Kardex Report showed Resident #59 was to have a pressure reducing device on her bed. There was no device documented for the resident's chair. There was no intervention to reposition Resident #59 on the Kardex or to check the resident routinely for incontinence. In an interview on 12/8/16 at 8:10 a.m., Certified Nursing Assistant (CNA) Staff I said the night shift got the resident up before she arrived in the morning. CNA Staff I said she would lay the resident down before lunch and change her brief. CNA Staff I said she would also lay resident down after lunch and change her brief again at that time. She said the resident would remain in bed until the next shift came on at 3:00 p.m., and they would get her up. On 12/8/16 at 9:43 a.m., the Assistant Director of Nursing (ADON) and Unit Manager (UM) Staff J were checking the Resident #59's backside. The resident's brief was observed saturated with yellow urine and the resident had bowel movement on her skin and in her brief. There was raised excoriation (raw irritated skin) noted to the lower edge of the left side of the perineum near the edge of where the diaper would hit the skin. There was an area over the resident's left buttocks that had a white substance that appeared to be zinc oxide (used for diaper rash). When the ADON cleaned the area, there was a wound noted approximately a centimeter in circumference covered in yellow slough (dead tissue and pus). There was another small open area that was open with granulation (new) tissue approximately the same size. The ADON verified there were two wounds on the resident's left buttocks and that one of the wounds was covered with slough. The ADON said she did not think the wounds were a pressure injury because they were not located over a bony prominence. Both the ADON and UM Staff J said they were not aware of the wounds on Resident #59. Review of the care plan for urinary incontinence read Resident #59, is incontinent of urine and is unable to cognitively or physically participate in a retraining program due to cognitive loss. Interventions listed on the care plan included, Provide perineal care as needed, and monitor for skin redness/irritation and report as indicated. On 12/8/16 at 11:00 a.m., CNA Staff K verified she had placed the zinc oxide cream on Resident #59's wounds when she had changed her the morning of 12/8/16. She said she had seen the wounds last Thursday and Friday when she took care of the resident and reported it. On 12/8/16 at 11:56 a.m., the Advanced Registered Nurse Practitioner (ARNP) said she had just assessed the wounds on the resident. The ARNP said this was the first time she had seen Resident #59. The ARNP verified there were two wounds on the resident's buttocks and one of the wounds could be covered in slough. The ARNP said she felt the wounds were not a pressure injury because it was not over a bony prominence. She said the wounds were urine related. On 12/8/16 at 1:27 p.m., the DON provided a Change in Condition assessment dated [DATE]. The DON verified this was the last documented full skin assessment for Resident #59. The DON said the resident was not on a routine check for incontinence and was scheduled to be changed on an as needed basis. On 12/9/16 at 3:15 p.m., CNA Staff K said she had changed Resident #59's brief on 12/8/16 between 5:00 and 6:00 a.m. On 12/8/16 at 9:45 a.m., Resident #59 ' s brief had been observed saturated in urine and feces. On 12/9/16 at 12:24 p.m., the Administrator said the facility had identified issues with wound care in October of 2016. She they had identified inconsistencies in care, of measurements, and assessments of wounds. She said the facility had identified turning and position was not being performed. The Administrator verified there were currently two residents in the facility that had pressure ulcers which included Resident #59.

Based on record review, interview and observation, the facility failed to prevent the abuse /neglect and mistreatment of [REDACTED]. This resulted from the willful spraying of water in the facial area of Resident #2, who had an order to receive only thickened liquids, palliative care and was known to be resistive to activities of daily living, including showering. The facility's failure to prevent Resident #2's abuse and their failure to identify the need to retrain staff on procedures to appropriately shower residents with similar conditions placed all residents with those conditions at risk for serious injury, harm, impairment, or death. This resulted in Immediate Jeopardy being identified on [DATE]. The Immediate Jeopardy began on [DATE] and remains ongoing. The findings include: On [DATE], a review of Resident #2's record contained a Nursing Progress note, dated [DATE], at 5:30 a.m., documenting, "Resident moaning loudly, (and) then screaming...Visible signs of pain on her face (fear and grimacing)." [MEDICATION NAME] 5 mg/0.25 cc SL given at 11:00 p.m. and 5:00 a.m., and back rubbing, both had positive calming effect. The progress note documented, "Took 80 cc of water during the night shift. Pulse 78, respirations 16; unlabored while awake, dyspnea noticed while sleeping. Resting with eyes closed. Will monitor." A nursing note at 12:20 p.m. documented MS04 ([MEDICATION NAME]) 0.25 cc was administered "with minimal effect" to Resident #2, who was "very anxious and moaning loudly." The note states at approximately 11:50 a.m., Certified Nurse Assistants (CNAs) called the nurse into shower room where the resident was found unresponsive with a faint pulse. The resident was returned to bed immediately, then a board was placed under her. CPR was administered and oxygen was placed over her face. No pulses were felt. The paramedics arrived and continued CPR. At 12:10 p.m., paramedics stated Resident #2 had passed away. The nursing note documented, the "DON (Director of Nursing) notified and family was being contacted by DON. Westside funeral home called." On [DATE], at 12:45 p.m., during an interview regarding the event on [DATE], Employee F stated, "I asked another CNA (Employee G) to help me give (Resident #2) a shower." During the shower, when Employee G sprayed water in Resident #2's face, Employee F said, "Do not do that, she is on thickened liquids." Employee G said, "She had soap in her eyes." After that, Employee F got the nurse because Resident #2 "was not acting normal." During this interview, Employee F stated, "I am CPR certified, (but) did not assist with it." When asked when the last training on abuse was received, Employee F said, "I do the modules on the computer; I believe last month." Regarding the facility staff to notify in a case of abuse, Employee F stated, "You notify the Abuse Coordinator, the DON (Director of Nursing), her name is on my badge." The incident was reported via phone call to Employee M, the Unit Manager, who was at home on [DATE], by Employees I and F. In an interview on [DATE], at 10:30 a.m., Employee M reported receiving a call at home on [DATE], at approximately 1:10 p.m. regarding Resident #2. Employees I and F reported that while giving Resident #2 a shower, Employee G sprayed Resident #2 in the face and the mouth. Employee I did not see the action, but Employee F witnessed Employee G spray Resident #2. Employees I and F's statements are documented in the police report from interviews conducted by facility Assistant Director of Nursing (ADON) and Regional Director of Clinical Office. During interviews on [DATE], Employees B, D, N and H stated they received training about abuse after [DATE]. Employee H stated the instruction provided during training regarding getting shampoo out of a resident's hair included "have them hold their head back and rinse it out." When asked if a resident has mucous coming out their nose and going into their mouth, can you spray it off with the shower head, Employee H answered, "It is okay to spray it (face) to get it out." On [DATE], a record review of Resident #2's MDS (Minimum Data Set) Kardex Report for 2880 noted Resident #2 as "Moderately Impaired" to perform Activities of Daily Living (ADL), but made no mention of bathing or behavior issues. There was no indication the resident was receiving thickened liquids. The Kardex report is used by staff as a quick review of resident information. On [DATE], review of the shower schedule used by the CNAs (last updated on [DATE] for Resident #2) revealed the resident is scheduled to receive a shower on "Saturday" by the ",[DATE] shift." The shower schedule notes no change can be made without the Unit Manager's approval. Resident #2 was given a shower on [DATE], during the 7 - 3 shift. On [DATE] a review of Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no indication the nursing staff knew to provide the palliative care on [DATE], [DATE] and [DATE], as no nurse initialed those dates. Record review on [DATE] documenting Resident #2 was admitted to the facility on [DATE]. On [DATE] the resident was documented with a "Medical [DIAGNOSES REDACTED]." During an interview on [DATE] at 2:25 p.m., the Administrator stated, "We are pretty much concluding with the investigation. We are unable to substantiate abuse." Regarding training provided since [DATE], the Administrator said, "We have done education on the Abuse and Neglect policy; what it means, how it is reported, with examples specifically of the scenario of Resident #2. If they (staff) have an understanding of what abuse is, they are more aware of how they are interacting with residents. I am comfortable with what has taken place so far." During the interview, the Administrator did not report any training was provided regarding the appropriateness of residents receiving showers, who are on palliative care, do not like showers, and have behavior issues." The facility had failed to prevent abuse, neglect or the mistreatment of [REDACTED]. ? Interviews and record review revealed staff failed to implement safe practice showering procedures with a resident that was on palliative care; had identified issues with exhibiting difficult behaviors, including while being showered and was on thicken liquids. ? On [DATE], [DATE] and [DATE], the facility administrative staff failed to retrain and monitor adequately direct care staff administering showers to residents. The facility has failed to ensure the critical incident will not be repeated.

Based on record review, interview and observation, the facility failed to ensure policies and procedures for prevention, identification, and investigation of abuse/ neglect/ mistreatment were implemented and followed by staff for of 1 (Resident #2) of 6 sampled residents. Resident #2, who had orders to receive only thickened liquids and palliative care, and was known to be resistive to activities of daily living - including showering, was observed being sprayed in the face with water. The facility failed to identify the need to retrain staff on procedures to shower residents with similar conditions appropriately, thereby placing all of those residents at risk for serious injury, harm, impairment, or death. These failures resulted in Immediate Jeopardy being identified on [DATE]. The Immediate Jeopardy began on [DATE] and remains ongoing. The findings include: 1. The facility's policy and procedure for the prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property for the position of Administrator, created January, 2008 and updated April, 2012, contained a job title of Administrator in Sections III - Protection, IV - Prevention; V - Identification and VI - Investigation (page 3 of 6), and VIII Policy Review & Quality management (page 4 of 6), documenting the Administration will oversee and ensure safe provision of care and services, safe environment and staff training - to prevent any hazardous conditions - are addressed: ? "3. The Administrator or his/her designee investigates allegations of abuse, takes action to protect the resident during the investigation, and implements corrective actions depending on the results of the investigation. ..." ? "4. The Department Heads/ designee educates staff on strategies to identify, correct and intervene in situations in which abuse, neglect, or misappropriation of resident property is likely to occur." ? "5. The Administrator / designee identifies events such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of investigations." ? "6. The Administrator /designee investigates allegations of abuse, neglect, misappropriation of resident property, identifies staff members responsible for initial reporting, investigation of alleged violation and reporting of results to the proper authorities." ? "11. The DNS / designee analyzes occurrences and makes recommendation to the Performance Improvement committee regarding what changes are needed, if any, to policy and procedures to prevent further occurrences." On [DATE], a review of Resident #2's record revealed Nursing Progress note, dated [DATE] at 5:30 a.m., which documented, "Resident moaning loudly, then screaming (and) squeezing CNA (Certified Nursing Assistant) hands. Visible signs of pain on her face (fear and grimacing). [MEDICATION NAME] 5 mg/0.25 cc SL given at 11 p.m. and 5 a.m. with + (positive) effect. Back rubbing also had positive effects to calm her down. Took 80 cc of water during the night shift. Pulse 78, respirations 16; unlabored while awake, dyspnea noticed while sleeping. Resting with eyes closed. Will monitor." A nursing note at 12:20 p.m. documented Resident #2 was "very anxious and moaning loudly;" MS04 ([MEDICATION NAME]) 0.25 cc was administered, with minimal effect. The note states that at approximately 11:50 a.m., CNAs called the nurse into shower room where the resident was found unresponsive with a faint pulse. The resident was returned to bed immediately, then a board was placed under her. CPR was administered and oxygen was placed over her face. No pulses were felt. The paramedics arrived and continued CPR. At 12:10, paramedics stated the resident had passed away. The nursing note documented the "DON (Director of Nursing) notified and family was being contacted by DON. Westside funeral home called." During interviews on [DATE], Employees B, D, N and H stated they received training about abuse after [DATE]. Employee H stated the instruction provided during training regarding getting shampoo out of a resident ' s hair included "have them hold their head back and rinse it out." When asked if a resident has mucous coming out their nose and going into their mouth, can you spray it off with the shower head, Employee H answered, "It is okay to spray it (face) to get it out." During an interview on [DATE] at 2:25p.m., the Administrator stated, "We are pretty much concluding with the investigation. We are unable to substantiate abuse." Regarding the appropriateness of Resident #2 receiving a shower, considering she was on palliative care and had behavior issues, the Administrator said, "I do not do the bathing in-services, I could not tell you about the specific training. In reading the in-service (documents) the head is tilted back and if something is in their eyes, they should be wiping it with a wet washcloth." During this interview regarding training provided since [DATE], the Administrator said, "I am comfortable with what has taken place so far. ...if they have an understanding of what abuse is, they are more aware of how they are interacting with residents." The review of these records revealed the facility administration failed to identify the potential for inappropriate processes: 1) Showering residents on thickened liquids only, and preventing water from entering their mouths or noses; 2) Residents on palliative care receiving personal hygiene activities that do not support comfort care; and 3) Behavioral modification techniques inappropriately used with residents known to be resistive during showering. This resulted in a lack of staff retraining addressing these residents needs and preventing abuse, neglect or mistreatment. 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 resulting in a continuation of the systems failure regarding facility approaches and all nursing and direct care staff understanding the facility expectations in the appropriate procedure to shower residents having orders for thicken liquids only, on palliative care and who are known to exhibit resistive behaviors during activities of daily living including showering.

Based on staff interview, observations and record review, including the facility's Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy and procedure, the facility administrator failed to attain and maintain effectively the highest practicable physical, medical, mental and psychosocial well-being impacting 1 (Resident #2) of the 3 residents sampled, as well as 17 random residents who had orders to receive only thickened liquids, and other random residents who had orders for palliative care and were known to be resistive to activities of daily living, including showering. The facility Administrator failed to provide Quality Assurance & Performance Improvement resource management to promote and ensure the health well-being of all facility residents, and effective training to nursing and direct care staff. The Administrator failed to provide administrative oversight to ensure a complete and thorough investigation was conducted. This resulted in the lack of Quality Assurance and Performance Improvement examination and root cause analysis, causing a continuation of the systems' failure regarding facility approaches. All nursing and direct care staff failed to demonstrate an understanding of facility expectations regarding appropriate procedure to shower residents with orders for thickened liquids only, on palliative care, and who are known to exhibit resistive behaviors during activities of daily living - including showering. This failure created a situation likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE] was identified on [DATE]. The findings include: 1. The facility's policy and procedure for the prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property for the position of Administrator, created January, 2008 and updated April, 2012, contained a job title of Administrator in Sections III - Protection, IV - Prevention; V - Identification and VI - Investigation (page 3 of 6), and VIII Policy Review & Quality management (page 4 of 6), documenting the Administration will oversee and ensure safe provision of care and services, safe environment and staff training - to prevent any hazardous conditions - are addressed: ? "3. The Administrator or his/her designee investigates allegations of abuse, takes action to protect the resident during the investigation, and implements corrective actions depending on the results of the investigation. ..." ? "4. The Department Heads/ designee educates staff on strategies to identify, correct and intervene in situations in which abuse, neglect, or misappropriation of resident property is likely to occur." ? "5. The Administrator / designee identifies events such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of investigations." ? "6. The Administrator /designee investigates allegations of abuse, neglect, misappropriation of resident property, identifies staff members responsible for initial reporting, investigation of alleged violation and reporting of results to the proper authorities." ? "11. The DNS / designee analyzes occurrences and makes recommendation to the Performance Improvement committee regarding what changes are needed, if any, to policy and procedures to prevent further occurrences." On [DATE], a review of Resident #2's record revealed Nursing Progress note, dated [DATE] at 5:30 a.m., which documented, "Resident moaning loudly, then screaming (and) squeezing CNA (Certified Nursing Assistant) hands. Visible signs of pain on her face (fear and grimacing). [MEDICATION NAME] 5 mg/0.25 cc SL given at 11 p.m. and 5 a.m. with + (positive) effect. Back rubbing also had positive effects to calm her down. Took 80 cc of water during the night shift. Pulse 78, respirations 16; unlabored while awake, dyspnea noticed while sleeping. Resting with eyes closed. Will monitor." A nursing note at 12:20 p.m. documented Resident #2 was "very anxious and moaning loudly;" MS04 ([MEDICATION NAME]) 0.25 cc was administered, with minimal effect. The note states that at approximately 11:50 a.m., CNAs called the nurse into shower room where the resident was found unresponsive with a faint pulse. The resident was returned to bed immediately, than a board was placed under her. CPR was administered and oxygen was placed over her face. No pulses were felt. The paramedics arrived and continued CPR. At 12:10 p.m., paramedics stated Resident #2 had passed away. The nursing note documented the "DON (Director of Nursing) notified and family was being contacted by DON. Westside funeral home called." During interviews on [DATE], Employees B, D, N and H stated they received training about abuse after [DATE]. Employee H stated the instruction provided during training regarding getting shampoo out of a resident ' s hair included "have them hold their head back and rinse it out." When asked if a resident has mucous coming out their nose and going into their mouth, can you spray it off with the shower head, Employee H answered, "It is okay to spray it (face) to get it out." During an interview on [DATE] at 2:25p.m., the Administrator stated, "We are pretty much concluding with the investigation. We are unable to substantiate abuse." Regarding the appropriateness of Resident #2 receiving a shower, considering she was on palliative care and had behavior issues, the Administrator said, "I do not do the bathing in-services, I could not tell you about the specific training. In reading the in-service (documents) the head is tilted back and if something is in their eyes, they should be wiping it with a wet washcloth." During this interview regarding training provided since [DATE], the Administrator said, "I am comfortable with what has taken place so far. ...if they have an understanding of what abuse is, they are more aware of how they are interacting with residents." The review of these records documenting the facility administration failed to identify the potential for inappropriate processes: 1) Showering residents on thickened liquids only, and preventing water from entering their mouths or noses; 2) Residents on palliative care receiving personal hygiene activities that do not support comfort care; and 3) Behavioral modification techniques inappropriately used with residents known to be resistive during showering. This resulted in a lack of staff retraining addressing these residents needs and preventing abuse, neglect or mistreatment. 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 resulting in a continuation of the systems failure regarding facility approaches and all nursing and direct care staff understanding the facility expectations in the appropriate procedure to shower residents having orders for thickened liquids only, on palliative care and who are known to exhibit resistive behaviors during activities of daily living including showering.