Every finding on record at Stonemere Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Medication Cart 3) of 3 carts and 1 of six residents (Resident #30) reviewed for pharmacy services. 1. The facility failed to ensure LVN D responsible for Medication Cart 3, counted controlled drugs every shift change on 06/01/2026, 06/04/2026, 06/05/2026, and 06/08/2026. 2. The facility failed to ensure LVN D documented administering prn cough medication to Resident #30 on 06/09/26. This failure could place residents at risk of not having the medication available due to possible drug diversion and residents may receive the wrong dose Findings Included: 1. Record review and observation on 06/09/26 at 1:27 PM of Medication Cart 3, with LVN C ,revealed missing signatures for Off going staff and On coming staff of the narcotic count sheet for:06/01/2026 (2:00 PM to 10:00 AM shift), 06/04/26 (2:00 PM to 10:00 AM shift), 06/05/26 (2:00 PM to 10:00 AM shift),06/08/26 (2:00 PM to 10:00 AM shift). In an interview on 06/10/2026 at 2:08 PM, LVN D stated he should have signed the narcotic sheet after counting the narcotics, on 06/01/01/26, 06/04/26, 06/05/26, and 06/08/26 at the beginning and at the end of the shift. He stated he got busy and did not go back to sign the count sheet. He stated he knew that he was supposed to sign immediately after the count was done. He stated the risk would be potential for drug diversion. Review of the facility's policy Controlled Substances reviewed December 2025 reflected the following: . Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services . 2. Review of Resident #30's face sheet undated reflected Resident #30 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of lack of coordination, type 2 diabetes (chronic disease characterized by high levels of sugar in the blood), hemiplegia (paralysis) affecting right dominant side and stroke. Review of Resident #30's Annual MDS dated [DATE] reflected Resident #30 had a BIMS of 13 indicating she was cognitively intact. Review of Resident #30's current physician's orders reflected physician order dated 06/08/26 of Robafen DM Cough Oral Liquid 10-100 MG/5ML (Dextromethorphan-Guaifenesin) Give 10 ml by mouth every 4 hours as needed for cough. Interview on 06/10/26 at 10:45 AM with Resident #30 revealed she was coughing yesterday (06/09/2026) and requested from LVN D prn cough medication. She stated LVN D did give her the prn cough medication in the late evening after dinner like 7 or 8 pm. Review of Resident #30's MAR for June 2026 reflected no medication administration of Robafen DM Cough Oral Liquid 10-100 MG/5ML (Dextromethorphan-Guaifenesin) Give 10 ml by mouth every 4 hours as needed for cough for 06/09/26. Review of Resident #30's June 2026 progress notes reflected no documentation of prn cough medication given to Resident #30 on 06/09/26. Interview on 06/10/26 at 2:12 PM with LVN D revealed between 9 pm and 10 pm on 06/09/26, Resident #30 complained of a cough and he gave her the prn cough medication. He stated he should have documented the cough medication prn dose he gave Resident #30.He stated it was important to document at time of medication administration so nurses knew when medication was given especially for prn medications. In an interview on 06/11/26 at 08:34 AM, the DON stated she expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff were not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated the ADONs would check the carts weekly. The DON stated nurses should document when medication administration was given on the MAR and the risk to the resident could be overdose of medication due to other nurses not knowing resident was given the prn medication. Review of facility's policy Administering Oral Medications last revised December 2025 reflected to provide guidelines for safe administration of oral medications. Under documentation Follow documentation guidelines. This policy did not specify about documenting the medication administration in the MAR.

Based on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, in that: Dietary [NAME] G and the Dietary Manager failed to wear effective hair restraints during lunch meal preparation on 06/10/26. This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination. Findings included: Observation on 06/10/26 at 11:29 AM to 11:36 AM revealed Dietary [NAME] G was wearing a hat that did not cover 0.5 inches in front of both sides of her ears and about 0.5 inches of the back of their hair. Dietary [NAME] G was observed taking hot food temperatures of lunch food prior to serving. Dietary [NAME] G was putting food on residents' plates for lunch. Observation on 06/10/26 at 11:37 AM and 11:48 AM revealed the Dietary Manager was wearing a hat in which the back of his hair was uncovered about 2 inches, during food meal time at lunch. He went into walk-in refrigerator to get yogurt and health shakes for residents' meal trays. Interview on 06/10/2026 at 1:52 PM with Dietary Manager revealed he was not aware of hair restraints not covering the back of his hair and on Dietary [NAME] G not having the hair near their ears being covered. He stated his hair restraint must have slipped up and he thought it was covering all of his hair in the back. He stated the importance of wearing effective hair restraints was to cover all hair, to keep hair from getting into the food and to prevent infection control. Review of facility's policy Procedure undated reflected For all team members.2. Wear hairnets or beard restraints if facial hair present.All hair including any facial hair must be completely covered. Review of the Food and Drug Administration US Food Code 2022 reflected under section 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #36) of 8 residents reviewed for ADLs. The facility failed to ensure Resident #36 had her fingernails cleaned on 6/9/26. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #36's Quarterly MDS assessment dated [DATE] reflected Resident #36 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (the death of brain tissue caused by a prolonged lack of blood flow and oxygen), age related cognitive decline, and cognitive communication deficit. Her BIMS couldn't be done because Resident #36 was rarely or never understood. Resident #36's cognition was severely impaired. The MDS assessment indicated Resident #36 required extensive assistance with personal hygiene. Record review of Resident #36's Care Plan dated 05/15/26, reflected the following: Focus: [Resident #36] has an ADL self-care performance deficit. Interventions: . [Resident #36] requires staff participation. In an observation on 06/09/26 at 10:22 AM revealed Resident #36 was lying in her bed. Her nails on her right hand were dirty and had yellow greenish colored residue on the nail beds. Resident #36 was confused and her answers were not pertinent to the subject. In an interview on 06/09/26 at 11:08 AM, CNA B stated CNAs and nurses were responsible for cleaning and cutting the residents' nails. CNA B stated did not notice Resident #36's nails. She stated she would do it right then. She stated the risk would be infections. In an interview on 06/11/26 at 8:34 AM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to clean residents' nails if they were dirty. The DON stated the ADONs and the DON would do the routine rounds to monitor. The DON stated residents having dirty nails could be an infection control issue. Record review of the facility's policy Care of Fingernails/Toenails revised December 2025, reflected the following: .The purposes of this procedure are to clean the nails bed, to keep nails trimmed, and to prevent infections.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #88) of two residents reviewed for incontinence care. The facility failed to ensure CNA A provided appropriate perineal care for Resident # 88 when she failed to clean the resident's labia on 6/9/26. This failure could place residents at risk for the development and/or worsening of urinary tract infections. Findings included: Record review of Resident #88's Quarterly MDS assessment, dated 04/17/26, reflected a [AGE] year-old female with an admission date of 11/03/22 with diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit, and cerebral infarction (occurs when blood flow to a section of the brain is blocked or significantly reduced leading to the death of brain cells). Resident #88 had a BIMS score of 02 which indicated Resident #88's cognition was severely impaired. Resident#88 was always incontinent of urine and frequently incontinent of bowel. Review of Resident #88's care plan, initiated 2/11/26, reflected .Focus: [Resident #88] has . bladder incontinence related to dementia . Goal: Resident will remain free from skin breakdown due to incontinence through next review date. Interventions: [Resident #88] uses disposable briefs. Change as needed. In an observation on 06/09/26 at 11:08 AM revealed CNA A entered Resident #88's room to provide incontinence care and change the resident's clothes. CNA A washed her hands, put on gloves and unfasted the brief to reveal the resident had been incontinent of urine. CNA A pushed the soiled brief down between the resident's legs, which were held tightly together, toward her buttocks and cleaned her peri area from front to back but did not separate the labia and clean down the middle. CNA A rolled the resident onto her side revealing the resident had soaked through her brief. It was noted that the resident's skin was wet but intact. CNA A continued to provide incontinence care, wiping from front to back and applied a clean brief, and she changed resident's clothes. CNA A removed her gloves, and she washed her hands. In an interview on 06/09/26 at 11:41 AM, CNA A stated she failed to separate the resident's labia and by missing that step could lead to an infection. She stated she had been in training and knew the importance of properly cleaning a resident and timely. In an interview on 06/11/26 at 08:34 AM, the DON stated when providing incontinent care staff were to clean the peri area including the labia for female residents then moving toward the buttocks. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. The DON stated the ADONs and the DON would do routine rounds for monitoring. Review of the CDC Epidemiology and Prevention of UTI a component of preventing a Urinary Tract Infection is to provide good perineal hygiene.Accessed at https://www.cdc.gov/nhsn/pdfs/training/2018/ltcf/epidemiology-prevention-uti-508.pdf accessed on 06/12/26 . Record review of the facility's policy titled, Perineal/Incontinent Care, revised December 2025, reflected, . For a female resident: . Wash perineal area, wiping from front to back. Separate labia and wash area downward from front to back.

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #2) of one resident reviewed for tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care. The facility failed to ensure LVN E followed the procedure for tracheostomy care for Resident #2 on 06/10/26 by using sterile technique. This failure could place residents at risk for respiratory infections.Findings include:Record review of Resident #2's Quarterly MDS assessment, dated 06/05/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her active diagnoses included acute respiratory failure with hypoxia (absence of oxygen), tracheostomy (a surgical procedure creating an opening in the neck to provide a direct airway). Resident #2 was unable to complete the BIMS. In Section O-Special Treatments, Procedures, and Programs it revealed she required tracheostomy (trach) care during the 14 day look back period. Review of Resident #2's care plan dated 03/26/2026, reflected, Focus: [Resident #2] has tracheostomy. Goal: . resident will have no clear and equal breath sounds bilaterally . Interventions: . Suction as necessary . Review of Resident #2's Consolidated Physician's orders dated June 2026, reflected, .Tracheostomy care every shift and as needed. In an observation on 06/10/26 at 8:32 AM revealed RN D washed his hands; he donned gown, clean gloves, and a mask. RN F was in the room wearing a gown and clean gloves and supplies were on the bedside table. LVN E removed the disposable canula and discarded it. He removed his dirty gloves and washed his hands. RN F opened the trach kit and placed it on the bedside table. LVN E opened the sterile gloves and donned the left glove. When putting the second glove on, he touched, with the sterile gloved left hand his bare skin on his right hand, breaking the sterile field. With the contaminated hand he picked up a new inner cannula from the trach kit and inserted it into the resident's trach and locked it. With the same gloves on LVN E attached the suction to the resident's in-line suction line and inserted the suction line into the trach 2 times. LVN E then cleared the line and turned off the suction machine. He discarded the suctioning catheter. Without changing gloves, LVN E put back the trach tube on the stoma. He removes his gloves and discarded them. RN F told him to wash his hands. He washed his hands and donned clean gloves. He checked the resident's oxygen and cleaned the working field. He removed his gloves and gown; he washed his hands and left the room. In an interview and observation with LVN E and RN F on 06/10/26 at 9:04 AM LVN E stated he did not know that he contaminated his sterile gloves. RN F, who was also the ADON, showed LVN E how to wear the sterile gloves and showed him how he contaminated his gloves. LVN E stated he knew the procedure was supposed to be a sterile procedure to reduce the risk of cross contamination. RN F stated the respiratory therapist and DON were responsible for nurses' training and skills checks. Review of LVN E's competency checks for tracheostomy care reflected he was skills checked on 01/03/26 and deemed competent in trach care. In an interview on 06/11/26 at 8:34 AM, the DON stated that trach care was to be an aseptic/sterile technique. She stated failure of staff to follow proper procedures could result in infections. She stated the facility would retrain all nursing staff on trach care and would check their skills. Record review of the facility's policy, Tracheostomy Care reviewed December 2025, reflected, The purpose of this procedure is to guide tracheostomy care .Aseptic technique must be used .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #10) of 3 observed for infection control. The facility failed to ensure CNA B changed gloves and completed hand hygiene during incontinent care for Resident #10 on 6/9/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness.Findings include: Record review of Resident #10's Quarterly MDS assessment dated [DATE] reflected Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (a decline in cognitive abilities, severe enough to interfere with daily life), cognitive communication deficit, and muscle weakness. Resident #10's BIMS score of 03, which indicated Resident #10's cognition was severely impaired. The MDS assessment indicated Resident #10 required assistance with toileting hygiene. Observation on 06/09/26 at 12:50 PM revealed CNA B entered Resident #10's room to provide incontinent care. CNA B washed her hands and put on gloves. She unfastened Resident #10's brief; she provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. Without changing gloves, she rolled the resident on her side, and she discarded the soiled brief. Without changing gloves, she put a clean brief under the resident's buttocks. She wiped the resident's buttocks area with peri-wipes, front to back. Without changing gloves, she applied skin barrier cream to the resident's peri-area (the area between the vaginal opening and anus)--. She rolled the resident on her back onto the contaminated brief. Once finished, she fastened the resident's brief. She covered the resident and she removed and discarded her gloves and washed her hands. In an interview on 06/09/26 at 1:08 PM, CNA B stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA B stated failing to provide proper care would expose the residents to infections. In an interview on 06/11/26 at 8:34 AM, the DON stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. She stated nursing staff were trained to perform hand hygiene between change of gloves. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated she would educate all nursing staff, and she would do random rounds for monitoring. Record review of the facility's policy, Hand Washing / Hand Hygiene, revised December 2025, reflected, . This facility considers hand hygiene the primary means to prevent the spread of infections . Use an alcohol-based hand rub, or alternatively, soap and water for the following situations: . Before moving from a contaminated body site to a clean body site during resident care .

Based on observation, interview and record review, the facility failed to ensure that the residents' right to review survey results had a posted notice of the availability of the survey results in a prominent, readily accessible to residents, family members and legal representatives of residents for 1 of 1 facility reviewed for postings. The facility failed to ensure a notice of survey results availability was prominent and accessible to residents. This failure could affect residents who reside in the facility and could result in a lack of awareness for visitors, family, and residents regarding the survey results and the plan of correction submitted by the facility.Findings included: In a confidential group interview on 06/10/26 at 10:30 AM with 7 residents revealed they were not aware of the residents' right to access survey results of the facility. They stated they would like to be able to review the survey results but did not know where they were located for them to access the survey results. Interview on 06/11/26 at 9:38 AM with the Activity Director revealed she had been working at the facility for over a year. She had not informed the resident council of the right to review survey results and where they the results were located. She stated the survey results binder was on a table right near the front door entrance. She stated it was important for residents to be informed of where the survey results were located so they could look at them for themselves and be aware of the facility's survey history. Observation on 06/11/26 at 9:51 AM revealed the survey results binder was behind pamphlets at the front entrance on the table to the right. There was no visible signage to indicate where the survey results were located. Interview on 06/11/26 at 9:58 AM with the Administrator revealed it was important for residents and families to know where the survey results of the facility were located so they could be informed of the facility's survey history. He stated residents and families were informed at admission and that he had spoke to resident council in the past about the right to review survey results and where they were located. Review of facility's undated policy Resident Rights Guidelines for all Nursing Procedures reflected to provide general guidelines for resident rights while caring for the resident. It did not specify the residents' right to review survey results of a facility without having to ask.

Based on observation, interview and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for one (Hall 200) of five medications carts reviewed for medication storage. The facility failed to ensure medication supplies were secured or attended by authorized staff when the medication cart on hall 200 was left unlocked by RN A. This failure could place residents at risk of having access to medications and/or lead to possible harm or drug diversions. Findings included: Observation on 04/02/2026 at 9:57 AM revealed a medication cart on Hall 200 unlocked with drawer pulled open. There was no nurse or medication aide observed anywhere near the medication cart. The medication cart was accessible to investigator to walk around the medication cart and access medications. Observations of Housekeeping staff, Hospice Aide, and Wound Care Nurse walking by the unsecured medication cart. At 10:02 AM RN A was observed walking out of a resident room down the hallway. Interview and observation with RN A on 04/02/2026 at 10:03 AM revealed the unsecured, unlocked medication cart belonged to RN A. RN stated the medication cart should be locked at all times and the narcotics were to be under double lock. RN A walked behind the medication cart and confirmed the cart was left unlocked and that drawers were open. RN A was not able to state why he had left the medication cart unlocked while unattended. RN A stated the cart should have been locked but was not. RN A stated there was a risk of residents taking medications from the cart. RN A then locked the cart. Interview with the DON on 04/02/2026 at 12:24 PM revealed medication carts should be locked at all times or within eyesight of the nurse or medication aide. For example, placing the medication cart directly outside of a resident's door to their room and pulling medications, and walking in to administer them. The DON was informed of the observations made during rounds earlier in the day. The DON stated leaving a medication cart unlocked and/or drawers open allowed anyone (including other staff, residents, or confused people) to have the ability to reach in the medication cart and take out medications and ingest. The DON stated it was up to all of the nurses, medication aides and administration to ensure medication carts were locked as rounds were being made throughout each day. Review of the Storage of Medications policy dated December 2025 revealed Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation.2. The nursing staff shall be responsible for maintaining medications storage AND preparation areas in a clean, safe, and sanitary manner.7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubical, drawer, or other holding area to prevent the possibility of mixing medication of several residents.10. Only person authorized to prepare and administer medications shall have access to the medication, including any keys.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five (Resident #1) observed for infection control. 1. The facility failed to ensure RN A sanitized the glucometer and surfaces with a recommended germicidal wipe by placing the clean, sanitized glucometer on top of an unsantized medication cart, on top of RN A's handwritten notes and then carried the glucometer into Resident #1's room, placed the glucometer on the unsantized overbed table and then back out to the medication cart. 2. The facility failed to ensure RN A prevented cross contamination of the insulin pin when RN A prepared and cleaned the tip of the insulin pin without wearing gloves, and then carried the insulin pin into Resident #1's room, raised his shirt, cleaned the skin, and injected insulin into Resident #1's abdomen without wearing gloves. These failures could place residents at risk for infection and cross contamination.Findings included: Review of Resident #1's face sheet dated 04/02/2026 revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was diagnosed with Dementia (memory loss), Dysphagia (difficulty swallowing), Acute Kidney Failure (sudden, often reversible loss of kidney function occurring within hours or days, causing waste buildup, reduced urine output and fluid retention), and Type 2 Diabetes Mellitus (chronic metabolic condition where the body resists insulin and fails to produce enough to maintain normal blood sugar levels). Review of Order Summary Report for Resident #1 dated 04/02/2026 revealed Resident #1 was ordered Inject 15 unit subcutaneously before meals for DM [Diabetes Mellitus].Insulin Lispro Subcutaneous Solution Cartridge 100 Unit/ML (Insulin Lispro) Inject per sliding scale if 71-130=0; 131-180=3 units; 181-240=6 units, 241-300=9 units; 301-350=12 units; 351-400=15 units higher than 400; notify MD/NP, subcutaneously five times a day for DM prior to meal. During an observation on 04/02/2026 at 12:05 PM revealed RN A was headed to Resident #1's room. The glucometer was noted on the top of the medication cart, sitting on a stack of handwritten papers. RN A removed a test strip, some alcohol pads, a lancet and pulled out some tissues. RN A performed hand hygiene, put on gloves, and entered Resident #1's room. RN A placed a tissue on the overbed table for Resident #1 and placed the glucometer on top of the tissue. RN A pricked Resident #1's finger, obtained a blood sample with a reading of 141. RN A returned to the medications, disposed of the lancet and test strip and placed the used glucometer on the top of the medication cart on top of the stack of handwritten papers. RN A then sanitized his hands. RN A pulled out the insulin pin, cleaned the top of the insulin pin with alcohol, without wearing gloves. RN A walked back into Resident #1's room, assisted Resident #1 with pulling up his hospital gown, RN A primed the insulin pin, then cleaned Resident #1's skin on the right side of his abdomen with an alcohol swab with his bare hands. RN A then administered it into Resident #1's abdomen with no gloves. RN A then went back to the medication cart, placed the soiled insulin pin on top of the medication cart, and went back into the bathroom and washed his hands. Interview with RN A on 04/02/2026 at 12:18 PM revealed RN A originally sanitized the glucometer prior to investigator walking up. RN A stated he sanitized the glucometer before use and then again after using it. RN A stated he did not clean the top of the medication cart. RN A stated there was a kill time of three minutes. RN A stated he should have worn gloves while prepping the insulin pin and administering the insulin to Resident #1. RN A stated this was to reduce the spread of possible infections. Interview with the DON on 04/02/2026 at 12:24 PM revealed glucometers were to be cleaned prior to use and after use. The DON stated the nurse should take the supplies needed in the room and obtain the blood sample, get the blood sugar reading and then come back out of the room and put the glucometer in a dirty spot on the medications cart which was usually a wash basin or on a piece of wax paper to prevent touching the medication cart. The DON stated then the nurse would draw up the insulin depending on the blood sugar reading and orders from physician. The nurse would then prepare the skin, inject the insulin, wipe the skin and discard the sharps. The DON stated the process should be completed while wearing gloves. The DON stated wearing gloves and completing hand hygiene in between tasks was to prevent spreading infections to the next person. The DON stated the nurse could pass anything onto the glucometer on to the next patient. The DON stated that tissue was not considered an effective barrier and should be using wax paper on a clean surface. The DON stated RN A was a new employee to the facility and would need to receive additional education regarding infection control practices. Review of Infection Control Guidelines for All Nursing Procedures dated revised December 2025 revealed Purpose To provide guidelines for general infection control while caring for residents.1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. Stand Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes.4. Employees must wash their hands for twenty (20) seconds or longer using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents:.d. After removing gloves;.e. After handling items potentially contaminated with blood, body fluids, or secretions;5. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are no visibly soiled, use an alcohol based hand rub containing 60-95% ethanol or isopropanol for all the following situations:a. Before and after direct contact with residents:b. Before donning sterile gloves;.d. Before preparing or handling medications;.g. After contact with a resident's intact skin;h. After handling used dressings, contaminated equipment, etc.;i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident: andj. After removing gloves. Review of Obtaining Accucheck/Fingerstick Glucose Level dated December 2025 revealed Purpose The purpose of this procedure is to obtain a blood sample to determined the resident blood glucose level.Steps in the Procedurel . Place the equipment on the bedside stand or overbed table. Arrange the supplies so that they ran be easily reached.2. If using the blood glucose monitoring system (blood glucose meter with test strips), use test strips before their expiration date. Do not use test strips that have been wet, bent or otherwise damaged.3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Single-resident use fingerstick devices (pen-like devices) should never be used by more than one resident.4. Wear clean gloves.gauze to seal the puncture site.17. Clean and disinfect reusable equipment between uses according- to the manufacturer's instructions and current infection control standards of practice.18. Remove gloves and discard into designated container.19. Wash hands.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #1) reviewed for infection control. 1. The facility failed to place Enhanced Barrier Precautions signage near Resident #1's room.2. CNA A and CNA B failed to implement Enhanced Barrier Precautions while providing incontinent care to Resident #1. 3. CNA A failed to perform hand hygiene while providing incontinent care to Resident #1.These failures could place residents at risk for healthcare associated cross contamination and infections. Findings include:Record review of Resident #1's face sheet, dated 08/19/25, reflected an [AGE] year-old male, who most recently admitted to the facility on [DATE]. Resident #1 had diagnoses which included sepsis (a life-threatening complication of an infection which occur when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body), functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine).Record review of Resident #1's MDS Assessment, dated 07/07/25, reflected he had a catheter (a thin, flexible medical tube used to drain fluids or deliver medications to or from the body, most commonly a urinary catheter which drains urine from the bladder ).Record review of Resident #1's Physician's Orders, dated 08/19/25, reflected he was on Enhanced Barrier Precautions and Standard Precautions due to having a catheter. The orders specified, .Resident is not limited to room or activities. [NAME] PPE inside the room.Staff must don gown and gloves when performing high contact care such as bathing/showering, peri -care/brief changes, dressing changes, meds via enteral tube or central line, toileting, transfers, providing hygiene, changing linens, device care. The start date for this order was 07/01/25 and there was no set end date.Record review of Resident #1's Care Plan, dated 08/19/25, reflected he had a catheter due to his diagnosis of benign prostatic hyperplasia and urinary obstruction. A goal for Resident #1 was to show no signs or symptoms of urinary infection. The start date for this focus area was 07/01/25 and there was no set end date. The Care Plan did not specify any focus area for Enhanced Barrier Precautions or standard precautions.Observation on 08/19/2025 at 12:20 PM revealed there was no Enhanced Barrier Precaution signage by Resident #1's room. Neither CNA A nor CNA B donned a gown upon entering Resident #1's room to provide incontinent care . When performing incontinent care, CNA A did not perform hand washing or hand hygiene or change gloves between wiping Resident #1's perineum and obtaining new wipes from the clean wipe pack. When CNA A did change gloves, she did not wash her hands or apply hand sanitizer before putting on another pair of gloves.During an interview with CNA A on 08/19/2025 at 12:30 PM, she stated she was allergic to hand sanitizer and forgot to wash her hands between glove changes. She stated the failure placed residents at risk for healthcare associated cross contamination and infections.During an interview with RN C on 08/19/2025 at 12:58 PM, he stated he was not aware Enhanced Barrier Precautions signage was not posted near Resident #1's door. He stated this placed residents at risk for infection, should staff fail to see the sign and use appropriate PPE.During an interview with the Director of Nursing on 08/19/2025 at 1:00 PM, she stated she was not aware Enhanced Barrier Precautions signage was not posted near Resident #1's door. She stated she would place a sign on the door immediately. The Director of Nursing said the risk of improper hand washing/hand hygiene during incontinent care included the risk of cross contamination and infection .Record review of the facility's Enhanced Barrier Precautions policy, dated 12/2024, reflected, .Enhanced Barrier Precautions shall apply to the care of all residents in the facility with an infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, colostomy care, medication administration via g-tube, and device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing.Record review of the facility's Hand-Washing/Hand Hygiene policy, dated 12/2024, reflected, .The facility considers hand hygiene the primary means to prevent the spread of infections.2.All personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.9.The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, and refrigerator areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, and refrigerator areas. 3. The facility failed to ensure that expired items in the dry storage pantry were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other food-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on [DATE] at 9:10 AM, revealed the following: * 3 boxes of 15 oz. raisins with an expiration date of [DATE]. * 1 box of unsealed 15 oz. raisins with an expiration date of [DATE]. * 2 packages of 24 oz. cherry gelatin mix with an expiration date of ,d+[DATE]. * 2 packages of 24 oz. raspberry gelatin mix with an expiration date of ,d+[DATE]. * 2 packages of 24 oz. stawberry gelatin mix with an expiration date of ,d+[DATE]. * 4 boxes of 40 oz. hasbrown potatoes with an expiration date of [DATE] * 1 package of peanut topping in a plastic zip top bag without label and use by date. * 2 unsealed packages of vanilla pudding mix that was exposed to air, without any use by dates. * 1 package of lemon gelatin with a hole in the package was exposed to air. * 2 unsealed plastic containers with blue lids labeled Oats and exposed to air. * 1 box of puree rice was unsealed and exposed to air. * 2 packages of pasta noodles were unsealed and exposed to air. * 1 opened package of powdered dry milk was unsealed and exposed to air. * 1 opened package of breadcrumbs was unsealed and exposed to air. * 1 plastic container of 13 oz. mediterranean style ground oregano was unsealed and exposed to air. * 1 plastic container of 30 oz. dill weed seasoning was unsealed and exposed to air. * 1 plastic container of sugar was unsealed and exposed to air. * 1 plastic container of flour was unsealed and exposed to air. Refrigerator area: * 1 package of sliced ham was unsealed in an unsealed clear plastic zip top bag and exposed to air. * 1 package of scambled eggs was not labeled and dated with an expiration date. * 1 clear plastic container labeled Jalapenos [DATE] @ 7:05 pm was unsealed and exposed to air. * 1 clear plastic container with blue lid labeled strawberries was unsealed and exposed to air. In an interview with the Executive Chef on [DATE] at 10:26 AM, he stated that he had been employed at the facility for 2 years. He was informed about the findings of the initial brief tour of the kitchen, which included expired and unsealed items in the dry storage, and refrigerator areas. He stated that all items that were unsealed would be discarded and thrown in the trash. He reported that all staff were responsible for ensuring that there were not any expired and unsealed items in the dry storage, refrigerator, and freezer areas. He reported that he would now make rounds of the aforementioned areas to make sure that there were here were not any expired and unsealed items in the dry storage, refrigerator, and freezer areas in the kitchen. The Chef stated that he had a total of 8 staff members that he supervises, and they work various shifts. He stated that the kitchen had new staff members, and he had done several in-service trainings with his staff regarding food storage and checking for expired items throughout the kitchen area. He reported that training his new staff was a work in progress, but he would have to give them some reeducation via in-service trainings relating to the findings of the initial brief tour of the kitchen. He stated that he gives his staff in-service trainings about three times per month. The Chef stated that if staff find anything such as expired items, he expectation for them was that they immediately throw away the item and then tell him about it. He stated that if there was something that was not labeled and/or dated, his expectation was for his staff to tell him about it and then he would reeducate and retrain the staff via an in-service training. He reported that all the staff in the kitchen to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired, unsealed, labeled and dated. He stated that the items found in the kitchen by the surveyor was a mishap and he would continue to provide education to his staff to ensure that everyone was on the same page with his expectations and the facility's policy on Food Storage. He stated that his expectation for his staff, was that they use the FIFO procedures to ensure that there were not any expired food items throughout the kitchen. He stated that his last in-service training with his staff on Food Storage was about 2 weeks ago. He stated that both residents, visitors and staff eat food that was served from the kitchen. He stated that if anyone eats food from the kitchen that was expired or comes from unsealed containers or bags, they could have the risk of becoming sick, which could cause them to have issues with their stomach. In an interview with [NAME] D on [DATE] at 10:45 AM, he stated that he had been employed as the cook at the facility for 2 years. He stated that he was unaware that there were expired and unsealed items in the dry storage, and refrigerator areas. He stated that all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas of the kitchen. [NAME] D stated that he had taken in-service trainings on food preparation and storage and his last in-service training was about 2 or 3 weeks ago. He reported that the in-service training he had taken in the past mentioned that staff were always to make sure that everything in the kitchen areas, such as the dry pantry, refrigerator and freezer areas were labeled (to include the date it was placed in the refrigerator and a use by date) and sealing of plastic containers and bags. He stated that if a staff member sees any item(s) that were expired, the staff member was to throw the item away in the trash can and then inform the Chef what they threw away. [NAME] D stated that with any exceptions, everything in the dry storage, freezer and refrigerator areas should be labeled and dated. [NAME] D stated that if someone ingested food that had been cross-contaminated, there was a risk that someone could die. He stated that if anyone eats food that came from the kitchen's dry pantry, refrigerator and freezer areas that were unsealed, and expired items it could cause someone become sick. He stated that if someone gets sick, it could cause them have stomach aches, headaches, and diarrhea. In an interview with the [NAME] E on [DATE] at 11:02 AM, he stated that he had been employed at the facility for 6 months. He stated that he was unaware that there were expired and unsealed items in the dry storage, and refrigerator areas. He stated that all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas of the kitchen. He stated that the Chef had hired some new people and had been trying to educate everyone in the kitchen about his expectations, but they were being trained by the Chef. [NAME] E stated that he had taken an in-service training on food preparation and storage and his last in-service training was about 2 weeks ago. He stated that he received education on using the FIFO method in his last in-service training. He stated that if he saw food that was expired in the dry pantry, refrigerator and/or freezer areas, he would throw it away and then notify the Chef about what he found. He stated that if he saw any food in the dry pantry, refrigerator and/or freezer areas that was unsealed, he would throw it away and notify the Chef of what he found. [NAME] E stated that if he saw anything that was not labeled and dated, he would notify the Chef. He stated that if he found something that was not labeled and/or dated, he would immediately throw it away because no one would know when the item was stored and if someone eats it, they could get sick. [NAME] E stated that if someone ingested any food that had been unsealed, and expired they were at risk for salmonella poisoning and the stomach bug. He stated that any ingestion of food that had been unsealed and expired, they could be harmed by being food poisoned. Record review of the facility's policy titled Food Storage: Policy and Procedure dated, 2022 reflected, Policy Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. Procedure: .7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. Old stock is always used first (first in - first out method or FIFO). The person designated to manage stock should be trained to rotate it properly. b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded. d. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging. 8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated . 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code . 13. Refrigerated food storage: .f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. 14. Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded . Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for two (Resident #15 and Resident #34) of five residents reviewed for PASRR Screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #15. The resident did not receive a PASRR Level II assessment Evaluation. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #34. The resident did not receive a PASRR Level II assessment Evaluation. This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: Record review of Resident #15's quarterly MDS assessment, dated 01/27/2025, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 12 indicating the resident's cognition was moderately impaired. Her diagnoses included Anxiety, Depression, Bipolar II, and Schizoaffective - Bipolar Type. Record review of Resident #15's Care Plan reflected: *02/06/2025: The resident was taking psychotropic medications to manage symptoms of schizoaffective disorder *02/06/2025: The resident was taking medications to manage symptoms of depression. Record review of Resident #15's PASSR level 1 screening, dated 05/01/2023, reflected the resident did not have a serious mental illness and serious mental illness was checked as no. Record review of Resident #15's Electronic Health Record revealed no PASSR level 2 evaluation was completed. Record review of Resident #34's quarterly MDS assessment, dated 01/18/2025, reflected the resident was a [AGE] year-old female originally admitted to the facility on [DATE]. The resident's Cognitive Skills for Daily Decision Making was coded at a 3 which is severely impaired. Her diagnosis included Major Depressive Disorder, Recurrent, Mild, and Generalized Anxiety Disorder. Record review of Resident #34's Care Plan reflected: *02/13/2025 The resident was taking medications to manage symptoms of depression. Record review of Resident #15's PASSR level 1 screening, dated 05/01/2023, reflected the resident did not have a serious mental illness and serious mental illness was checked as no. Record review of Resident #34'ss Electronic Health Record revealed no PASSR level 2 evaluation was completed. An interview on 04/09/2025 at 1:35 p.m. with MDS Nurse 1 revealed Resident #15 had a negative PASSR Level 1 because of her diagnosis of dementia. When asked to clarify that diagnosis, MDS Nurse 1 stated Resident #15 had a cerebrovascular stroke which causes vascular dementia. When asked again to clarify the dementia diagnosis, she stated she is trying to clarify with Resident #15's physician to see if she has dementia. An interview on 04/09/2025 at 1:35 p.m. with MDS Nurse 2 revealed in May of 2023 the facility switched over to a new system and she had to redo all residents PASSR assessments. She reported Resident #15's PASSR was most likely a mis-entry. When asked if Resident #15 has a diagnosis of dementia she stated no. An interview on 04/10/2025 at 2:00 p.m. with the DON revealed around May of 2023 the facility started a new program in which all resident charts were switched over. She reported that the MDS department told her when those charts were switched over it may have resulted in a glitch in the system resulting in incorrectly entered PASSR evaluations. The DON reported she cannot speak specifically on resident's PASSR evaluations since she does not do them. Review of the facility's policy and procedure PASSR Requirements Level 1 & Level II dated March 2022 reflected, Procedure: 1. During the admissions process, Business Development will communicate with the facility regarding prospective admissions. A Level 1 PASSR will be provided prior to admission to the Skilled Nursing Facility. The facility administration will confirm that a Level I review has been completed prior to transfer to the SNF setting. Procedure: 2. Determine if a serious mental illness &/or intellectual disability or a related condition exists while reviewing the PASSR from completed by the Acute Care Facility. (Trigger for Level II Completion.

Based on observation, interview, and record review the facility failed to establish and maintain an infection and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of 3 residents (Residents #72 and #344) reviewed for infection control. CNA A failed to complete hand hygiene or change gloves when providing incontinent care to Resident #72. CNA B failed to complete hand hygiene or change gloves when providing incontinent care to Resident #344. This failure could place residents at risk for spread of infection and cross contamination. Findings include: Record review Resident #72's face sheet, dated 10/10/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #72 had diagnoses which included hypertension, epilepsy, rheumatoid arthritis, lack of coordination, and repeated falls. Record review of Resident #72's admission Minimum Data Set, dated dated dated [DATE] reflected, Resident #72's Brief Interview for Mental Status reflected a score of 14 indicating no cognitive impairment. Resident #72 was occasionally incontinent of bowel and bladder and required assistance with toileting. Record review of Resident #72's care plan, initiated on 02/12/25, reflected Resident #72 had activities of daily living self-care performance deficit. Goal was to improve the function level. Intervention/Tasks reflected Resident #72 required extensive assistance of 1 staff participation to use toilet. Record review Resident #344's face sheet, dated 10/10/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #344 had diagnoses which included hypertension, anxiety, dementia, lack of coordination, parkinsonism, and pressure ulcer. Record review of Resident #344's admission Minimum Data Set, dated dated dated [DATE] reflected, Resident #344's Brief Interview for Mental Status reflected a score of 03 indicating severe cognitive impairment. Section H on bowel and bladder had not been completed. Record review of Resident #344's care plan, initiated on 04/3/25, reflected Resident #344 had activities of daily living self-care performance deficit. Goal was to improve the function level. Intervention/Tasks reflected Resident #344 required total assistance of 1 staff participation for toileting. In an observation on 04/10/25 at 11:35 AM revealed CNA A providing incontinent care to Resident #72. CNA A entered the resident's room and completed hand hygiene, and then gloved. CNA A then started to provide incontinent care to the resident. After cleaning the resident who was moderately soiled with urine, CNA A took off the dirty brief and then without any form of hand hygiene or change of gloves, CNA A applied the clean brief, positioned the resident in bed and touched the resident's linens. Then CNA A proceeded to clean her hands after care. In an interview on 04/10/25 at 11:43 AM with CNA A, she stated she had been educated on infection control about one and half months ago. CNA A stated she was only supposed to complete hand hygiene in between care if the gloves were visibly soiled, but if they were not, she did not need to change gloves or complete hand hygiene after cleaning the resident. CNA A stated she was supposed to maintain infection control during patient care to prevent cross contamination. In an observation on 04/10/25 at 12:06 MP reflected CNA B was providing incontinent care to Resident #344. The resident was on enhanced barrier precaution and the staff had gown and gloves on. CNA B positioned the resident and provided incontinent care to the resident, the resident was moderately soiled with urine. After cleaning the resident, CNA B did not complete hand hygiene or change gloves, and with the same gloves CNA B applied the clean brief, positioned the resident, touched the resident's linens and wheelchair, and then took off the gloves. In an interview on 04/10/25 at 12:25 PM with CNA B, she stated she was not aware she was supposed to complete hand hygiene after cleaning the resident. She stated she was supposed to complete hand hygiene before and after care. CNA B stated she had been in-serviced on infection control about 1 week ago, and the in-service was about making sure the staff-maintained infection control to prevent cross contamination. In an interview on 04/10/25 at 12:43 PM with ADON C revealed she was the infection preventionist. ADON C stated the nursing staff had been in-serviced on infection control. Regarding providing incontinent care, the ADON C stated the staff were supposed to complete hand hygiene and change gloves after cleaning the resident before applying the clean brief or touching the resident's linens. The staff were to maintain infection control to prevent cross contamination. ADON C provided the infection control in-serviced completed on reflected CNA A and CNA B had been in-serviced on infection control. In an interviewed on 04/10/25 at 03:14 PM with the DON she stated she expected the aides to complete hand hygiene after cleaning the resident before applying the clean brief due to infection control. She stated the staff had been educated on infection control and the staff were supposed to maintain infection control to prevent cross contamination. Review of the facility policy reviewed December 2024, titled Perineal/Incontinent Care reflected, The purposes of this procedures are to provide cleanness and comfort to the resident, to prevent infection and skin irritation . Review of the facility policy reviewed December 2024, titled Infection Control Guidelines for all Nursing Procedures reflected, To provide guidelines for general infection control while caring for residents. 4. Employee must wash their hands .After contact with blood, body fluids, secretions .

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 3 of 5 of residents (Resident #11, Resident #14, and Resident #50) reviewed for MDS assessment accuracy. 1.The facility failed to accurately document Resident #11's Vision status on the Quarterly MDS dated [DATE]. 2. The facility failed to accurately document Resident #50's Vision status on the Quarterly MDS dated [DATE] 3. The facility failed to accurately document Resident #14's Tracheostomy care on the Quarterly MDS dated [DATE]. These failures placed residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #11's Face Sheet, dated 04/10/25, revealed the resident was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted to the facility on o 12/01/20 and 11/28/24. The resident's diagnoses included: chronic kidney disease, type 2 diabetes mellitus with hyperglycemia (chronic condition that happens when one had persistently high blood sugar levels), heart failure, and unspecified visual loss. Record review of Resident #11's Quarterly MDS assessment, dated 01/30/25, revealed the resident had a BIMS score of 13 indicating his cognition was intact. Resident #11 could demonstrate normal cognitive abilities and likely required minimal assistance related to memory and cognitive skills. Section B - Hearing, Speech, and Vision revealed in Section B1000. Vision: Ability to see in adequate light (with glasses or other visual appliances) was coded as 0, which indicated that Resident #11, sees fine detail, such as regular print in newspapers/books. Section Z - Assessment Administration was signed by SW Assistant for Section B for Vision on 01/30/25. Record review of Resident #11's Care Plan dated, 03/26/2025, revealed: Focus: Resident #11 is legally blind Date Initiated: 03/26/2025 Created by: DON Revision on: 03/26/2025 Revision by: MDS Nurse 1 Goals: Resident #11 will maintain optimal quality of life within the limitations imposed by my visual deficits through the review date. Date Initiated: 03/26/2025 Created by: DON Revision on: 03/26/2025 Revision by: MDS Nurse 1 Target Date: 03/24/2025 Interventions/Tasks: Activities or designee assists me with completing menus weekly. Resident #11 is oriented to his meal tray as needed. Date Initiated: 03/26/2025 Revision on: 03/26/2025 Revision by: MDS Nurse 1 Arrange consultation with eye care practitioner as required. Date Initiated: 03/26/2025 Created by: DON . Ensure appropriate visual aids are available to support my participation in activities. Date Initiated: 03/26/2025 Created by: DON Revision on: 03/26/2025 Revision by: MDS Nurse 1 Resident #11 is able to: negotiate his familiar environment using my rollator. Date Initiated: 03/26/2025 Created by: Social Worker Revision on: 03/26/2025 Revision by: MDS Nurse 1 Monitor and report to MD any changes in vision Date Initiated: 03/26/2025 Created by: DON Revision on: 03/26/2025 Revision by: MDS Nurse 1 During an observation and interview on 03/08/25 at 11:10 AM of Resident #11 in his room revealed the resident was alert and sitting on his bed. Resident #11 stated that he had been at the facility for several years. Resident #11 stated that he was legally blind, and he could not see anything. Resident #11 stated that he used a cane for assistance with walking around the facility. Record review of Resident #14's Face Sheet, dated 04/10/25, revealed the resident was a [AGE] year-old female originally admitted to the facility on [DATE], readmitted to the facility on o 03/28/18 and 08/31/24. The resident's diagnoses included: encephalopathy (refers to any brain disease, damage, or malfunction, resulting in altered brain function), quadriplegia (paralysis that affects all a person's limbs), anterior cord syndrome at the C1 and C2 level of the cervical spinal cord, sequela, indicates a condition resulting from a previous injury where the anterior spinal artery (ASA) was affected at the C1 and C1 levels, hydrocephalus (the buildup of fluid in cavities called ventricles deep within the brain), chronic respiratory failure, encounter for attention to tracheostomy , dysphagia (difficulty breathing ), bacterial infection, stiffness, and contracture of muscles, multiple sites. Record review of Resident #14's Quarterly MDS assessment, dated 12/07/24, revealed the resident's BIMS score was empty indicating that the BIMS interview was not successful. The MDS revealed, Section O - Special Treatments, Procedures, and Programs revealed Resident #14 has Respiratory Treatments, Section C1: Oxygen Therapy, Section D1: Suctioning, Section E1. Tracheostomy care was blank. Section Z - Assessment Administration was signed by SW Assistant for Sections C, D and E on 11/20/24. Section Z - Signature of RN Assessment Coordinator Verifying Assessment Completion was electronically signed by the DON on 12/08/2024. Record review of Resident #14's Quarterly MDS assessment, dated 03/09/25, revealed the resident had a BIMS score that was empty indicating she had Severe Cognitive Impairment and may require more support for daily living and activities. The MDS revealed, Section O - Special Treatments, Procedures, and Programs revealed Resident #14 has Respiratory Treatments, Section C1: Oxygen Therapy, Section D1: Suctioning, Section E1. Tracheostomy care was blank. Section Z - Assessment Administration was signed by SW Assistant for Sections C, D and E on 02/25/25. Section Z - Signature of RN Assessment Coordinator Verifying Assessment Completion was electronically signed by the DON on 03/10/2025. Record review of Resident #14's Care Plan, dated 01/16//25, revealed the following: Focus: Resident #14 has tracheostomy in place Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Goal: Resident #14 will have clear and equal breath sounds bilaterally (having or relating to two sides; affecting both sides) through the review date. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Intervention/Tasks: Ensure that trach ties are secured at all times. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Give humidified oxygen as prescribed. Date Initiated: 01/16/2025 Focus: Resident #14 uses physical restraints (B/L handmitts) r/t being at risk to decannulate self secondary to involuntary movement (thrashing and flailing arms), confusion and anxiety. Striking trach area causing potential decannulation Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Goal: Resident #14 will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal through review date. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Target Date: 04/16/2025 Intervention/Tasks: Anticipate and intervene for potential causes which have precipitated prior falls or accidents. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Discuss and record with Resident #14/family/caregivers, the risks and benefits of the restraint, when the restrains should/will be applied, routines while restrained and any concerns or issues regarding restraint use. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: Nurse 1 Ensure that I am positioned correctly with proper body alignment Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Monitor/document/report to MD PRN changes regarding effectiveness of restraint, less restrictive device, if appropriate; any negative or adverse effects noted, including: decline in mood, change in behavior, decrease in adl self-performance, decline in cognitive ability or communication, contracture formation, skin breakdown, s/sx of delirium, falls/accidents/injuries, agitation, weakness. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Focus: Resident #14 will have Oxygen Therapy r/t tracheotomy, Resident #14's husband performs my trach care at times Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 During an observation of Resident #14 on 04/08/25 at 10:40 AM revealed she was lying in bed in her room. Resident #14 was non-verbal and had a tracheostomy. Record review of Resident #50's face sheet, dated 04/10/25, revealed the resident was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted to the facility on o 01/15/22 and 08/25/23 Resident #50's diagnoses included: thyrotoxicosis without a thyrotoxic crisis or storm (a condition where the thyroid gland produces too much thyroid hormone), diabetes mellitus with hyperglycemia, where hyperglycemia (the presence of high blood sugar, could occur due to various underlying conditions), blindness of left eye Category 3, (specific level of visual impairment based on visual acuity), unspecified visual loss, and hypertensive heart disease. Record review of Resident #50's Quarterly MDS assessment, dated 01/24/25, revealed the resident had a BIMS score of 15 indicating her cognition was intact. Resident #50 could demonstrate normal cognitive abilities and likely require minimal assistance related to memory and cognitive skills. Section B - Hearing, Speech, and Vision revealed in Section B1000. Vision: Ability to see in adequate light (with glasses or other visual appliances) was Coded as 0, which indicate that Resident #50, sees fine detail, such as regular print in newspapers/books. Section Z - Assessment Administration was signed by SW Assistant for Section B for Vision on 01/16/25. During an observation of Resident #50 on 04/09/25 at 12:30 PM revealed that he was walking in hallway with staff. Resident #50 was observed using a white walking cane to detect obstacles and navigate his surroundings in the hallway. In an observation and interview with Resident #50 on 04/10/2025 at 11:35 AM, he stated that he lost his vision many years ago due to his diabetes. He stated that diabetes ran in his family and his A1C levels were extremely high, and it led him to losing vision in his eyes. Resident #50 stated that he was diagnosed by his doctor as being legally blind. He stated that he could walk around the facility without any assistance of staff but used his white cane for assistance. He reported that he had not had any falls at the facility due to his blindness. In an interview with LVN F on 04/10/25 at 11:20 AM in Resident #14's room, she stated that Resident #14 received tube feeding and had a trach. She stated that she was not aware that Resident #14's MDS Assessment did not reveal that she had a trach. She stated that she cares for Resident #14 frequently and she knows that she had a trach. LVN F stated that Resident #14, and Resident #50 were both legally blind. She stated that when she was assigned a resident, she would check the resident's POC, doctor's orders and care plan to confirm what kind of care the resident needs from her. She stated that she did not have access to a resident's MDS Quarterly Assessment, therefore she did not believe that there could be any risk of harm to Resident #14 due to her MDS Assessment being incorrect. In an interview with MDS Nurse 1 on 04/10/25 at 12:45 PM, she stated that she was responsible for completing the MDS Assessment for Section E1. Tracheostomy Care. She stated that she was not aware that the Section E1. Tracheostomy Care for Resident #14 was blank. She confirmed that Resident #14 had a trach and that Section E1. Tracheostomy Care should be marked with an x. She stated that there was a risk to a resident if the MDS Assessment was not completed correctly. She stated that a resident could aspirate (the drawing of fluid or tissue from a body cavity by suction). In a telephone interview on 04/10/25 at 3 PM with Resident #14's family member, he confirmed that Resident #14 was non-verbal and had a trach due to some health issues, which caused Resident #14 to have a stroke a couple of years ago. He stated that he did not have any concerns regarding the care Resident #14 was receiving at the facility. In an interview with the SW Assistant on 04/10/25 at 1:05 PM, she had her laptop and was able to review the MDS Assessments for Resident #11, Resident #14, and Resident #50. She stated that Resident #11 and Resident #14 were both legally blind. She stated that the Section B - Hearing, Speech, and Vision revealed in Section B1000. Vision: Ability to see in adequate light (with glasses or other visual appliances) was Coded as 0, which indicate that Resident #11 and Resident #48, sees fine detail, such as regular print in newspapers/books. She confirmed that she signed, Section Z of the MDS - Assessment Administration was signed by SW Assistant for Section B for Vision. She stated that she made an error in coding the MDS Assessment for both resident's vision. She stated that she would correct the MDS Assessments for both residents. She reported that she did not think there was any risk or harm for the MDS Assessments for both residents being coded incorrectly. In an interview with the DON on 04/10/25 at 3 PM, she stated that she had been employed at the facility for 2 1/2 years. She stated that she was informed by the SW Assistant that there were issues with the MDS Assessments for 3 residents, Resident #11, Resident #14, and Resident #50. The DON stated that Resident #14 had a trach. She stated that the Resident #11 was considered legally blind but could find his way around the facility by himself without any assistance and she was unsure how much he could truly see. She stated that Resident #50 had total blindness, and he recognizes her by the sound of her voice. She reported that Resident #50 could walk around the facility unassisted by staff and uses his walking cane for assistance. She stated that the Social Worker and the SW Assistant were responsible for ensuring that the Vision Section of MDS Assessments were completed correctly for each resident. She reported that the facility had 2 MDS Coordinators (1 for short term residents and 1 for long term residents). She reported that the MDS Coordinators were responsible for ensuring that the MDS Assessments were completed for each resident. She stated that all 3 residents were long term care residents at the facility. DON stated that a nurse or CNA was not going to see the MDS Assessment for a resident, therefore she did not think that there was any risk or harm to Resident #11, Resident #14, and Resident #50 due to the information not being on the MDS Assessment. The DON further stated there was not time to go through each residents' assessment. A nurse or CNA was not going to see the MDS and the POC and they would not see it and they did not have a lot to do with each other. MDS oversight would not make a difference in what they do. She stated that the facility did not hire agency and did not have a high turnover with staff and leadership. She reported that there would be some auditing of the MDS Assessments, and reeducation and retraining of the staff that were responsible for their Sections on the MDS Assessments to ensure that nothing like this would happen again. She stated that she felt that there was not any risk to any of the residents with the care there were receiving from the staff at the facility because the facility did not hire any agency staff and staff were familiar with the residents they care for. She stated that back in the day, when she was on the floor paperwork would be used to check of everything and she would have been able to catch the errors. She stated that there was no difference in the care the residents were receiving by staff based on the MDS errors due to the nursing staff reviewing the residents care plans, plan of care and doctor's orders. She stated that she felt that there were not any risks or harm could have been done to the residents due to the discrepancies that were found on their MDS Assessments. During a telephone interview on 04/14/25 at 2:10 PM with the SW, she stated that she had been employed at the facility for 2 years. She stated that the facility was quite large and difficult to tackle all the tasks required for her to do, therefore the SW Assistant helps her complete of job tasks including reviewing and completing the MDS Assessments. She stated that she was ultimately responsible for ensuring that Sections B, C, D, E, and Q were completed on the MDS Assessments. She stated that the SW Assistant completed the MDS Assessments for Resident #11, and Resident #50. She stated that the SW Assistant knows that Resident #14 had a trach and Resident #11and Resident #50 were both legally blind. She stated that error on the MDS Assessments was an oversight and an error and once the error was brought to the attention of the SW Assistant by the surveyor, she reopened the MDS Assessment and made modifications for all 3 residents and fixed the mistakes on their MDS Assessments. She stated that going forward, she would go over the list of MDS Assessments that were completed by the SW Assistant on a weekly basis to ensure that everything that had been entered on the residents' MDS' were correct. The SW reported that she would also perform quarterly audits on the MDS Assessments before everything was locked and transmitted. The SW reported that Resident #11 and Resident #50 have the same optometry services offered to them relating to their diagnoses of blindness, but there was not anything that would assist them with vision since they were blind. She stated that Resident #11 was very independent and would take the elevator downstairs and walk to the cafe to get his coffee every afternoon. She stated that Resident #11 knows his way around the facility without any issues. She stated that Resident #50's vision was highly impaired and could ambulate throughout the facility and his environment properly. She stated that she did not think that there was any risk or harm to Resident #11 and Resident #14 due to their MDS Assessments being incorrectly coded by the SW Assistant. The SW reported that the MDS Coordinators were responsible for completing the Section E of the MDS Assessment relating to Resident #50. Record review of the facility's Assessment Frequency/Timelines policy dated 2001, reviewed/revised 12/2024 revealed, Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. Policy Explanation and Compliance Guidelines: 1. The MDS/RAI Coordinator will be responsible for tracking due dates for all MDS assessments . a. A calendar of scheduled assessments, including type of assessment and assessment reference date, will be communicated to those individuals responsible for completing portions of the MDS on a monthly basis . 4. A quarterly review assessment will be completed no less than once every 3 months .

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. The facility failed to report to the State agency when Resident #1 died in the facility after a choking episode in the facility's dining room. This failure could place residents at risk of neglect. Findings include : Record review of Resident #1's Admission Record, dated [DATE], reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS assessment, dated [DATE], reflected her diagnoses included history of stroke, dysphagia (difficulty swallowing) following cerebrovascular disease (disease involving blood vessels in the brain), other speech and language deficits following a stroke, falls, hypertension (high blood pressure), and diabetes. She had severe cognitive impairment, she was totally dependent on staff for eating (helper does all of the effort) and all other ADLs, and she was on a mechanically altered diet. Record review of Resident #1's Care Plan reflected the following Special Instructions: Assist with Feeding Aspiration (accidental breathing in food or fluids) Precautions-Nectar Thick Liquids or Thin via 5cc (Blue) Provale Cup (specialized cup that only allows a small amount to be sipped at a time). An entry initiated [DATE] reflected: Focus: I am on a NAS/CC Diet, Thin liquids with provable cup, Minced texture, may have regular bread and desserts, No pureed vegetables, requires assistance with meals, refuses assistance frequently will not let anyone help with meals, eats with hands, may wear glove when eating. Interventions/Tasks included: Dietary Consult as needed; offer a varied menu with choices; offer other condiments to substitute for sugar/sweets and Salt. Another entry, dated [DATE], reflected: Focus: I am a DNR. Interventions/Tasks: If found absent of vital sign do not initiate CPR. Record review of Resident #1's Order Summary Report, dated [DATE], reflected the following orders were included: NAS/CC diet Minced & Moist texture, Nectar (Level 2 mildly thick) consistency. May have thin liquids via 5 cc (Blue) Provale cup. May have Regular bread and dessert. No pureed vegetables. The order was dated [DATE]. DNR. Order dated [DATE]. Record review of Resident #1's Progress Notes reflected the following entries: An entry, dated [DATE] at 8:33 PM, reflected, Resident was observed coughing during her dinner in the Dinning [sic] Room at [5:35 PM], Hemlock [sic] maneuver was applied immediately by this nurse, resident was observed not responsive, Resident was assisted to the room, help was called, resident was transferred to bed by nursing staff, assessment was done by RN and pulse was felt, oxygen applied at 3 Lpm via nasal canula. 911 called - they came immediately and took over. Resident was a DNR, MD notified, as well as resident's daughter and DON by staffing co-coordinator. The entry was signed by LVN A. An entry, dated [DATE] at 9:00 PM, reflected, 911 pronounced resident at [5:47 PM], 911 called medical examiner who came and pick resident remains in the presence of resident's daughter. The entry was signed by LVN A. Record review of a Speech Therapy Encounter Note, dated [DATE], reflected the following: .MBSS completed on [DATE] with recommendations for puree and thin liquids via controlled flow cup and no straw. Following 24-hour trial of puree texture pt requested to return to minced moist textured diet despite being educated regarding risks of aspiration, aspiration pneumonia and possible death. SLP left message on daughters VM regarding MBSS results, dietary recommendations and pt's request to return to MM texture. Pt agreed to continue on NTL while SLP trains pt in Provale cup and compensatory swallow strategies to reduce aspiration risks on thin liquids. During an interview on [DATE] at 10:45 AM, LVN B stated she had cared for Resident #1. She stated Resident #1 was unable to drink well by herself and had difficulty managing a cup. She stated Resident #1 was always fed by staff and had difficulty getting food into her mouth on her own. She stated the resident was at risk for aspiration and choking due to swallowing difficulties. LVN B stated Resident #1 would tell you, 'let me do it' and would try but you had to be there with her. LVN B stated she was not working at the time Resident #1 passed away but heard she had choked. She stated she cared for her during the day shift on [DATE] and did not recall her having any respiratory issues or anything else out of the ordinary. During an interview with MA C on [DATE] at 10:56 AM, she stated she typically passed medications to Resident #1 during the day shift. She stated Resident #1 had to have her medications crushed and could choke on thin liquids. MA C stated she occasionally picked up extra shifts as a CNA and fed Resident #1 during meals. She stated whenever she cared for Resident #1, the nurse insisted they stayed with her anytime she was eating, even if she wanted to feed herself, she had to be there at all times because of her risk for choking or coughing. MA C stated she was working the day shift on [DATE] and was not in the facility at the time Resident #1 passed. She stated she had passed her medications that day and did not recall anything unusual occurring. During an interview on [DATE] at 11:19 AM, CNA D stated she worked at the facility for 5 years and regularly cared for Resident #1. She stated Resident #1 was always fed in the dining room and they offered her thickened liquids throughout the day. She stated she often fed Resident #1 and never noticed her coughing or choking. She stated someone was always sitting with her in the dining room because everyone knew she was at risk for choking. CNA D stated she cared for Resident #1 on the day she passed and did not recall anything out of the ordinary with her that day, she stated she was surprised and sad to learn she had died . During an interview on [DATE] at 12:36 PM, SLP E stated she began working at the facility in [DATE]. She stated Resident #1 was at risk for choking and aspiration. She stated Resident #1 and had a waiver in place since prior to her arrival that had been discussed with her family. She stated Resident #1 did well with her meal most of the time but wanted thin liquids rather than thickened. She stated they got a Provale cup for her which only allowed 5 cc at a time. She stated Resident #1 liked some of the foods pureed and would request it at times. SLP E stated Resident #1 would reach for food from other resident's plates at times so there was always someone with her at her table. She stated food was not left at the tables until staff were sitting and ready to feed the residents due to the risk for aspiration and choking. SLP E stated she was not present at the time Resident #1 had her choking episode. She stated she was not aware of any other incidents which involved Resident #1 or any other resident since she had been with the facility. An interview with the DON on [DATE] at 1:05 PM revealed she was not in the facility at the time Resident #1 had the choking episode in the dining room on [DATE]. She stated she saw her in the TV area after lunch that day. She stated Resident #1 ate in the dining room [ROOM NUMBER]% of the time at a table with other residents who needed assistance with their meals. The DON stated Resident #1 received meals that were minced and moist and could occasionally pick something up and eat it, such as finger food, but was unable to manage the use of utensils. When asked about bread, the DON stated, if the food was soft, she did okay. The DON stated she was typically in the facility from 4:00 AM to 2:30 PM every day so she could see all three shifts. She stated she investigated the incident and spoke with everyone who was in attendance. The DON stated she was told it may have been a piece of bread and her charge nurse told her he thought a part of a sandwich possibly become lodged in her throat. The DON stated LVN A performed the Heimlich maneuver they took her out of the dining room and put her to bed, called 911, and administered oxygen. She stated she was aware Resident #1 had a DNR order but that did not mean do not treat and she felt they acted appropriately. The DON stated the paramedics arrived and initiated CPR. She stated LVN A informed them Resident #1 had a DNR order, but the paramedics continued until they spoke with her family for confirmation. She stated LVN A notified the family and they spoke with the paramedics and asked them to stop. The DON stated the police and coroner were there at the facility and took over her care. The DON stated the Administrator was made aware of the situation immediately after it occurred and had been speaking with staff throughout the incident. She stated staff sent her a text message, but she did not see it until the following morning. When asked why they had not reported the incident to the State, the DON stated she discussed it with the Administrator and neither of them suspected neglect, foul play, or anything done by anyone that could have caused the incident and they determined it did not warrant reporting . During an interview on [DATE] at 1:46 PM, LVN A stated he worked for the facility for about 1 year and 4 months. He stated he always worked the evening shift and typically cared for Resident #1. He stated Resident #1 had swallowing issues, was on a modified diet with thickened liquids and was fed by staff. LVN A stated, on [DATE], staff were feeding residents in the dining room which included Resident #1 who was at a table in her wheelchair. He stated CNA H was feeding Resident #1 when he entered the dining room and saw Resident #1 beginning to cough. He stated he rushed to her and thought he recalled seeing bread and mashed potatoes on her plate and she appeared to be choking. LVN A stated he performed the Heimlich on her which was not successful. He called for help and began moving her out of the dining room and she was still conscious at the time. He stated two other nurses met him near the dining room entrance and immediately began working with her, they attempted the Heimlich again and moved her to her room while he called 911. LVN A stated RN F placed Resident #1 on oxygen and LVN G was assisting with assessing her. He stated the paramedics arrived very quickly as he was still on the phone with the 911 operator when they arrived. He stated the paramedics moved Resident #1 to the floor and began CPR. He stated he informed the paramedics Resident #1 had a DNR order, but they continued CPR and told him they wanted to confirm it with her family. LVN A stated he called Resident #1's family and placed them on the phone with a paramedic, after which, they stopped CPR. LVN A stated the paramedics pronounced Resident #1 as deceased . He stated the police and Medical Examiner arrived and waited for Resident #1's family to arrive. LVN A stated the Medical Examiner removed Resident #1 from the facility after her family arrived. LVN A stated he had not fed Resident #1 himself recently but was not aware of her having any other issues of concern that day. He stated the Administrator was informed of the situation. During an interview on [DATE] at 2:26 PM, RN F stated she began working at the facility in [DATE] and always worked 2:00 PM to 10:00 PM shift. She stated she was working on her hall on [DATE] when she heard someone calling for help from the dining room area. She stated she rushed over and saw LVN A moving Resident #1 out of the dining room. She stated she felt for a pulse, and one was present. She stated another nurse, LVN G assisted with getting her to her room while she ran to retrieve oxygen. She stated LVN A was calling 911. She stated Resident #1 was breathing at that point, she could see her chest rise and fall and did not attempt another Heimlich. She was told Resident #1 was DNR. She stated LVN G checked the resident's pulse oximeter (measures oxygen in the blood) and assisted placing oxygen on her. She stated she stayed with Resident #1 and the paramedic arrived quickly. She stated she left once the paramedics took over her care and returned to her residents. RN F stated staff were always present in the dining room due to risks for choking and aspiration. In an interview on [DATE] at 2:47 PM, LVN G stated she just began working at the facility on [DATE] and never took care of Resident #1. She stated she was working the 2:00 PM to 10:00 PM shift on [DATE]. She stated she was at the far end of the hall, heard someone yelling, and saw LVN A rushing Resident #1 out of the dining room in her wheelchair. LVN G stated she rushed over and attempted the Heimlich maneuver with no results. She stated they rushed her to her room and got her into bed. LVN A went to call 911 and RN F went to retrieve oxygen, and she attempted to get an oxygen reading on her but was unable to get a reading. She stated Resident #1 was not responsive but breathing at that point. She stated they placed her on oxygen and the paramedics arrived quickly. LVN G stated, after they arrived, she rushed out to assist with getting her paperwork together and learned it had already been retrieved. She stated, at that point, Resident #1 was in their care, and she went back to check on the other residents. She stated she regularly checked the dining room to ensure residents were getting assistance with meals and that the staff assisting them were taking it slow and monitoring the residents for any signs of aspiration or choking. LVN G stated she was not aware of any other incidents while she worked at the facility. During an interview on [DATE] at 3:43 PM, CNA H stated she worked at the facility for approximately 6 months on the 2:00 PM to 10:00 PM shift and assisted with feeding residents in the dining room. She stated she was with Resident #1 in the dining room on [DATE] during dinner. She stated they typically brought the residents to the dining room at about 4:45 PM and got them situated. They would sometimes provide drinks for them while they waited. She stated she fed Resident #1 several times before without any issues. CNA H stated the nurses typically checked the trays for accuracy and brought them to the CNAs when they were ready to feed them. Trays were never left with residents until they were there with them because residents could not be left alone with their food if at risk for choking. CNA H stated, on [DATE], she was sitting with Resident #1 and was situated between her table and an adjacent one, Resident #1 was the only one at her table. She stated Resident #1 had been joking that day and stated she wanted a strawberry [NAME], and someone brought her some thickened cranberry juice which made her laugh. She stated Resident #1 took some sips of her juice and began to cough. She stated she moved the juice away from her at that point to allow her to catch her breath. CNA H stated Resident #1 was fine when her tray arrived. She stated she recalled she was served minced meat with gravy on bread along with mashed potatoes. CNA H stated she mixed a little bit of the mashed potatoes with some of the minced meat and bread on a spoon and fed it to Resident #1. She stated Resident #1 began to cough and she called out for assistance. She stated LVN A was already approaching her when she turned around and went directly to the resident. She stated LVN A told her to call for help and he began administering the Heimlich maneuver. CNA H stated she called for a nurse who was walking by and LVN A was already moving her out of the dining room. She stated she saw another nurse arrive and she went back to the dining room to continue with the other residents. CNA H stated she had never seen anything like that happen before. She stated she was trained in CPR and the Heimlich and was last recertified in [DATE]. She stated they were trained never to leave residents unattended in the dining room because they could choke or aspirate. She stated she never saw Resident #1 cough during her meals or when she offered her drinks during her shift . In an interview on [DATE] at 4:47 PM, the Administrator stated he was contacted about the incident involving Resident #1 on [DATE]. He stated, from what he knew, LVN A noticed Resident #1 was choking or thought she was choking, performed the Heimlich maneuver and brought her to a flat area and called 911. He stated other nurses were there to assist him. He stated Resident #1 was a DNR and she still had a pulse. He stated EMS arrived quickly and initiated CPR. He stated LVN A provided them her DNR document, but they continued CPR because they wanted to hear from her family. The Administrator stated there were numerous staff present in the dining room and he did not believe there was anything suspicious or concerning. He stated the Medical Examiner arrived and Resident #1's family member arrived who lived 2 hours away. The Administrator stated a Nurse Manager, (QA/Staffing Coordinator), was present and was assisting and keeping him informed of the events. He stated there was nothing suspicious, they talked to all the staff involved and concluded the nurse took all the actions he was supposed to. He stated he read the Provider Letter, discussed everything with the DON again the next morning and reviewed all their processes. He stated EMS pronounced her death. When asked how he was certain there was no neglect or felt the need to report to the State, the Administrator stated they looked at everything, the QA/Staffing Coordinator said he checked her tray himself to ensure she had the correct meal, and they did not suspect any neglect. He stated they never heard anything back from the Medical Examiner or EMS and he felt they would have if they had suspected wrongdoing. The Administrator stated they had recently implemented a system that included nurse managers on duty to also serve as meal managers to ensure the meals were correct, on time, and staff were available and assisted the residents. He stated they implemented the system prior to the facility's last State Survey which was in [DATE] . During an observation and interview with the QA/Staffing Coordinator on [DATE] at 5:12 PM, he stated he was on duty on [DATE] when Resident #1 had the choking incident. He stated he checked her dinner tray when he was told she may have choked and stated she received the correct meal. He stated he observed sliced white bread with minced meat and gravy, mixed vegetables, and mashed potatoes. He stated someone called him and said they needed to get her DNR document printed. He stated he ran for the book to retrieve her document. The QA/Staffing Coordinator walked to a facility crash cart (a cart with medical supplies used during a life-threatening emergency) and identified the contents of the cart including a binder. The binder contained the names of the residents in the facility along with their code status (full resuscitation or Do Not Resuscitate) as well as copies of the resident's Do Not Resuscitate documents. The QA/Staffing Coordinator stated the documents were also available in the electronic record, but the binder allowed faster access in case the computers or printers were down. He stated, when he arrived, EMS was providing CPR and LVN A was on the phone with Resident #1's family member. He stated an EMS member got on the phone with Resident #1's family then stopped CPR and pronounced her death. He stated Resident #1 was on the floor and he assisted with moving her roommate from the room. The QA/Staffing Coordinator stated the Medical Examiner arrived and waited for Resident #1's family to arrive before leaving with her remains. The QA/Staffing Coordinator stated he kept the Administrator informed of all developments. He stated part of his duties in the facility was to back up the nurses in the dining rooms by checking trays for correct diets and textures and ensuring there was adequate staff to assist the residents. He stated he assisted with feeding residents as well whenever needed. He stated he had never encountered a situation such as the one involving Resident #1. He stated the risk for inadequate staff and failure to ensure the correct trays were passed included risks for aspiration or choking. During an interview on [DATE] at 6:38 PM, the Administrator stated he believed in reporting any suspected abuse or neglect occurring in his facility was very important and he did not believe neglect occurred related to Resident #1's death. He stated the risk of not reporting potential abuse or neglect was harm to the people for whom they provided care. During an interview on [DATE] at 6:45 PM, the DON stated she looked at every angle of Resident #1's death the following day when she learned about it and did not believe any neglect had occurred. She stated the risk of not reporting suspected abuse or neglect included repeating the same behaviors. Record review of the facility's policy and procedure titled Risk Management: Abuse, Neglect, exploitation, Mistreatment of Resident, or Misappropriation of Resident Property, dated revised [DATE], reflected the following: Policy: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of residents property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation . 1. The Administrator is responsible for designating an Abuse Coordinator . 3. The Administrator, DON and Risk Manager are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. 4. The Administrator, DON and Risk Manager are also ultimately responsible for the following . - Reporting . Reporting . Facility will be in compliance with Federal regulations and State specific reporting Requirements . An Immediate report will be filed with DADS for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuses or result in serious bodily injury, or not later than 24 hours if the events that cause the a/legation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides/or jurisdiction in long-term care facilities) in accordance with State law through established procedures

Based on observation, interview and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #5) reviewed for freedom from physical restraints. - The facility failed to obtain consent, physician's order, and care plan for Resident #5's full bed rails in which the resident movements were restricted and there was no documentation the restraints were required to treat his medical symptoms. This failure could put residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). Findings included: Record review of Resident #5's admission record dated 03/07/24, revealed a [AGE] year-old male admitted to the facility 12/13/22 and readmitted on [DATE]. Admitting diagnoses included, senile degeneration of the brain (trouble remembering; difficulty paying attention, difficulty communicating with people, challenges related to reasoning, judging situations), repeated falls, legal blindness, muscle wasting, lack of coordination and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - Behavior not exhibited, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - Behavior not exhibited. E0900: Wandering - 0 (Behavior not exhibited). Section G: Functional Status. G0300: Balance during transitions and walking: A. Moving from seated to standing position - 88 (Not attempted due to medical condition or safety concerns). E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Section P0100: Physical Restraints: Not used. Record review of Resident #5's Care Plan initiated 01/29/24 reflected, Focus I use enabler(s) (1/2 rails) related to family request. Goal, I will remain free of complications related to enabler including contractures, skin breakdown, altered mental status, isolation or withdrawal through review date. Interventions, Anticipate and intervene for potential causes which have precipitated prior falls or accidents. Discuss and record with me (DON), family, caregiver. Ensure valid consent on chart prior to initiating enablers. The full side rails were not care planned. Record review of Resident #5's enabler utilization assessment effective date 10/13/23 and signed 10/13/23 reflected the resident was assessed for 1/4 side rails on both sides of the bed per family request. Record review of Resident #5's enabler utilization assessment effective date 11/14/23 and not signed reflected an handwritten note that stated the family insistent of full rails. The assessment did not reflect who completed it. Observation of 03/06/24 at 12: 42 PM revealed CNA Q assisting the resident to get in bed. CNA Q explained to the resident what she is doing and after placing the resident in bed CNA Q pulled up full side rails on both sides of the bed, lowered the bed and placed a fall mat besides the bed. Resident #5 was not observed moving in bed or trying to get out of bed. In an interview on 03/06/24 at 12:01 pm, with Resident #5's responsible party she stated the family pushed for the full side rails, and they wanted the resident to have the full side rails because of the constant falls. She stated since the resident had the side full rails there had not been any reports of fall. She stated they will continue to push the facility for the full side rails even if it made to take and extra step. In an interview on 03/06/24 at 12:03 pm with LVN O revealed she was the charge nurse for the resident. LVN O stated Resident #5 required total assistance with activities of daily living. Resident #5 was legally blind, non-verbal, and heard of hearing. Resident #5 was a high risk for fall and had prior history of falls by trying to get out of bed. Resident #5 was not ambulatory and required assistance with transfers. LVN O stated full side rails were used on Resident #5 to prevent the resident from falling and had not witnessed the resident trying to get out of bed when the side rails were up. LVN O stated Resident #5 was on hospice and hospice provided the bed with the full side rails. LVN O stated she did not remember when the resident started using the full side rails. LVN O stated there was potential for injury if the resident got trapped in the rail, but the resident had not tried to get out of bed and there had not been reports of fall since Resident #5 started using the full side rails. LVN O stated there was supposed to be an order and care plan for the full side rails, and she was not aware why Resident #5 did not have the order and care plan. LVN O stated she did no know who got the order for the full side rails or completed the full side rails consent. In an interview on 03/06/24 at 01:36 pm with CNA Q revealed she provided care to Resident #5. CNA Q stated Resident #5 was not oriented, he was confused, he required total assistance with activities of daily living. Resident #5 initially he was ambulatory but had declined to using a wheelchair, he was weaker and required two staff to assist with transfer. Resident #5 was a high fall risk and had prior constant fall, he would slide out of the chair because of constantly moving and from bed he would slide out. CNA Q stated Resident #5 was constantly moving in bed and at times he would be sideways but not in the rails. CNA Q stated she had not witnessed Resident #5 trying to climb over the rails or being caught in the rails. CNA Q stated she had not witnessed Resident # fall. In an interview on 03/06/24 at 02:19 pm with LVN R revealed she was not aware Resident #5 had full side rails. LVN R stated she was the one responsible to update the care plan, but she was to receive the information from the nursing department for her to be able to update at the care plan. LVN R stated since this was a new care plan for full side rails the nursing department were to initiate the care plan. LVN R stated the care plan was needed to make sure the resident goal and interventions were met. In an interview on 03/06/24 at 04:06 pm with the DON revealed she was aware of Resident #5 having the full side rails. The DON stated initially Resident #5 had 1/4 side rails, and the responsible party talked to the hospice company who brought the bed with full side rails. The DON stated the facility had informed the resident's family it was against the regulation to use the full side rails, but the family declined and insisted for the resident to use the full side rails. DON stated the family's rationale was that the resident hadn't had a fall from bed since the resident started using the full side rails. The DON stated she was the one who talked with the family and got the consent for the full side rails and at the time she explained to the family the risk of using the full side rails. The DON did not remember the time she got the family consent, but per the enabler utilization assessment effective date was 11/14/23 for the full side rails. The DON stated she was responsible on making sure the full side rails were care planned and there was an order for the full side rails. The DON stated an order was required for any equipment used by the resident, so that the staff were able to monitor for the effectiveness. The DON stated the care plan was required to show the resident's needs, and to help meet the resident's needs, also to the staff to be able to monitor the resident when side rails in use. Record review of the facility policy revised 2023 titled, Use of Restraints, reflected, Restraints shall only be used for safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls.1.Physical Restraints are defied as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual can not remove easily, which restricts freedom of movement or restricts normal access to one's body. 4. Practices that inappropriately utilize equipment to prevent resident's mobility are considered restraints and are not permitted including: a. Using the bedrails to keep a resident from voluntary getting out of bed as opposed to enhancing mobility while in bed;. 9. Restraints shall only be used upon written orders of a physician and after obtaining a consent from the resident and/or representative (sponsor). The order should include the following; a. The specific reason for the restraint (as it relates to the resident's medical symptoms) b. How the restraints will be used to benefit the resident 's medical symptoms. c. The type of restraint, and the period of time for the use of the restraint.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 10 of (108, 117, 118, 120, 121, 218, 224, 227, 231, 238) of 62 resident bathrooms reviewed for environment. The facility failed to ensure 10 (108, 117, 118, 120, 121, 218, 224, 227, 231, 238) rubber shower [NAME] were properly glued down to ensure a safe environment. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment. Findings included: Observations on 03/05/2024 between 12:02 PM and 1:15 PM, revealed the rubber Shower Dam (used in roll in showers to stop water from moving past the shower area to the rest of the bathroom floor), in rooms #224, #227, and #238, were not completely glued down. The rubber Shower [NAME] were attached to the floor on each end and the glue in the middle appeared to have failed and allowed the rubber strip to move two - three inches in each direction. Observations on 03/06/2024 between 7:31 PM and 8:00 AM, revealed the rubber Shower Dam in rooms #108, #117, #118, #120, and #121, were not completely glued down. The rubber Shower [NAME] were glued to the floor on each end and the glue in the middle appeared to have failed and allowed the rubber dam to move two - three inches in each direction. In an interview on 03/05/2024 at 12:02 PM, a resident who resided in room [ROOM NUMBER] said staff assisted her shower to the shower but she could shower on her own. She stated she had not noticed that the rubber dam was not completely attached to the floor in the shower. She said she if her foot got caught on it, she could trip. She said the shower chair could also get tangled in the loose rubber dam. In an interview on 03/06/2024 at 7:31 AM, a resident who resided in room [ROOM NUMBER] said she only required staff to turn the shower was able to do the rest herself. She stated she had not noticed that the rubber dam was not completely attached to the floor in the shower. She said the loose rubber could cause her to trip while in the shower. In an interview on 03/06/2024 at 8:30 AM, ADON B stated she was not aware of the loose Shower [NAME]. She said she completed Concierge Rounds for rooms #234 - #239 and did not check the shower in the rooms. She said they were definitely a trip hazard for residents who were able to walk into the shower on their own. She said they were a safety concern because shower chairs could get caught on them as well. She said staff were instructed to log any maintenance concerns in the logbook at the nurse's station. She reviewed the Maintenance Logbook between the dates of 12/19/2023 - 03/05/2024 with this surveyor and found no record of loose Shower [NAME]. In an interview on 03/06/2024 at 9:19 AM, the Maintenance Director said he did have problems with securing the Shower [NAME] to the floor. He said they required an epoxy glue that needed to and when he repaired them he placed signs on the bathroom door for staff not to use the shower until the glue had dried, but staff removed the signs and used the showers anyway. He stated he needed to find an alternate fix because he was constantly gluing them down. He said they needed to be secured to the floor to prevent the risk for residents or staff tripping on them. He said staff were required to enter any maintenance issue in the logbook and he checked he book daily to address needed repairs. He said he initialed the logbook when repairs had been completed. He stated there were no entries in the Logbook for him to repair shower [NAME] between 12/19/2023 - 03/05/2024. He stated sometime staff would stop him in the hall to tell him of maintenance issues and that could be why the issue was not logged in the Maintenance Logbook. In an interview on 03/06/2024 at 1:15 PM, the Housekeeping Director stated she completed Concierge Rounds for rooms #215 - #217 and had not noticed the loose Shower Dam in room [ROOM NUMBER]. She stated she checked for maintenance issues and resident concerns. She said she had not thought to check the bathrooms. She said she would log the issue in the maintenance log for repair had she seen it. She said it was a safety concern as residents could trip and fall. In an interview on 03/06/2024 at 1:25 PM, the Administrator stated he expected staff to note any maintenance concerns in the Maintenance Logbook at the nurses' stations and Maintenance staff to address the concerns timely. He said he also implemented Concierge Rounds, where facility management were assigned rooms to check daily. He said management staff had a form to complete for each room which addressed environment, safety issues, and clinical and dignity issues. He said each manager brought their forms to the morning meetings where concerns were discussed and follow up planned. He said he had not been made aware of the loose Shower [NAME]. He stated they were a safety concern in that residents and staff could trip on them. In an interview on 03/06/2024 at 2:15 PM, LVN D stated she completed Concierge Rounds for rooms #224 - #227 and had not noticed the loose Shower [NAME] in rooms #224 and #227. She said and maintenance issues should be logged in the maintenance log for repair. She said the loos rubber on the floor in the shower posed a safety risk to residents because they could trip. In an interview on 03/06/2024 at 2:32 PM, the Executive Assistant stated she was responsible to complete Concierge Rounds for rooms #228 - #233. She said the purpose of completing rounds daily was to identify any issues the resident may have or concerns with the room. She said she last completed the rounds about 8:40 AM on 03/06/2024. She said she had not noticed the loos Shower Dam in room [ROOM NUMBER]. She stated it could be a safety risk for residents because they could trip on the loose rubber. In an interview on 03/06/2024 at 2:45 PM, the LVN E stated she completed Concierge Rounds for rooms #120 - #124 and had not noticed the loose Shower [NAME] in rooms #120 and #121 when she completed rounds on 03/05/2024 and 03/06/2024. She stated one of the purposes of Concierge rounds was to ensure the rooms were safe, but she did not think to check the shower. She said the loose rubber on the floor, in the shower was a safety concern to residents as they could trip. In an interview on 03/06/2024 at 2:50 PM, ADON C stated she completed Concierge Rounds for rooms #106 - #112 but had not noticed the loose Shower Dam in room [ROOM NUMBER]. She stated it the [NAME] were not glued down and were loose, the posed a safety risk to residents and staff. In an interview on 03/06/2024 at 3:05 PM, the DON stated Concierge Rounds were done daily to help to identify maintenance issues, ensure quality and address any concerns residents may have. She said any concerns would be addressed in their morning meeting and maintenance concerns should be logged in the Maintenance Logbook at the nurses' station. She said any loose rubber in the showers posed a safety risk to residents as they could trip. Record review of the Maintenance Logbooks between the dates of 12/19/2023 and 03/05/2024 reflected no record of loose Shower [NAME]. Record review of the facility's policy, titled, Hazardous Areas, Devices and Equipment, reviewed December 2023, reflected All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazards 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: a. Equipment and devices that are left unattended or are malfunctioning; b. Devices and equipment that are improperly used or poorly maintained; c. Sharp objects that are accessible to vulnerable residents; d. Open areas or items that should be locked when not in use; e. Irregular floor surfaces (cords, buckled carpeting, etc.); f. Objects in the hallways that obstruct a clear path; g. Access to toxic chemicals; h. Insufficient lighting or glare .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the walk-in cooler and dry-storage areas were stored away from soiled surfaces and airborne contaminants. The facility failed to ensure kitchen equipment (Ice Machine, Coffee Maker, free standing Fans) were free of airborne contaminants. These failures could place residents, who received food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation on 03/05/24 08:25 AM revealed the vents on both sides of the Ice Machine covered with black dust and fuzz. The vent on the left side faced a food preparation area and the vent on the right side of the Ice Machine faced a drink dispenser, drink dispenser gun, and ice scoop. The insulated coolant hose in the walk-in cooler was observed to be covered in thick, moist black dirt and fuzz. The hose ran the length of the walk-in cooler and was directly above food stored on shelves in the cooler. An observation on 03/05/24 08:35 AM, in the dry food storage room, revealed three covered bins, one labeled cornmeal, one labelled breadcrumb, and one labeled brown sugar. Dust and food particles were observed on the lids. A free-standing fan in the corner of the kitchen pointing toward the cooking area had a buildup of dust and fuzz on the blades and the front and back blade cage. The fan was not on at the time of observation. An observation 03/07/24 11:45 AM revealed the vent on the top of the coffee maker covered with black sticky fuzz. A second free standing fan placed on top of the food warmer had dust and fuzz on the blades and the blade cage. The fan was not on at the time of observation. A measuring cup was observed in a bin containing rice, in the cooking area. In an interview on 03/05/24 08:25 AM, the Dietary Manager and Corporate Dietician said the [NAME] machine was cleaned daily. They said there should not be any dirt or dust on the vents because it could be dislodged and contaminate food in the prep area or near the drink dispenser. They stated the black dust built up on the insulated coolant hose in the walk-in cooler posed a risk of food contamination as it could get into food stored immediately below the hose or anywhere in the cooler. The Dietary Manager said the lids on the three bins containing breadcrumb, brown sugar, and cornmeal should be kept clean to prevent any dirt or food particles from contaminating the produce when staff opened the lids. He stated the fan on the floor facing the cooking area was used to help cool the kitchen. He said his should be free of any dust to prevent any air-borne contaminants. The Dietary Manager said the walk-in cooler was cleaned after each delivery, but he had not noticed the grime buildup in the refrigerant pipes. In an interview on 03/05/24 02:52 PM, the Administrator stated he expected the Dietary Manager to ensure kitchen equipment was kept clean and food was stored appropriately to ensure residents were not exposed to contaminated food or food borne illness. In an interview on 03/07/24 07:31 AM, the DON stated she expected kitchen staff to store and prepare food according to professional standards. She said equipment should not have a buildup of dust because it could blow onto food. She said the kitchen should be maintained clean and sanitary to prevent food contamination and food-borne illness to the residents. In an interview on 03/07/24 11:45 AM, the Dietary Manager said the fan on top of the food warmer was used to help cool the kitchen and should be free of any dirt and dust to prevent it from getting into food and a potential for food- borne illness. He said the vent on top of the coffee maker should also be clean and free of dust build up because when the fan ran, it could blow dust into food. He stated the measuring cup stored in the rice bin posed a risk to contaminate food and should not be left in the bin. He stated staff were expected to sign off on kitchen cleaning tasks, on the cleaning schdule. He said he was responsible to train and monitor kitchen staff to ensure they completed cleaning tasks. Record review of the facility's cleaning schedule dated 02/04/2024, reflected the initials indicating completion of the following: Ice Machine, Door, inside and out. Clean & Restock Coffee/Juice Area. Cleaning of the walk-in cooler and dry storage areas were not noted on the cleaning schedule. Record review of the facility's policy titled, Recommended Storage Practices, revised 2017, reflected, A. Dry: tore all foods six inches above the floor and eighteen inches below the sprinkler heads, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater back flow or contamination by condensation, leakage, rodents, or vermin. Store all packaged food, canned foods, or food items in clean and dry place at all times. *Keep shelving and floor clean and dry at all times. *Schedule cleaning of storage room at regular intervals. *Do not store scoops in food containers. C. Refrigerated: .Schedule regular cleaning of refrigerators . IV: Food Storage: .The Nutrition Services Manager (NSM) is responsible for proper storage of nutrition services food and supplies . Record review of Federal Drug Administration Food Code, reflected, section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3-305.11 Food Storage. (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. 14 Food Preparation. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-602.

Based on Observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for one of one trash bin and trash corral reviewed garbage disposal. The facility failed to ensure trash, in the dumpster coral, was contained and maintained in a sanitary condition. This failure could place residents at risk of unsanitary conditions. Findings included: An observation on 03/05/2024 at 8:45 AM, revealed the gate to the trash corral in back of the facility to be open. Although the trash bin was closed, trash and broken furniture littered the open coral area. Rubber gloves, plastic cups and bottles, food wrappers, food waste, wheelchairs and parts, and reclining chairs in various conditions. In an interview on 03/05/2024 at 08:45 AM, the Dietary Manager stated the coral gat should be closed and there should not be any food waste or trash of any kind on the ground in the corral. He said coyotes were known to come to the back of the facility, likely attracted by trash in the coral. He said the bins and the coral should be closed to minimize the possibility of attracting pests and rodents. He said because the bins were used by all facility departments, he thought he, the Housekeeping, and Maintenance Directors were responsible to ensure the trash area was clean and free of spilled trash and debris. He said he trained his staff on the need to ensure the area was kept clean and secure. He said he did not know if other department heads did the same. In an interview on 03/05/2024 at 02:11 PM, the Maintenance Director stated the trash coral gates should be closed at all times. He said he went to look at the area and saw the spilled food, trash, and broken furniture. He said the facility had a shortage of storage, so staff often placed broken furniture and equipment in the coral. He said he did check the coral from time to time and had pressure washed it in the past. He said it was important to keep the area clean to prevent the attraction of pest and rodents. He said he did not keep a log of the power washing, but his department and the kitchen staff alternated this task so both maintenace and kitchen staff were responsible to ensure the corral was kept clean. He said he had not had any formal / recorded in services but reminded his staff verbally on several occasions. In an interview on 03/05/2024 at 02:52 PM, the Administrator said all staff were responsible to ensure the trash bins and corral were kept clean and free of spilled food and other trash. He said he had not had a written in-service but had a verbal discussion with department heads to ensure they checked the area frequently. He said he expected maintanence and kitchen staff to ensure the area was kept clean. He said he did randome grounds checks to ensure the areas outsidet the facility were clean. He said it was important to keep the area clean to limit the attraction of pests and rodents. In an interview on 03/07/2024 at 07:31 AM, the DON said she did not follow up with the trash disposal issues. She said the facility was limited on space which could be why broken equipment was in the trash coral. She stated she would expect that anyone who placed trash in the bins would be responsible to ensure the area was kept tidy, free of debris, and secured. Record review of the facility's policy titled, Maintenance Service, revised December 2017, reflected, Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. c. Maintaining the fire alarm system and emergency generator system in good working order. d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. e. Maintaining lighting levels that are comfortable and assuring that exit lights are in good working order. f. Establishing priorities in providing repair service. g. Maintaining the paging system in good working order. h. Maintaining the grounds, sidewalks, parking lots, etc., in good order. i. Providing routinely scheduled maintenance service to all areas. j. Others that may become necessary or appropriate .

Based upon observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and under proper temperature controls for 4 (Resident #1, Resident #8, Resident #13, and Resident #57) of 38 and 1 of 3 medication carts (200 Hall Nursing Cart) reviewed for drug labeling and storage. - The facility failed to ensure the 200 Hall Nursing Cart Nursing Cart did not contain an in-use insulin pen for Resident #1, Resident #8, Resident #13, and Resident #57 with no open date. This failure could place residents at risk of adverse medication reactions and drug diversions. Findings included: Record review of Resident #1's admission record dated [DATE] revealed a [AGE] years-old female, initially admitted on [DATE] and readmitted on [DATE]. Admitting diagnoses included, but not limited to: Type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dysphagia (difficult with swallowing) anxiety, chronic pain and dementia. Record review of Resident #1's physician orders dated [DATE] revealed an active order of Humalog Kwik pen 100unit/ml to administer per sliding scale, order date [DATE]. Record review of Resident #8's admission record dated [DATE] revealed an [AGE] years-old female, admitted to the facility on [DATE]. Admitting diagnosis included, but not limited to, dysphagia (difficult swallowing, chronic kidney disease, muscle wasting and gastro-esophageal reflux disease without esophagitis (happens when acidic stomach contents flow back into the esophagus) Record review of Resident #8's physician orders dated [DATE] revealed an active order of Humalog Kwik pen 100unit/ml to administer per sliding scale, order date [DATE]. Record review of Resident #13's admission record dated [DATE] revealed an [AGE] years-old female, admitted to the facility on [DATE]. Admitting diagnoses included, type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) dysphagia (difficulty swallowing), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), anxiety (feeling of fear, dread, and uneasiness), hypertensive (High blood pressure, also called hypertension) and speech and language deficit. Record review of Resident #13's physician orders dated [DATE] revealed an active order of Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously in the morning for DM, order date [DATE]. Record review of Resident #57's admission record dated [DATE] revealed an [AGE] years-old female, admitted to the facility on [DATE]. Admitting diagnoses included, acute pain, morbid obesity, type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), epilepsy (disorder of the brain characterized by repeated seizures) and pneumonia (inflammation and fluid in your lungs caused by a bacterial, viral, or fungal infection). Record review of Resident #57's physician orders dated [DATE] revealed an active order of HumuLIN R Injection Solution 100 UNIT/ML Insulin Regular (Human)) Inject 15 unit subcutaneously with meals for DM Hold if BS <125, order date [DATE] and HumuLIN R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale, order date [DATE]. In an observation and interview on [DATE] at 11:34 AM, inventory of the 200 Hall Nursing Cart with LVN P revealed: insulin Kwik pen were in the cart and the insulin pens were noted dated the open dates, Lispro Kwik pen for Resident #1, Lispro Kwik pen for Resident #8, Lantus Kwik pen for Resident #13 and Humulin R Kwik pen for Resident #57. LVN P said nursing staff are expected to check their carts daily for inappropriately labeled medications. She said insulin must be labeled with the date opened in order to track the expiration date because when insulin expired it becomes less effective. LVN P said since the insulin pen did not have an open date it must be discarded in the sharp's container because use of expired insulin could place residents at risk for uncontrolled blood sugars and not being effective. In an interview on [DATE] 01:08 PM, the DON said nursing staff are expected to check their carts daily at the beginning of their shift to make sure they did not have expired medication, and the insulin was supposed to be dated and discarded after 28 days. She said ultimately the ADON, DON were responsible for ensuring the carts are monitored and perform audits of carts every other week to ensure nursing staff maintained their carts, there was no documentation of the audits. The DON stated the insulin could be ineffective or change to a different consistence which could be harmful to the resident. Record review of the facility policy titled Storage of Medications revised ,d+[DATE] revealed, . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biological. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on interview and record review, the facility failed to immediately consult with the resident's physician and/or notify the resident representative when there was a significant change in the residents physical status for one (Resident #1) of 14 residents reviewed for notification of changes. The facility failed to ensure Resident #1 was assessed, treated, and monitored after ants were discovered in her room, on her bed, on her body, and in her hair and multiple ant bites were observed on the resident on 07/30/19. On 08/01/19 Resident #1 continued to experience a significant change in condition and had over 20 red, raised [MEDICAL CONDITION] and pustules to the right upper side of her back, right side/ribs and right axilla (armpit) without facility intervention. The facility did not take action to address the change of condition, including notifying Resident #1's physician and responsible party, until Resident #1's hospice provider intervened on 08/02/19. An Immediate Jeopardy was identified on 08/09/19. While the Immediate Jeopardy was removed on 08/12/19, the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure could place residents at risk for harm, deteriorating health, or death. Findings include: Review of Resident #1's face sheet, dated 08/09/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's quarterly Minimum Data Set (MDS) Assessment, dated 08/05/19, revealed Resident #1 had unclear speech, sometimes understood others, sometimes was understood by others, and her cognition was severely impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #1 was totally dependent on staff for locomotion on/off unit, toilet use, and bathing. The assessment reflected Resident #1's [DIAGNOSES REDACTED]., anxiety disorder, depression, muscle wasting and atrophy, chronic pain, muscle weakness, and abnormal posture. Observation on 08/08/19 at 11:18 AM revealed Resident #1 was sitting in her geri chair in the common area near station 2. An interview was attempted with Resident #1, but Resident #1 did not respond. Observation on 08/09/19 at 10:26 AM, with the DON and Treatment Nurse, of Resident #1's back revealed over 15 fading red spots to her upper right back, right rib area, and near her right armpit. Review of the facility's 24-Hour Report/Change of Condition Report, dated 07/30/19, revealed a handwritten note under Remarks (Night) for Resident #1: Ants on her side of the room, on wall, in bed, and on res (resident). Red, raised areas noted to R (right) side of back possibly due to scratching. No staff signature, staff initials, or time was documented. There was no documentation regarding monitoring, interventions, or assessment for Remarks (Day) and Remarks (Evening) for Resident #1. Review of the Maintenance Book revealed on 07/30/19 it was documented that room [ROOM NUMBER]A was full of ants. The ESD initialed on 07/31/19 with no further documentation. Review of Resident #1's Weekly Skin Assessment, dated 07/30/19, and signed by LVN C, revealed the following: right side of back area from top to bottom- red, raised areas. The assessment did not include any documentation about the ants found on Resident #1 and ants found in her bed. Review of Resident #1's Progress Notes (department notes) revealed no documentation on 07/30/19 or 08/01/19 of the incident related to the ants and ant bites. Review of pictures taken by Hospice Aide A on 08/01/19 (provided by Resident #1's hospice provider on 08/08/19 at 10:38 AM) revealed the following: one picture of approximately seven ants on Resident #1's bed; one picture of Resident #1's right upper back, right rib area, and towards her right armpit with over 20 red bumps, some with pustules. Review of Resident #1's hospice RN Recertification summary notes, completed by Hospice RN D and dated 08/02/19, revealed on 08/01/19 Hospice Aide A arrived at the facility to provide ADL care to Resident #1 and discovered ants on Resident #1's body, in her hair, and in her bed. Hospice Aide A reported Resident #1 had multiple ant bites on her right upper back, side and axilla (armpit). Hospice Aide A reported she notified LVN B (Resident #1's 6:00 AM to 6:00 PM charge nurse), as well as the off-going night shift nurse (no name documented). According to the summary notes, Hospice RN D discussed the incident with ADON [NAME] and RN F , Resident #1's nurse. ADON [NAME] and RN F stated they were not aware of the ant bites. RN F reviewed the nurses' notes in Resident #1's chart and said there was no mention of the incident and no record of treatment obtained for Resident #1. Both ADON [NAME] and RN F said ants were discovered in the resident's bed sometime last week and the resident was temporarily moved to another room while her room (room [ROOM NUMBER]) was treated. Resident #1 was subsequently returned to her room (room [ROOM NUMBER]). Hospice RN D advised ADON [NAME] and RN F that her supervisor, Hospice RN G notified the facility ADM of the incident on 08/01/19 and sent him pictures of the ants and the bites to Resident #1, taken by Hospice Aide [NAME] ADON [NAME] requested RN F and Hospice RN D assess Resident #1 together. Hospice RN D and RN F inspected Resident #1's bed and found no current evidence of ants. They conducted a head to toe skin assessment of Resident #1 and found Resident #1 had approximately 20 to 30 small, red, raised [MEDICAL CONDITION], some with small pustules, to her upper right back, right side/ribs, and right axilla. Resident #1 had several large patches of psoriasis in the same area and some of the [MEDICAL CONDITION] were on top of the psoriasis. Hospice RN D notified the hospice physician and obtained orders for oral [MEDICATION NAME] and topical [MEDICATION NAME] cream which were ordered from the hospice pharmacy for stat delivery. Hospice RN D instructed RN F to start new medications as soon as they arrived and to monitor for signs and symptoms of infection or any worsening of [MEDICAL CONDITION]. Hospice RN D called Resident #1's responsible party to advise her of situation and she said she had not been made aware of the incident last week or on 08/01/19. Review of Resident #1's Progress Notes (department notes), documented on 08/02/19 at 9:31AM by RN F, revealed the following, Did a skin assessment on pt (patient) with hospice nurse. Pt seen to have ant bites on her right posterior back, towards her under arm presented as pustules. New order given. Will continue to monitor. Review of Resident #1's physician orders [REDACTED]. Review of a facility grievance/concern report, dated 08/05/19, revealed Resident #1's hospice nurse filed a grievance related to Resident #1 being covered in ants and the daughter and doctor not being notified. Documentation of facility follow-up reflected the grievance was assigned to the DON to take action. The follow-up reflected the resident was moved to another room, pest control was notified, and the room was sprayed and inspected (no date documented). The resolution reflected rooms were inspected and sprayed (specific rooms not identified). There were no ant sightings and Resident #1 had been moved to another room. In an interview on 08/08/19 at 12:07 PM Hospice RN D stated Resident #1 was bedbound unless she was transferred to her geri chair. She stated the resident had [MEDICAL CONDITION] and dementia. She stated the resident was mostly nonverbal. Hospice RN D stated Resident #1 might mumble a bit, but could not answer direct questions. She stated Resident #1 was unable to utilize the call light. Hospice RN D stated on 08/01/19 Hospice Aide A informed her about ants in Resident #1's bed and the ant bites Resident #1 suffered. Hospice RN D stated Hospice Aide A told the nurses (not specified) at the facility what she (hospice aide) saw and they told her they would take care of it. Hospice RN D stated she went to the facility on [DATE] and spoke with RN F about the ant bites. Hospice RN D stated RN F told her she (RN F) was not made aware of Resident #1 having ants on her or having ant bites. Hospice RN D stated she was informed by RN F that there was no documentation of any treatment being ordered for Resident #1's ant bites (post incident). Hospice RN D stated she spoke with ADON [NAME] and she did not know anything about the ant incident or Resident #1's ant bites. Hospice RN D stated ADON [NAME] asked that RN F and she (Hospice RN D) assess Resident #1 together. She stated Resident #1 was still in the same room (room [ROOM NUMBER]). Hospice RN D stated she and RN F assessed Resident #1, and Resident #1 had 20 to 30 ant bites on her right upper back, her side and right armpit area. She stated the bites were very red, raised and some had pustules. She stated she could not imagine that (the bites) felt good. Hospice RN D stated she did not see any ants when she assessed Resident #1. Hospice RN D stated she notified Resident #1's responsible party (RP). She stated Resident #1's RP told her she had not been notified of the ant incident or skin change. Hospice RN D stated she (Hospice RN D) also was not notified by the facility. Hospice RN D stated ADON [NAME] and RN F told her that a week or two prior to this incident Resident #1 had been moved to another room because there had been ants in Resident #1's room. Hospice RN D stated she was told Resident #1's room was treated and the resident was moved back into her room, but was not provided with a date of when this previous incident occurred. Hospice RN D stated [MEDICATION NAME] and [MEDICATION NAME] cream were ordered for Resident #1. In a telephone interview on 08/08/19 at 7:52 PM LVN C, who worked from 6:00 PM on 07/29/19 to 6:00 AM on 07/30/19, stated she was told by CNA I that there were ants in Resident #1's room and on the resident. Initially, LVN C stated she could not remember when she was told this , but then stated she had reviewed the 24 hour report and she believed she documented the incident on 07/30/19 at 4:30 AM. (Review of the 24 hour report revealed there was no staff signature, staff initials, or time documented for the entry of this incident). LVN C stated Resident #1 was in bed in room [ROOM NUMBER] at the time of the incident. She stated when she went to assess Resident #1 she observed ants on Resident #1's back, on her bed, and on the wall. LVN C stated Resident #1 was removed from bed, wiped down, and her clothes changed. She stated Resident #1's bedding was changed and she was removed from the room. LVN C stated she saw some red, raised areas on the right side of Resident #1's back. She stated the raised areas looked more like where the resident had been scratching and she could not tell if the red areas were bites. LVN C stated she notified ADON E, the DON, and the ADM of the incident, and they said they would take care of it as soon as possible. LVN C stated she did not document the incident in Resident #1's chart and did not have a specific reason why she did not. She stated she was waiting for further instruction from management (on how to proceed). LVN C stated according to the 24 hour report she did relay information to LVN B (on-coming day shift nurse). LVN C stated looking back it probably would have been better to document the incident in the resident's chart. She stated the attending physician was not notified at that time because she could not tell if Resident #1 had been bitten by the ants. She stated she did not notify Resident #1's RP and did not know if the day nurse (LVN B) had notified her. LVN C stated it was better to notify the attending physician and the RP to be on the safe side. When asked if the incident should have been documented in Resident #1's chart LVN C stated when she returned to work on Wednesday (07/31/19 at 6:00 PM) she did not see any more ants. She stated she saw bumps to Resident #1's right side of her back but could not recall if she saw them on Wednesday (07/31/19) or Thursday (08/01/19). LVN C stated she did not recall Hospice Aide A reporting to her on 08/01/19 that Resident #1 had additional ant bites. She stated it was possible Hospice Aide A told her, but she did not recall the conversation. LVN C stated when she first saw the bumps on Resident #1 there was not a treatment order in place. LVN C stated she was not sure where to document pest sightings/concerns. She stated the family, physician, and supervisor should be notified immediately if a resident had a change in condition. Observation on 08/08/19 at 10:52 AM of room [ROOM NUMBER] revealed Resident #3 still resided in the room. Attempted to interview the resident but she did not respond to surveyor questions. In an interview on 08/08/19 at 1:00 PM Hospice Aide A stated she worked with Resident #1 while the resident's usual aide was on leave. She stated her first time to work with Resident #1 was on 07/19/19, and at that time Resident #1 was in her usual room (room [ROOM NUMBER]). Hospice Aide A stated the next time she went to the facility on [DATE] Resident #1 was in a different room. She stated at that time she was told by facility staff Resident #1 was moved to a new room due to ants, but she could not recall who told her that. Hospice Aide A stated the resident did not have any ant bites at that time. She stated when she started providing care to Resident #1 on 07/30 /19 (review of her sign in sheet showed this to be at 6:55 AM) she found quite a few ants in Resident #1's bed and on the resident. Hospice Aide A stated she informed LVN B (Resident #1's charge nurse)of the ants in Resident #1's bed. Hospice Aide A stated she removed the sheets from the resident's bed, washed Resident #1's hair, and provided a bed bath. Hospice Aide A stated she could not recall informing her supervisor on 07/30/19 of ants being found on Resident #1. She stated the resident was fine at the time but she probably should have informed her supervisor. Hospice Aide A stated she did not see Resident #1's skin on 07/31/19 because the facility aide, CNA H, bathed the resident that day. She stated CNA H did not tell her about Resident #1 having any ant bites on 07/31/19. Hospice Aide A stated she worked with Resident #1 again on 08/01/19 (sign in sheet revealed she signed in at 6:15 AM)and at that time she saw bumps on the resident's skin. She stated there were approximately 15 to 20 bumps that were raised and some were pustules. Hospice Aide A stated she informed LVN B and the night nurse, but she could not recall the night nurse's name. Hospice Aide A stated LVN B said that she (LVN B) was not aware of Resident #1 having the bumps, and LVN B said the bumps were probably from the ants. Hospice Aide A stated the night nurse also said she (night nurse) was not aware of the bumps on Resident #1. In an interview on 08/08/19 at 11:24 AM LVN B said Resident #1 was non-verbal, but could understand some questions. LVN B stated Resident #1 recently had a change in condition and had bumps on her back along the rib area. She said the bumps were being treated with [MEDICATION NAME] cream and [MEDICATION NAME], but she was not sure who had ordered the medications. LVN B stated she did not know what the bumps were. LVN B stated LVN C told her Resident #1 was moved from her normal room to a different room, by the night nurse, because of ants. She stated she could not recall the exact date LVN C told her that but maybe it was last week (07/28/19-08/03/19). LVN B stated when she initially saw Resident #1's skin (could not recall date) she did not see any bumps, but when she returned to work on Thursday (08/01/19 at 6:00 AM) she noticed Resident #1 had red bumps on her back. LVN B stated on 08/01/19 Hospice Aide A reported to her a concern about a change in Resident #1's skin and asked her to look at the resident's back, but did not say anything about finding ants on Resident #1 or in her bed. LVN B stated she when she assessed Resident #1 she did see red bumps on the resident but could not say how many. LVN B stated findings from skin assessment should be documented in the resident's electronic medical record, but she could not recall if she documented her assessment of Resident #1's skin. She stated if she recalled correctly Resident #1 had an order for [REDACTED].#1's room. She stated the ADM and DON also checked the resident's room. She stated if a resident had a change in condition the physician, supervisors and the family would be notified upon the change. LVN B stated she was not certain if there was a place to document pest sightings or concerns but maybe in the maintenance log at the nurses' station. In an interview on 08/08/19 at 2:15 PM LVN B stated she did not recall Hospice Aide A telling her on 08/01/19 that she (hospice aide) saw ants on Resident #1. LVN B stated she thought she recalled Hospice Aide A removing Resident #1's sheets but Hospice Aide A did not mention seeing ants to her. LVN B stated either LVN C or RN F notified the responsible party of Resident #1's change in condition related to her skin. LVN B stated she assessed Resident #1's skin along with Hospice Aide A, but she did not notify the resident's responsible party because she thought someone else had. In an interview on 08/08/19 at 2:59 PM ADON [NAME] stated Resident #1 was on hospice, was bed bound, and total care. She stated the ADM told her on 08/01/19 that ants had been found in Resident #1's room. ADON [NAME] stated on 08/01/19 she inspected Resident #1's bed, the floor the roommate's side of the room, but she did not see any ants. She stated she believed on 08/01/19 the ESD checked Resident #1's room and treated the room. ADON [NAME] stated Resident #1's responsible party came to the facility . She stated she told the RP she did not see any ants but the RP wanted Resident #1 moved to another room. ADON [NAME] stated she did not speak with Hospice RN D about ants being found on Resident #1 or the resident having bites. She stated Hospice RN G showed her a picture of Resident #1's skin with a moderate amount of ant bites on the right side of Resident #1's back, and she (Hospice RN G) had reported the issue to the ADM. She stated she could not recall when she was shown the picture. ADON [NAME] stated after she saw the pictures she did not assess Resident #1, and had not observed Resident #1's skin since becoming aware of the ant bites. ADON [NAME] stated she was not shown any pictures of ants in Resident #1's bed. ADON [NAME] stated she thought hospice notified the RP of the ant incident and change of condition. She stated she did not know if the facility nurses knew about ants being found on Resident #1 and/or Resident #1's change in condition because they did not tell her about it. ADON [NAME] stated she was not aware of ants being found in Resident #1's room on a previous date in (MONTH) (2019). ADON [NAME] stated if staff saw ants they should inform the charge nurse and the ESD. She stated if they saw ants on a resident the nurse should be informed and a change of condition (form) should be completed in the electronic chart. She stated a skin assessment should be conducted, the resident should be removed from the situation, and the family should be informed as well. ADON [NAME] stated if a resident has a change in condition, including with their skin, the family should be notified and staff should document in the resident's electronic chart. In an interview on 08/08/19 at 3:32 PM CNA H stated in (MONTH) (2019) she assisted Resident #1 to bed and saw an ant by Resident #1's knee and it alarmed her. She stated she turned the resident's covers back and saw a couple more ants. She stated she brushed the ants away and told the nurse. CNA H could not recall the date of the incident the nurse she told, but she thought it was on a Saturday. She stated the resident was put into a clean bed and moved to another room. She stated she did not know if the nurse assessed the resident. CNA H stated that was the only incident involving ants and Resident #1 of which she was aware. In an interview on 08/09/19 at 8:47 the DON stated the ADM and she received a message from LVN C on 07/30/19 or 07/31/19 through an app they used for secure conversations saying ants were found in Resident #1's room. The DON stated she saw the message early in the morning. She stated she did not recall the message saying ants were found on Resident #1 or in her bed. The DON stated LVN C checked Resident #1's clothes, stripped the bed, checked her bed and moved her to another room. The DON stated when she got to the facility in the morning, same day she received notification from LVN C, the ADM and the ESD had been to Resident #1's room and did not see any ants. The DON stated the ADM, ADON E, and she went to Resident #1's room, room [ROOM NUMBER], and they did not see any ants. The DON stated she did not assess Resident #1 at that time because the resident was already in the dining room eating breakfast. The DON stated she asked LVN B if she had seen any ants in Resident #1's room and if she (LVN B) had a chance to look at the resident's skin. She stated LVN B said she (LVN B) assessed Resident #1 and saw a couple of small, red, raised areas near her rib area. The DON stated she could not recall which side of the resident's body LVN B said the bites were located. The DON stated there was an order to apply [MEDICATION NAME] cream, but she was not sure if that was a new order. She stated Resident #1 was moved back to her room the same day and she had not heard any more reports of ants. The DON stated she believed LVN C notified Resident #1's RP of the incident on 07/30/19 or 7/31/19, but she had not specifically talked to LVN C about the situation. The DON stated the ADM told her Hospice Aide A took a picture of Resident #1's ant bites. She stated she did not know if the ADM saw the picture but she (DON) did not see it. The DON stated she had not seen Resident #1's skin on 08/01/19 or 08/02/9. The DON stated if a resident had a skin change the ADM, DON, ADON, physician, and RP should be notified. She stated staff should fill out a change of condition (form) for skin under risk management in the electronic chart. The DON stated she was not aware of any other ant incidents. She stated staff should document pest signings and any maintenance issues in the maintenance log at the nurse's stations. In an interview on 08/09/19 at 10:46 AM RN F (6:00 AM to 6:00 PM charge nurse for Resident #1) stated on 07/31/19 CNA H did not report Resident #1 having a change of condition. She stated on Friday (08/01/19) Hospice RN D came to the facility. She stated Hospice RN D asked her if Resident #1 had bugs on her bed, and she told the hospice nurse, no. RN F stated Hospice RN D showed her a picture of Resident #1 . RN F stated she reviewed Resident #1's chart for documentation related to an incident involving ants, but did not find anything. She stated Hospice RN D spoke with ADON E. RN F stated Hospice RN D and she conducted a skin assessment on Resident #1 and she (RN F) documented what she saw. She stated Resident #1 had over 15 pustules to her right back and axilla that looked pretty fresh. She stated Hospice RN D notified Resident #1's RP of the resident's condition and she also notified the hospice physician. RN F stated she did not see a treatment ordered for Resident #1's ant bites prior to 08/02/19. RN F stated on 07/31/19 CNA H did not report to her that Resident #1 had experienced a change of condition. RN F stated when Resident #1's RP came to the facility she told RN F the hospice nurse contacted her about the ants. RN F stated the RP told her she was not notified and did not understand why facility staff had not notified her. RN F stated the hospice nurse told her pictures of Resident #1's ant bites were forwarded to facility management on 08/01/19. RN F stated she was told Resident #1 was moved to another room due to ants found in her room and that the ESD was made ware. She stated she could not recall the date or who told her, but did recall it was prior to 07/30/19. In an interview on 08/09/19 at 12:17 PM Physician J stated she was not made aware of ants being found on Resident #1 or Resident #1 having a change in condition. She stated she expected facility staff to notify her of changed in condition and incidents, including changes or injuries to a resident's skin, even if the resident was on hospice. She stated she liked to know what was going on with her patients. Physician J stated she thought the staff was required to inform her and that it was not just a general preference. In an interview on 08/09/19 at 12:29 PM the ESD stated the aides informed him about ants in Resident #1's room about two weeks ago. He stated he could not recall the date. The ESD stated he sprayed Resident #1 room and the room next to hers the same day. He sated he had not seen ants in Resident #1's room. He stated the bed was cleaned and there was no sign of ants. The ESD stated he checked Resident #1's room for ants the day after he sprayed. The ESD stated if staff verbally told him about maintenance issues he may not document it. He stated it was possible there were pest issues on other days than what was documented in the maintenance log The ESD stated he was notified of an ant sighting in room [ROOM NUMBER] today. He stated there was no longer a resident in the room. In an interview in 08/09/19 at 12:50 PM CNA I stated she did care for Resident #1 even though LVN C indicated CNA I reported finding ants on Resident #1 on 07/30/19. She stated she did not report to LVN C an incident where Resident #1 had ants on her. Review of the daily staffing schedule, dated 07/29/19, for station 2 revealed CNA I was not listed as scheduled to work on the 6:00 PM (07/29/19) to 6:00 AM shift (07/30/19). In an interview on 08/09/19 at 1:24 PM CNA H stated she did bathe Resident #1 on Wednesday (07/31/19), but she did not notice any skin changes that she needed to report to the nurse. She stated when she came onto her shift no one reported to her that ants had been found in Resident #1's room the previous day. In an interview on 08/09/19 at 1:29 PM Hospice RN G stated Hospice Aide A took the pictures of the ants on Resident #1's bed and the ant bites and sent them to Hospice RN D. She stated Hospice RN D sent the pictures to her. Hospice RN G stated she called the facility ADM on 08/01/19 and sent him the pictures of Resident #1's back through text as they were talking. She stated she informed him of what she learned about the ant incident and resident's change of condition and he told her he would follow-up. In an interview in 08/09/19 at 2:58 PM the DON stated she did not check other rooms when she became aware of ants being found on Resident #1 The DON stated she did not know if the ADM conducted an investigation or documented anything. She stated he checked Resident #1's room but she did not know if he checked other resident rooms. The DON stated there was no staff training related to the incident after the incident occurred. In an interview on 08/09/19 5:05 PM Resident #1's RP stated she was not notified by the facility about ants being found on the resident or the ant bites. She stated the hospice nurse notified her on 08/01/19 . Resident #1's RP stated she spoke with ADON [NAME] on 08/02/19 and asked why someone did not notify her of the incident and change in condition. She stated the ADON told her she had just found out that morning (08/02/19). Resident #1's RP stated she was told by the nursing staff the ADM was aware of what happened. She stated hospice showed her the picture of the resident's back. She stated Resident #1 did complain to her of the bites itching. She stated Resident #1 would not understand if she had an insect on her and would not be able to brush ants off of her back. In an interview on 08/10/19 at 11:24 AM the ADM stated that on 07/30/19 LVN C notified him via a secure communication app that ants were found in Resident #1's room and the resident was being moved. The ADM stated he thought he received the message from LVN C in the evening, but he was not sure and could have received the message in the morning. The ADM stated he told LVN C the room would be treated tomorrow by the ESD. He stated he wanted the resident moved out of the room right away. The ADM stated the room was treated, and he did not see any ants when he looked around the room. He stated staff ensured the room was free from ants for at least 24 hours before Resident #1 was moved back to the room. The ADM stated he was not sure if the resident's RP was notified. He stated it was the charge nurse's responsibility to notify the family and if ants were found on a resident the physician should be notified. The ADM stated Hospice RN G was at the facility on 08/01/19, but did not mention ants or ant bites. He stated he did not recall Hospice RN G calling him on 08/01/19. The ADM stated Hospice RN G sent him a picture of a resident's irritated skin that he assumed was Resident #1 through text around 4:51 PM on 08/01/19. He stated the text message did not specify who the picture was of. He stated he could not recall what he did once he received the picture. He stated he was sure they discussed the ant incident in the morning meeting and he had instructed the ESD to treat the room. The ADM stated he did not document what he did post incident. He stated they should follow up once ants are found on a resident and should monitor. There was no documented evidence of other monitoring of ant sightings and no indication of monitoring put into place. In a subsequent interview on 08/10/19 at 1:23 PM the ADM showed the surveyor the text message he received from Hospice RN G. The text message contained a picture of a resident's back with numerous red bumps to their upper right back, right rib area, and under arm area. He stated he assumed he was not the first person to receive that picture. He stated other staff at the facility might have received it as well. The ADM stated he was not sure if the DON or ADON [NAME] received the picture, and he could not recall if he showed the picture to either of them, but he assumed he did. The ADM stated when he examined the picture sent by hospice he saw skin that appeared irritated. He stated he was not trained to assess skin, but he could tell there was redness and approximately 30 bumps present. He stated he did not know when the picture was taken but assumed it was around the time the ants were found. In an interview on 08/12/19 at 9:07 AM Hospice Aide A stated she took the pictures of Resident #1's back and of the ants in the resident's bed. She stated the picture of Resident #1's back was taken on 08/01/19 and the picture of the ants in her bed was taken on 07/30/19. She stated she sent both pictures to her supervisor, Hospice RN D. Hospice Aide A stated when she was at the facility on 07/30/19 she was not informed ants were found on Resident #1 or in her bed previously. Hospice Aide A stated on 08/01/19 she did not find ants in Resident #1's bed but found ant bites on her. In an interview and observation on 08/08/19 at 10:58 AM Resident #2's RP revealed she had seen ants in Resident #2's room, room [ROOM NUMBER], on Tuesday (08/06/19). She stated there were about 10 ants crawling around the pantry table. She stated she told a nurse but did not know the nurse's name. Resident #2's RP stated Resident #2 had not been affected by ants. Resident #2's RP showed the surveyor a live ant, similar to a fire ant, crawling on the floor (in the resident's room), left side of the room, near the pantry table. The ant's head and thorax was reddish brown and the a

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibited neglect of residents for one (Resident #1) of 14 residents reviewed for neglect. On 07/30/19 Resident #1 was found with ants in her bed and on her body. The facility failed to ensure the attending physician, hospice provider, and responsible party were notified timely. The facility failed to follow the policy when they failed to ensure Resident #1 was assessed, treated, and monitored after ants were discovered in her room, on her bed, on her body, and in her hair and multiple ant bites were observed on the resident on 07/30/19. On 08/01/19 Resident #1 continued to experience a significant change in condition and had over 20 red, raised [MEDICAL CONDITION] and pustules to the right upper side of her back, right side/ribs and right axilla (armpit) without facility intervention. The facility did not take action to address the change of condition, including notifying Resident #1's physician and responsible party, until Resident #1's hospice provider intervened on 08/02/19. On 08/01/19 Hospice Aide A found Resident #1 had red, raised [MEDICAL CONDITION] to the right upper side of her back, right side/ribs and right axilla. The facility failed to notify the attending physician, Resident #1's responsible party, and the hospice provider and start treatment. Resident #1 suffered from over 20 ant bites. An Immediate Jeopardy was identified on 08/09/19. While the Immediate Jeopardy was removed on 08/12/19, the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed residents at risk of serious physical harm from ant or other pest bites. Findings include: Review of the facility's Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Definitions: Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's Acute Condition Changes- Clinical Protocol, dated (MONTH) (YEAR), revealed, .6. Before contacting the physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician. 7. The nursing staff will contact the Physician based on urgency of the situation. For emergencies they will call or page the Physician and request a prompt response (within approximately one-half hours or less). Treatment/Management: 1. The Physician will help identify and authorize appropriate treatments. Monitoring and Follow-Up: 1. The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. 2. The Physician will help the staff monitor a resident with a recent acute change od condition until the problem or condition has resolved or stabilized. Review of Resident #1's face sheet, dated 08/09/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's quarterly Minimum Data Set (MDS) Assessment, dated 08/05/19, revealed Resident #1 had unclear speech, sometimes understood others, sometimes was understood by others, and her cognition was severely impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #1 was totally dependent on staff for locomotion on/off unit, toilet use, and bathing. The assessment reflected Resident #1's [DIAGNOSES REDACTED]., anxiety disorder, depression, muscle wasting and atrophy, chronic pain, muscle weakness, and abnormal posture. Observation on 08/08/19 at 11:18 AM revealed Resident #1 was sitting in her geri chair in the common area near station 2. An interview was attempted with Resident #1, but Resident #1 did not respond. Observation on 08/09/19 at 10:26 AM, with the DON and Treatment Nurse, of Resident #1's back revealed over 15 fading red spots to her upper right back, right rib area, and near her right armpit. Review of the facility's 24-Hour Report/Change of Condition Report, dated 07/30/19, revealed a handwritten note under Remarks (Night) for Resident #1: Ants on her side of the room, on wall, in bed, and on res (resident). Red, raised areas noted to R (right) side of back possibly due to scratching. No staff signature, staff initials, or time was documented. There was no documentation regarding monitoring, interventions, or assessment for Remarks (Day) and Remarks (Evening) for Resident #1. Review of the Maintenance Book revealed on 07/30/19 it was documented that room [ROOM NUMBER]A was full of ants. The ESD initialed on 07/31/19 with no further documentation. Review of Resident #1's Weekly Skin Assessment, dated 07/30/19, and signed by LVN C, revealed the following: right side of back area from top to bottom- red, raised areas. The assessment did not include any documentation about the ants found on Resident #1 and ants found in her bed. Review of Resident #1's Progress Notes (department notes) revealed no documentation on 07/30/19 or 08/01/19 of the incident related to the ants and ant bites. Review of pictures taken by Hospice Aide A on 08/01/19 (provided by Resident #1's hospice provider on 08/08/19 at 10:38 AM) revealed the following: one picture of approximately seven ants on Resident #1's bed; one picture of Resident #1's right upper back, right rib area, and towards her right armpit with over 20 red bumps, some with pustules. Review of Resident #1's hospice RN Recertification summary notes, completed by Hospice RN D and dated 08/02/19, revealed on 08/01/19 Hospice Aide A arrived at the facility to provide ADL care to Resident #1 and discovered ants on Resident #1's body, in her hair, and in her bed. Hospice Aide A reported Resident #1 had multiple ant bites on her right upper back, side and axilla (armpit). Hospice Aide A reported she notified LVN B (Resident #1's 6:00 AM to 6:00 PM charge nurse), as well as the off-going night shift nurse (no name documented). According to the summary notes, Hospice RN D discussed the incident with ADON [NAME] and RN F, Resident #1's nurse. ADON [NAME] and RN F stated they were not aware of the ant bites. RN F reviewed the nurses' notes in Resident #1's chart and said there was no mention of the incident and no record of treatment obtained for Resident #1. Both ADON [NAME] and RN F said ants were discovered in the resident's bed sometime last week and the resident was temporarily moved to another room while her room (room [ROOM NUMBER]) was treated. Resident #1 was subsequently returned to her room (room [ROOM NUMBER]). Hospice RN D advised ADON [NAME] and RN F that her supervisor, Hospice RN G notified the facility ADM of the incident on 08/01/19 and sent him pictures of the ants and the bites to Resident #1, taken by Hospice Aide [NAME] ADON [NAME] requested RN F and Hospice RN D assess Resident #1 together. Hospice RN D and RN F inspected Resident #1's bed and found no current evidence of ants. They conducted a head to toe skin assessment of Resident #1 and found Resident #1 had approximately 20 to 30 small, red, raised [MEDICAL CONDITION], some with small pustules, to her upper right back, right side/ribs, and right axilla. Resident #1 had several large patches of psoriasis in the same area and some of the [MEDICAL CONDITION] were on top of the psoriasis. Hospice RN D notified the hospice physician and obtained orders for oral [MEDICATION NAME] and topical [MEDICATION NAME] cream which were ordered from the hospice pharmacy for stat delivery. Hospice RN D instructed RN F to start new medications as soon as they arrived and to monitor for signs and symptoms of infection or any worsening of [MEDICAL CONDITION]. Hospice RN D called Resident #1's responsible party to advise her of situation and she said she had not been made aware of the incident last week or on 08/01/19. Review of Resident #1's Progress Notes (department notes), documented on 08/02/19 at 9:31AM by RN F, revealed the following, Did a skin assessment on pt (patient) with hospice nurse. Pt seen to have ant bites on her right posterior back, towards her under arm presented as pustules. New order given. Will continue to monitor. Review of Resident #1's physician orders revealed the following orders with a start date of 08/02/19: [MEDICATION NAME] cream 1%, apply to ant bites topically four times a day for (R)(right) posterior back, and axilla for 5 days and [MEDICATION NAME] allergy tablet every 6 hours as needed for itching. Review of a facility grievance/concern report, dated 08/05/19, revealed Resident #1's hospice nurse filed a grievance related to Resident #1 being covered in ants and the daughter and doctor not being notified. Documentation of facility follow-up reflected the grievance was assigned to the DON to take action. The follow-up reflected the resident was moved to another room, pest control was notified, and the room was sprayed and inspected (no date documented). The resolution reflected rooms were inspected and sprayed (specific rooms not identified). There were no ant sightings and Resident #1 had been moved to another room. In an interview on 08/08/19 at 12:07 PM Hospice RN D stated Resident #1 was bedbound unless she was transferred to her geri chair. She stated the resident had [MEDICAL CONDITION] and dementia. She stated the resident was mostly nonverbal. Hospice RN D stated Resident #1 might mumble a bit, but could not answer direct questions. She stated Resident #1 was unable to utilize the call light. Hospice RN D stated on 08/01/19 Hospice Aide A informed her about ants in Resident #1's bed and the ant bites Resident #1 suffered. Hospice RN D stated Hospice Aide A told the nurses (not specified) at the facility what she (hospice aide) saw and they told her they would take care of it. Hospice RN D stated she went to the facility on [DATE] and spoke with RN F about the ant bites. Hospice RN D stated RN F told her she (RN F) was not made aware of Resident #1 having ants on her or having ant bites. Hospice RN D stated she was informed by RN F that there was no documentation of any treatment being ordered for Resident #1's ant bites (post incident). Hospice RN D stated she spoke with ADON [NAME] and she did not know anything about the ant incident or Resident #1's ant bites. Hospice RN D stated ADON [NAME] asked that RN F and she (Hospice RN D) assess Resident #1 together. She stated Resident #1 was still in the same room (room [ROOM NUMBER]). Hospice RN D stated she and RN F assessed Resident #1, and Resident #1 had 20 to 30 ant bites on her right upper back, her side and right armpit area. She stated the bites were very red, raised and some had pustules. She stated she could not imagine that (the bites) felt good. Hospice RN D stated she did not see any ants when she assessed Resident #1. Hospice RN D stated she notified Resident #1's responsible party (RP). She stated Resident #1's RP told her she had not been notified of the ant incident or skin change. Hospice RN D stated she (Hospice RN D) also was not notified by the facility. Hospice RN D stated ADON [NAME] and RN F told her that a week or two prior to this incident Resident #1 had been moved to another room because there had been ants in Resident #1's room. Hospice RN D stated she was told Resident #1's room was treated and the resident was moved back into her room, but was not provided with a date of when this previous incident occurred. Hospice RN D stated [MEDICATION NAME] and [MEDICATION NAME] cream were ordered for Resident #1. In a telephone interview on 08/08/19 at 7:52 PM LVN C, who worked from 6:00 PM on 07/29/19 to 6:00 AM on 07/30/19, stated she was told by CNA I that there were ants in Resident #1's room and on the resident. Initially, LVN C stated she could not remember when she was told this, but then stated she had reviewed the 24 hour report and she believed she documented the incident on 07/30/19 at 4:30 AM. (Review of the 24 hour report revealed there was no staff signature, staff initials, or time documented for the entry of this incident). LVN C stated Resident #1 was in bed in room [ROOM NUMBER] at the time of the incident. She stated when she went to assess Resident #1 she observed ants on Resident #1's back, on her bed, and on the wall. LVN C stated Resident #1 was removed from bed, wiped down, and her clothes changed. She stated Resident #1's bedding was changed and she was removed from the room. LVN C stated she saw some red, raised areas on the right side of Resident #1's back. She stated the raised areas looked more like where the resident had been scratching and she could not tell if the red areas were bites. LVN C stated she notified ADON E, the DON, and the ADM of the incident, and they said they would take care of it as soon as possible. LVN C stated she did not document the incident in Resident #1's chart and did not have a specific reason why she did not. She stated she was waiting for further instruction from management (on how to proceed). LVN C stated according to the 24 hour report she did relay information to LVN B (on-coming day shift nurse). LVN C stated looking back it probably would have been better to document the incident in the resident's chart. She stated the attending physician was not notified at that time because she could not tell if Resident #1 had been bitten by the ants. She stated she did not notify Resident #1's RP and did not know if the day nurse (LVN B) had notified her. LVN C stated it was better to notify the attending physician and the RP to be on the safe side. When asked if the incident should have been documented in Resident #1's chart LVN C stated when she returned to work on Wednesday (07/31/19 at 6:00 PM) she did not see any more ants. She stated she saw bumps to Resident #1's right side of her back but could not recall if she saw them on Wednesday (07/31/19) or Thursday (08/01/19). LVN C stated she did not recall Hospice Aide A reporting to her on 08/01/19 that Resident #1 had additional ant bites. She stated it was possible Hospice Aide A told her, but she did not recall the conversation. LVN C stated when she first saw the bumps on Resident #1 there was not a treatment order in place. LVN C stated she was not sure where to document pest sightings/concerns. She stated the family, physician, and supervisor should be notified immediately if a resident had a change in condition. Observation on 08/08/19 at 10:52 AM of room [ROOM NUMBER] revealed Resident #3 still resided in the room. Attempted to interview the resident but she did not respond to surveyor questions. In an interview on 08/08/19 at 1:00 PM Hospice Aide A stated she worked with Resident #1 while the resident's usual aide was on leave. She stated her first time to work with Resident #1 was on 07/19/19, and at that time Resident #1 was in her usual room (room [ROOM NUMBER]). Hospice Aide A stated the next time she went to the facility on [DATE] Resident #1 was in a different room. She stated at that time she was told by facility staff Resident #1 was moved to a new room due to ants, but she could not recall who told her that. Hospice Aide A stated the resident did not have any ant bites at that time. She stated when she started providing care to Resident #1 on 07/30 /19 (review of her sign in sheet showed this to be at 6:55 AM) she found quite a few ants in Resident #1's bed and on the resident. Hospice Aide A stated she informed LVN B (Resident #1's charge nurse)of the ants in Resident #1's bed. Hospice Aide A stated she removed the sheets from the resident's bed, washed Resident #1's hair, and provided a bed bath. Hospice Aide A stated she could not recall informing her supervisor on 07/30/19 of ants being found on Resident #1. She stated the resident was fine at the time but she probably should have informed her supervisor. Hospice Aide A stated she did not see Resident #1's skin on 07/31/19 because the facility aide, CNA H, bathed the resident that day. She stated CNA H did not tell her about Resident #1 having any ant bites on 07/31/19. Hospice Aide A stated she worked with Resident #1 again on 08/01/19 (sign in sheet revealed she signed in at 6:15 AM)and at that time she saw bumps on the resident's skin. She stated there were approximately 15 to 20 bumps that were raised and some were pustules. Hospice Aide A stated she informed LVN B and the night nurse, but she could not recall the night nurse's name. Hospice Aide A stated LVN B said that she (LVN B) was not aware of Resident #1 having the bumps, and LVN B said the bumps were probably from the ants. Hospice Aide A stated the night nurse also said she (night nurse) was not aware of the bumps on Resident #1. In an interview on 08/08/19 at 11:24 AM LVN B said Resident #1 was non-verbal, but could understand some questions. LVN B stated Resident #1 recently had a change in condition and had bumps on her back along the rib area. She said the bumps were being treated with [MEDICATION NAME] cream and [MEDICATION NAME], but she was not sure who had ordered the medications. LVN B stated she did not know what the bumps were. LVN B stated LVN C told her Resident #1 was moved from her normal room to a different room, by the night nurse, because of ants. She stated she could not recall the exact date LVN C told her that but maybe it was last week (07/28/19-08/03/19). LVN B stated when she initially saw Resident #1's skin (could not recall date) she did not see any bumps, but when she returned to work on Thursday (08/01/19 at 6:00 AM) she noticed Resident #1 had red bumps on her back. LVN B stated on 08/01/19 Hospice Aide A reported to her a concern about a change in Resident #1's skin and asked her to look at the resident's back, but did not say anything about finding ants on Resident #1 or in her bed. LVN B stated she when she assessed Resident #1 she did see red bumps on the resident but could not say how many. LVN B stated findings from skin assessment should be documented in the resident's electronic medical record, but she could not recall if she documented her assessment of Resident #1's skin. She stated if she recalled correctly Resident #1 had an order for [REDACTED].#1's room. She stated the ADM and DON also checked the resident's room. She stated if a resident had a change in condition the physician, supervisors and the family would be notified upon the change. LVN B stated she was not certain if there was a place to document pest sightings or concerns but maybe in the maintenance log at the nurses' station. In an interview on 08/08/19 at 2:15 PM LVN B stated she did not recall Hospice Aide A telling her on 08/01/19 that she (hospice aide) saw ants on Resident #1. LVN B stated she thought she recalled Hospice Aide A removing Resident #1's sheets but Hospice Aide A did not mention seeing ants to her. LVN B stated either LVN C or RN F notified the responsible party of Resident #1's change in condition related to her skin. LVN B stated she assessed Resident #1's skin along with Hospice Aide A, but she did not notify the resident's responsible party because she thought someone else had. In an interview on 08/08/19 at 2:59 PM ADON [NAME] stated Resident #1 was on hospice, was bed bound, and total care. She stated the ADM told her on 08/01/19 that ants had been found in Resident #1's room. ADON [NAME] stated on 08/01/19 she inspected Resident #1's bed, the floor the roommate's side of the room, but she did not see any ants. She stated she believed on 08/01/19 the ESD checked Resident #1's room and treated the room. ADON [NAME] stated Resident #1's responsible party came to the facility . She stated she told the RP she did not see any ants but the RP wanted Resident #1 moved to another room. ADON [NAME] stated she did not speak with Hospice RN D about ants being found on Resident #1 or the resident having bites. She stated Hospice RN G showed her a picture of Resident #1's skin with a moderate amount of ant bites on the right side of Resident #1's back, and she (Hospice RN G) had reported the issue to the ADM. She stated she could not recall when she was shown the picture. ADON [NAME] stated after she saw the pictures she did not assess Resident #1, and had not observed Resident #1's skin since becoming aware of the ant bites. ADON [NAME] stated she was not shown any pictures of ants in Resident #1's bed. ADON [NAME] stated she thought hospice notified the RP of the ant incident and change of condition. She stated she did not know if the facility nurses knew about ants being found on Resident #1 and/or Resident #1's change in condition because they did not tell her about it. ADON [NAME] stated she was not aware of ants being found in Resident #1's room on a previous date in (MONTH) (2019). ADON [NAME] stated if staff saw ants they should inform the charge nurse and the ESD. She stated if they saw ants on a resident the nurse should be informed and a change of condition (form) should be completed in the electronic chart. She stated a skin assessment should be conducted, the resident should be removed from the situation, and the family should be informed as well. ADON [NAME] stated if a resident has a change in condition, including with their skin, the family should be notified and staff should document in the resident's electronic chart. In an interview on 08/08/19 at 3:32 PM CNA H stated in (MONTH) (2019) she assisted Resident #1 to bed and saw an ant by Resident #1's knee and it alarmed her. She stated she turned the resident's covers back and saw a couple more ants. She stated she brushed the ants away and told the nurse. CNA H could not recall the date of the incident the nurse she told, but she thought it was on a Saturday. She stated the resident was put into a clean bed and moved to another room. She stated she did not know if the nurse assessed the resident. CNA H stated that was the only incident involving ants and Resident #1 of which she was aware. In an interview on 08/09/19 at 8:47 the DON stated the ADM and she received a message from LVN C on 07/30/19 or 07/31/19 through an app they used for secure conversations saying ants were found in Resident #1's room. The DON stated she saw the message early in the morning. She stated she did not recall the message saying ants were found on Resident #1 or in her bed. The DON stated LVN C checked Resident #1's clothes, stripped the bed, checked her bed and moved her to another room. The DON stated when she got to the facility in the morning, same day she received notification from LVN C, the ADM and the ESD had been to Resident #1's room and did not see any ants. The DON stated the ADM, ADON E, and she went to Resident #1's room, room [ROOM NUMBER], and they did not see any ants. The DON stated she did not assess Resident #1 at that time because the resident was already in the dining room eating breakfast. The DON stated she asked LVN B if she had seen any ants in Resident #1's room and if she (LVN B) had a chance to look at the resident's skin. She stated LVN B said she (LVN B) assessed Resident #1 and saw a couple of small, red, raised areas near her rib area. The DON stated she could not recall which side of the resident's body LVN B said the bites were located. The DON stated there was an order to apply [MEDICATION NAME] cream, but she was not sure if that was a new order. She stated Resident #1 was moved back to her room the same day and she had not heard any more reports of ants. The DON stated she believed LVN C notified Resident #1's RP of the incident on 07/30/19 or 7/31/19, but she had not specifically talked to LVN C about the situation. The DON stated the ADM told her Hospice Aide A took a picture of Resident #1's ant bites. She stated she did not know if the ADM saw the picture but she (DON) did not see it. The DON stated she had not seen Resident #1's skin on 08/01/19 or 08/02/9. The DON stated if a resident had a skin change the ADM, DON, ADON, physician, and RP should be notified. She stated staff should fill out a change of condition (form) for skin under risk management in the electronic chart. The DON stated she was not aware of any other ant incidents. She stated staff should document pest signings and any maintenance issues in the maintenance log at the nurse's stations. In an interview on 08/09/19 at 10:46 AM RN F (6:00 AM to 6:00 PM charge nurse for Resident #1) stated on 07/31/19 CNA H did not report Resident #1 having a change of condition. She stated on Friday (08/01/19) Hospice RN D came to the facility. She stated Hospice RN D asked her if Resident #1 had bugs on her bed, and she told the hospice nurse, no. RN F stated Hospice RN D showed her a picture of Resident #1. RN F stated she reviewed Resident #1's chart for documentation related to an incident involving ants, but did not find anything. She stated Hospice RN D spoke with ADON E. RN F stated Hospice RN D and she conducted a skin assessment on Resident #1 and she (RN F) documented what she saw. She stated Resident #1 had over 15 pustules to her right back and axilla that looked pretty fresh. She stated Hospice RN D notified Resident #1's RP of the resident's condition and she also notified the hospice physician. RN F stated she did not see a treatment ordered for Resident #1's ant bites prior to 08/02/19. RN F stated on 07/31/19 CNA H did not report to her that Resident #1 had experienced a change of condition. RN F stated when Resident #1's RP came to the facility she told RN F the hospice nurse contacted her about the ants. RN F stated the RP told her she was not notified and did not understand why facility staff had not notified her. RN F stated the hospice nurse told her pictures of Resident #1's ant bites were forwarded to facility management on 08/01/19. RN F stated she was told Resident #1 was moved to another room due to ants found in her room and that the ESD was made ware. She stated she could not recall the date or who told her, but did recall it was prior to 07/30/19. In an interview on 08/09/19 at 12:17 PM Physician J stated she was not made aware of ants being found on Resident #1 or Resident #1 having a change in condition. She stated she expected facility staff to notify her of changed in condition and incidents, including changes or injuries to a resident's skin, even if the resident was on hospice. She stated she liked to know what was going on with her patients. Physician J stated she thought the staff was required to inform her and that it was not just a general preference. In an interview on 08/09/19 at 12:29 PM the ESD stated the aides informed him about ants in Resident #1's room about two weeks ago. He stated he could not recall the date. The ESD stated he sprayed Resident #1 room and the room next to hers the same day. He sated he had not seen ants in Resident #1's room. He stated the bed was cleaned and there was no sign of ants. The ESD stated he checked Resident #1's room for ants the day after he sprayed. The ESD stated if staff verbally told him about maintenance issues he may not document it. He stated it was possible there were pest issues on other days than what was documented in the maintenance log The ESD stated he was notified of an ant sighting in room [ROOM NUMBER] today. He stated there was no longer a resident in the room. In an interview in 08/09/19 at 12:50 PM CNA I stated she did care for Resident #1 even though LVN C indicated CNA I reported finding ants on Resident #1 on 07/30/19. She stated she did not report to LVN C an incident where Resident #1 had ants on her. Review of the daily staffing schedule, dated 07/29/19, for station 2 revealed CNA I was not listed as scheduled to work on the 6:00 PM (07/29/19) to 6:00 AM shift (07/30/19). In an interview on 08/09/19 at 1:24 PM CNA H stated she did bathe Resident #1 on Wednesday (07/31/19), but she did not notice any skin changes that she needed to report to the nurse. She stated when she came onto her shift no one reported to her that ants had been found in Resident #1's room the previous day. In an interview on 08/09/19 at 1:29 PM Hospice RN G stated Hospice Aide A took the pictures of the ants on Resident #1's bed and the ant bites and sent them to Hospice RN D. She stated Hospice RN D sent the pictures to her. Hospice RN G stated she called the facility ADM on 08/01/19 and sent him the pictures of Resident #1's back through text as they were talking. She stated she informed him of what she learned about the ant incident and resident's change of condition and he told her he would follow-up. In an interview in 08/09/19 at 2:58 PM the DON stated she did not check other rooms when she became aware of ants being found on Resident #1 The DON stated she did not know if the ADM conducted an investigation or documented anything. She stated he checked Resident #1's room but she did not know if he checked other resident rooms. The DON stated there was no staff training related to the incident after the incident occurred. In an interview on 08/09/19 5:05 PM Resident #1's RP stated she was not notified by the facility about ants being found on the resident or the ant bites. She stated the hospice nurse notified her on 08/01/19 . Resident #1's RP stated she spoke with ADON [NAME] on 08/02/19 and asked why someone did not notify her of the incident and change in condition. She stated the ADON told her she had just found out that morning (08/02/19). Resident #1's RP stated she was told by the nursing staff the ADM was aware of what happened. She stated hospice showed her the picture of the resident's back. She stated Resident #1 did complain to her of the bites itching. She stated Resident #1 would not understand if she had an insect on her and would not be able to brush ants off of her back. In an interview on 08/10/19 at 11:24 AM the ADM stated that on 07/30/19 LVN C notified him via a secure communication app that ants were found in Resident #1's room and the resident was being moved. The ADM stated he thought he received the message from LVN C in the evening, but he was not sure and could have received the message in the morning. The ADM stated he told LVN C the room would be treated tomorrow by the ESD. He stated he wanted the resident moved out of the room right away. The ADM stated the room was treated, and he did not see any ants when he looked around the room. He stated staff ensured the room was free from ants for at least 24 hours before Resident #1 was moved back to the room. The ADM stated he was not sure if the resident's RP was notified. He stated it was the charge nurse's responsibility to notify the family and if ants were found on a resident the physician should be notified. The ADM stated Hospice RN G was at the facility on 08/01/19, but did not mention ants or ant bites. He stated he did not recall Hospice RN G calling him on 08/01/19. The ADM stated Hospice RN G sent him a picture of a resident's irritated skin that he assumed was Resident #1 through text around 4:51 PM on 08/01/19. He stated the text message did not specify who the picture was of. He stated he could not recall what he did once he received the picture. He stated he was sure they discussed the ant incident in the morning meeting and he had instructed the ESD to treat the roo

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (Resident #1) of 14 residents reviewed for quality of care. The facility failed to ensure Resident #1 was assessed, treated, and monitored after ants were discovered in her room, on her bed, on her body, and in her hair and multiple ant bites were observed on the resident on 07/30/19. On 08/01/19 Resident #1 continued to experience a significant change in condition and had over 20 red, raised [MEDICAL CONDITION] and pustules to the right upper side of her back, right side/ribs and right axilla (armpit) without facility intervention. The facility did not take action to address the change of condition, including notifying Resident #1's physician and responsible party, until Resident #1's hospice provider intervened on 08/02/19. An Immediate Jeopardy was identified on 08/09/19. While the Immediate Jeopardy was removed on 08/12/19, the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed residents at risk of decreased quality of care, significant decline in health and well-being, and serious physical harm. Findings include: Review of Resident #1's face sheet, dated 08/09/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's quarterly Minimum Data Set (MDS) Assessment, dated 08/05/19, revealed Resident #1 had unclear speech, sometimes understood others, sometimes was understood by others, and her cognition was severely impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #1 was totally dependent on staff for locomotion on/off unit, toilet use, and bathing. The assessment reflected Resident #1's [DIAGNOSES REDACTED]., anxiety disorder, depression, muscle wasting and atrophy, chronic pain, muscle weakness, and abnormal posture. Observation on 08/08/19 at 11:18 AM revealed Resident #1 was sitting in her geri chair in the common area near station 2. An interview was attempted with Resident #1, but Resident #1 did not respond. Observation on 08/09/19 at 10:26 AM, with the DON and Treatment Nurse, of Resident #1's back revealed over 15 fading red spots to her upper right back, right rib area, and near her right armpit. Review of the facility's 24-Hour Report/Change of Condition Report, dated 07/30/19, revealed a handwritten note under Remarks (Night) for Resident #1: Ants on her side of the room, on wall, in bed, and on res (resident). Red, raised areas noted to R (right) side of back possibly due to scratching. No staff signature, staff initials, or time was documented. There was no documentation regarding monitoring, interventions, or assessment for Remarks (Day) and Remarks (Evening) for Resident #1. Review of the Maintenance Book revealed on 07/30/19 it was documented that room [ROOM NUMBER]A was full of ants. The ESD initialed on 07/31/19 with no further documentation. Review of Resident #1's Weekly Skin Assessment, dated 07/30/19, and signed by LVN C, revealed the following: right side of back area from top to bottom- red, raised areas. The assessment did not include any documentation about the ants found on Resident #1 and ants found in her bed. Review of Resident #1's Progress Notes (department notes) revealed no documentation on 07/30/19 or 08/01/19 of the incident related to the ants and ant bites. Review of pictures taken by Hospice Aide A on 08/01/19 (provided by Resident #1's hospice provider on 08/08/19 at 10:38 AM) revealed the following: one picture of approximately seven ants on Resident #1's bed; one picture of Resident #1's right upper back, right rib area, and towards her right armpit with over 20 red bumps, some with pustules. Review of Resident #1's hospice RN Recertification summary notes, completed by Hospice RN D and dated 08/02/19, revealed on 08/01/19 Hospice Aide A arrived at the facility to provide ADL care to Resident #1 and discovered ants on Resident #1's body, in her hair, and in her bed. Hospice Aide A reported Resident #1 had multiple ant bites on her right upper back, side and axilla (armpit). Hospice Aide A reported she notified LVN B (Resident #1's 6:00 AM to 6:00 PM charge nurse), as well as the off-going night shift nurse (no name documented). According to the summary notes, Hospice RN D discussed the incident with ADON [NAME] and RN F , Resident #1's nurse. ADON [NAME] and RN F stated they were not aware of the ant bites. RN F reviewed the nurses' notes in Resident #1's chart and said there was no mention of the incident and no record of treatment obtained for Resident #1. Both ADON [NAME] and RN F said ants were discovered in the resident's bed sometime last week and the resident was temporarily moved to another room while her room (room [ROOM NUMBER]) was treated. Resident #1 was subsequently returned to her room (room [ROOM NUMBER]). Hospice RN D advised ADON [NAME] and RN F that her supervisor, Hospice RN G notified the facility ADM of the incident on 08/01/19 and sent him pictures of the ants and the bites to Resident #1, taken by Hospice Aide [NAME] ADON [NAME] requested RN F and Hospice RN D assess Resident #1 together. Hospice RN D and RN F inspected Resident #1's bed and found no current evidence of ants. They conducted a head to toe skin assessment of Resident #1 and found Resident #1 had approximately 20 to 30 small, red, raised [MEDICAL CONDITION], some with small pustules, to her upper right back, right side/ribs, and right axilla. Resident #1 had several large patches of psoriasis in the same area and some of the [MEDICAL CONDITION] were on top of the psoriasis. Hospice RN D notified the hospice physician and obtained orders for oral [MEDICATION NAME] and topical [MEDICATION NAME] cream which were ordered from the hospice pharmacy for stat delivery. Hospice RN D instructed RN F to start new medications as soon as they arrived and to monitor for signs and symptoms of infection or any worsening of [MEDICAL CONDITION]. Hospice RN D called Resident #1's responsible party to advise her of situation and she said she had not been made aware of the incident last week or on 08/01/19. Review of Resident #1's Progress Notes (department notes), documented on 08/02/19 at 9:31AM by RN F, revealed the following, Did a skin assessment on pt (patient) with hospice nurse. Pt seen to have ant bites on her right posterior back, towards her under arm presented as pustules. New order given. Will continue to monitor. Review of Resident #1's physician orders [REDACTED]. Review of a facility grievance/concern report, dated 08/05/19, revealed Resident #1's hospice nurse filed a grievance related to Resident #1 being covered in ants and the daughter and doctor not being notified. Documentation of facility follow-up reflected the grievance was assigned to the DON to take action. The follow-up reflected the resident was moved to another room, pest control was notified, and the room was sprayed and inspected (no date documented). The resolution reflected rooms were inspected and sprayed (specific rooms not identified). There were no ant sightings and Resident #1 had been moved to another room. In an interview on 08/08/19 at 12:07 PM Hospice RN D stated Resident #1 was bedbound unless she was transferred to her geri chair. She stated the resident had [MEDICAL CONDITION] and dementia. She stated the resident was mostly nonverbal. Hospice RN D stated Resident #1 might mumble a bit, but could not answer direct questions. She stated Resident #1 was unable to utilize the call light. Hospice RN D stated on 08/01/19 Hospice Aide A informed her about ants in Resident #1's bed and the ant bites Resident #1 suffered. Hospice RN D stated Hospice Aide A told the nurses (not specified) at the facility what she (hospice aide) saw and they told her they would take care of it. Hospice RN D stated she went to the facility on [DATE] and spoke with RN F about the ant bites. Hospice RN D stated RN F told her she (RN F) was not made aware of Resident #1 having ants on her or having ant bites. Hospice RN D stated she was informed by RN F that there was no documentation of any treatment being ordered for Resident #1's ant bites (post incident). Hospice RN D stated she spoke with ADON [NAME] and she did not know anything about the ant incident or Resident #1's ant bites. Hospice RN D stated ADON [NAME] asked that RN F and she (Hospice RN D) assess Resident #1 together. She stated Resident #1 was still in the same room (room [ROOM NUMBER]). Hospice RN D stated she and RN F assessed Resident #1, and Resident #1 had 20 to 30 ant bites on her right upper back, her side and right armpit area. She stated the bites were very red, raised and some had pustules. She stated she could not imagine that (the bites) felt good. Hospice RN D stated she did not see any ants when she assessed Resident #1. Hospice RN D stated she notified Resident #1's responsible party (RP). She stated Resident #1's RP told her she had not been notified of the ant incident or skin change. Hospice RN D stated she (Hospice RN D) also was not notified by the facility. Hospice RN D stated ADON [NAME] and RN F told her that a week or two prior to this incident Resident #1 had been moved to another room because there had been ants in Resident #1's room. Hospice RN D stated she was told Resident #1's room was treated and the resident was moved back into her room, but was not provided with a date of when this previous incident occurred. Hospice RN D stated [MEDICATION NAME] and [MEDICATION NAME] cream were ordered for Resident #1. In a telephone interview on 08/08/19 at 7:52 PM LVN C, who worked from 6:00 PM on 07/29/19 to 6:00 AM on 07/30/19, stated she was told by CNA I that there were ants in Resident #1's room and on the resident. Initially, LVN C stated she could not remember when she was told this, but then stated she had reviewed the 24 hour report and she believed she documented the incident on 07/30/19 at 4:30 AM. (Review of the 24 hour report revealed there was no staff signature, staff initials, or time documented for the entry of this incident). LVN C stated Resident #1 was in bed in room [ROOM NUMBER] at the time of the incident. She stated when she went to assess Resident #1 she observed ants on Resident #1's back, on her bed, and on the wall. LVN C stated Resident #1 was removed from bed, wiped down, and her clothes changed. She stated Resident #1's bedding was changed and she was removed from the room. LVN C stated she saw some red, raised areas on the right side of Resident #1's back. She stated the raised areas looked more like where the resident had been scratching and she could not tell if the red areas were bites. LVN C stated she notified ADON E, the DON, and the ADM of the incident, and they said they would take care of it as soon as possible. LVN C stated she did not document the incident in Resident #1's chart and did not have a specific reason why she did not. She stated she was waiting for further instruction from management (on how to proceed). LVN C stated according to the 24 hour report she did relay information to LVN B (on-coming day shift nurse). LVN C stated looking back it probably would have been better to document the incident in the resident's chart. She stated the attending physician was not notified at that time because she could not tell if Resident #1 had been bitten by the ants. She stated she did not notify Resident #1's RP and did not know if the day nurse (LVN B) had notified her. LVN C stated it was better to notify the attending physician and the RP to be on the safe side. When asked if the incident should have been documented in Resident #1's chart LVN C stated when she returned to work on Wednesday (07/31/19 at 6:00 PM) she did not see any more ants. She stated she saw bumps to Resident #1's right side of her back but could not recall if she saw them on Wednesday (07/31/19) or Thursday (08/01/19). LVN C stated she did not recall Hospice Aide A reporting to her on 08/01/19 that Resident #1 had additional ant bites. She stated it was possible Hospice Aide A told her, but she did not recall the conversation. LVN C stated when she first saw the bumps on Resident #1 there was not a treatment order in place. LVN C stated she was not sure where to document pest sightings/concerns. She stated the family, physician, and supervisor should be notified immediately if a resident had a change in condition. Observation on 10:52 AM at 08/08/19 of room [ROOM NUMBER] revealed Resident #3 still resided in the room. Attempted to interview the resident but she did not respond to surveyor questions. In an interview on 08/08/19 at 1:00 PM Hospice Aide A stated she worked with Resident #1 while the resident's usual aide was on leave. She stated her first time to work with Resident #1 was on 07/19/19, and at that time Resident #1 was in her usual room (room [ROOM NUMBER]). Hospice Aide A stated the next time she went to the facility on [DATE] Resident #1 was in a different room. She stated at that time she was told by facility staff Resident #1 was moved to a new room due to ants, but she could not recall who told her that. Hospice Aide A stated the resident did not have any ant bites at that time. She stated when she started providing care to Resident #1 on 07/30 /19 (review of her sign in sheet showed this to be at 6:55 AM) she found quite a few ants in Resident #1's bed and on the resident. Hospice Aide A stated she informed LVN B (Resident #1's charge nurse)of the ants in Resident #1's bed. Hospice Aide A stated she removed the sheets from the resident's bed, washed Resident #1's hair, and provided a bed bath. Hospice Aide A stated she could not recall informing her supervisor on 07/30/19 of ants being found on Resident #1. She stated the resident was fine at the time but she probably should have informed her supervisor. Hospice Aide A stated she did not see Resident #1's skin on 07/31/19 because the facility aide, CNA H, bathed the resident that day. She stated CNA H did not tell her about Resident #1 having any ant bites on 07/31/19. Hospice Aide A stated she worked with Resident #1 again on 08/01/19 (sign in sheet revealed she signed in at 6:15 AM)and at that time she saw bumps on the resident's skin. She stated there were approximately 15 to 20 bumps that were raised and some were pustules. Hospice Aide A stated she informed LVN B and the night nurse, but she could not recall the night nurse's name. Hospice Aide A stated LVN B said that she (LVN B) was not aware of Resident #1 having the bumps, and LVN B said the bumps were probably from the ants. Hospice Aide A stated the night nurse also said she (night nurse) was not aware of the bumps on Resident #1. In an interview on 08/08/19 at 11:24 AM LVN B said Resident #1 was non-verbal, but could understand some questions. LVN B stated Resident #1 recently had a change in condition and had bumps on her back along the rib area. She said the bumps were being treated with [MEDICATION NAME] cream and [MEDICATION NAME], but she was not sure who had ordered the medications. LVN B stated she did not know what the bumps were. LVN B stated LVN C told her Resident #1 was moved from her normal room to a different room, by the night nurse, because of ants. She stated she could not recall the exact date LVN C told her that but maybe it was last week (07/28/19-08/03/19). LVN B stated when she initially saw Resident #1's skin (could not recall date) she did not see any bumps, but when she returned to work on Thursday (08/01/19 at 6:00 AM) she noticed Resident #1 had red bumps on her back. LVN B stated on 08/01/19 Hospice Aide A reported to her a concern about a change in Resident #1's skin and asked her to look at the resident's back, but did not say anything about finding ants on Resident #1 or in her bed. LVN B stated she when she assessed Resident #1 she did see red bumps on the resident but could not say how many. LVN B stated findings from skin assessment should be documented in the resident's electronic medical record, but she could not recall if she documented her assessment of Resident #1's skin. She stated if she recalled correctly Resident #1 had an order for [REDACTED].#1's room. She stated the ADM and DON also checked the resident's room. She stated if a resident had a change in condition the physician, supervisors and the family would be notified upon the change. LVN B stated she was not certain if there was a place to document pest sightings or concerns but maybe in the maintenance log at the nurses' station. In an interview on 08/08/19 at 2:15 PM LVN B stated she did not recall Hospice Aide A telling her on 08/01/19 that she (hospice aide) saw ants on Resident #1. LVN B stated she thought she recalled Hospice Aide A removing Resident #1's sheets but Hospice Aide A did not mention seeing ants to her. LVN B stated either LVN C or RN F notified the responsible party of Resident #1's change in condition related to her skin. LVN B stated she assessed Resident #1's skin along with Hospice Aide A, but she did not notify the resident's responsible party because she thought someone else had. In an interview on 08/08/19 at 2:59 PM ADON [NAME] stated Resident #1 was on hospice, was bed bound, and total care. She stated the ADM told her on 08/01/19 that ants had been found in Resident #1's room. ADON [NAME] stated on 08/01/19 she inspected Resident #1's bed, the floor the roommate's side of the room, but she did not see any ants. She stated she believed on 08/01/19 the ESD checked Resident #1's room and treated the room. ADON [NAME] stated Resident #1's responsible party came to the facility . She stated she told the RP she did not see any ants but the RP wanted Resident #1 moved to another room. ADON [NAME] stated she did not speak with Hospice RN D about ants being found on Resident #1 or the resident having bites. She stated Hospice RN G showed her a picture of Resident #1's skin with a moderate amount of ant bites on the right side of Resident #1's back, and she (Hospice RN G) had reported the issue to the ADM. She stated she could not recall when she was shown the picture. ADON [NAME] stated after she saw the pictures she did not assess Resident #1, and had not observed Resident #1's skin since becoming aware of the ant bites. ADON [NAME] stated she was not shown any pictures of ants in Resident #1's bed. ADON [NAME] stated she thought hospice notified the RP of the ant incident and change of condition. She stated she did not know if the facility nurses knew about ants being found on Resident #1 and/or Resident #1's change in condition because they did not tell her about it. ADON [NAME] stated she was not aware of ants being found in Resident #1's room on a previous date in (MONTH) (2019). ADON [NAME] stated if staff saw ants they should inform the charge nurse and the ESD. She stated if they saw ants on a resident the nurse should be informed and a change of condition (form) should be completed in the electronic chart. She stated a skin assessment should be conducted, the resident should be removed from the situation, and the family should be informed as well. ADON [NAME] stated if a resident has a change in condition, including with their skin, the family should be notified and staff should document in the resident's electronic chart. In an interview on 08/08/19 at 3:32 PM CNA H stated in (MONTH) (2019) she assisted Resident #1 to bed and saw an ant by Resident #1's knee and it alarmed her. She stated she turned the resident's covers back and saw a couple more ants. She stated she brushed the ants away and told the nurse. CNA H could not recall the date of the incident the nurse she told, but she thought it was on a Saturday. She stated the resident was put into a clean bed and moved to another room. She stated she did not know if the nurse assessed the resident. CNA H stated that was the only incident involving ants and Resident #1 of which she was aware. In an interview on 08/09/19 at 8:47 the DON stated the ADM and she received a message from LVN C on 07/30/19 or 07/31/19 through an app they used for secure conversations saying ants were found in Resident #1's room. The DON stated she saw the message early in the morning. She stated she did not recall the message saying ants were found on Resident #1 or in her bed. The DON stated LVN C checked Resident #1's clothes, stripped the bed, checked her bed and moved her to another room. The DON stated when she got to the facility in the morning, same day she received notification from LVN C, the ADM and the ESD had been to Resident #1's room and did not see any ants. The DON stated the ADM, ADON E, and she went to Resident #1's room, room [ROOM NUMBER], and they did not see any ants. The DON stated she did not assess Resident #1 at that time because the resident was already in the dining room eating breakfast. The DON stated she asked LVN B if she had seen any ants in Resident #1's room and if she (LVN B) had a chance to look at the resident's skin. She stated LVN B said she (LVN B) assessed Resident #1 and saw a couple of small, red, raised areas near her rib area. The DON stated she could not recall which side of the resident's body LVN B said the bites were located. The DON stated there was an order to apply [MEDICATION NAME] cream, but she was not sure if that was a new order. She stated Resident #1 was moved back to her room the same day and she had not heard any more reports of ants. The DON stated she believed LVN C notified Resident #1's RP of the incident on 07/30/19 or 7/31/19, but she had not specifically talked to LVN C about the situation. The DON stated the ADM told her Hospice Aide A took a picture of Resident #1's ant bites. She stated she did not know if the ADM saw the picture but she (DON) did not see it. The DON stated she had not seen Resident #1's skin on 08/01/19 or 08/02/9. The DON stated if a resident had a skin change the ADM, DON, ADON, physician, and RP should be notified. She stated staff should fill out a change of condition (form) for skin under risk management in the electronic chart. The DON stated she was not aware of any other ant incidents. She stated staff should document pest signings and any maintenance issues in the maintenance log at the nurse's stations. In an interview on 08/09/19 at 10:46 AM RN F (6:00 AM to 6:00 PM charge nurse for Resident #1) stated on 07/31/19 CNA H did not report Resident #1 having a change of condition. She stated on Friday (08/01/19) Hospice RN D came to the facility. She stated Hospice RN D asked her if Resident #1 had bugs on her bed, and she told the hospice nurse, no. RN F stated Hospice RN D showed her a picture of Resident #1. RN F stated she reviewed Resident #1's chart for documentation related to an incident involving ants, but did not find anything. She stated Hospice RN D spoke with ADON E. RN F stated Hospice RN D and she conducted a skin assessment on Resident #1 and she (RN F) documented what she saw. She stated Resident #1 had over 15 pustules to her right back and axilla that looked pretty fresh. She stated Hospice RN D notified Resident #1's RP of the resident's condition and she also notified the hospice physician. RN F stated she did not see a treatment ordered for Resident #1's ant bites prior to 08/02/19. RN F stated on 07/31/19 CNA H did not report to her that Resident #1 had experienced a change of condition. RN F stated when Resident #1's RP came to the facility she told RN F the hospice nurse contacted her about the ants. RN F stated the RP told her she was not notified and did not understand why facility staff had not notified her. RN F stated the hospice nurse told her pictures of Resident #1's ant bites were forwarded to facility management on 08/01/19. RN F stated she was told Resident #1 was moved to another room due to ants found in her room and that the ESD was made ware. She stated she could not recall the date or who told her, but did recall it was prior to 07/30/19. In an interview on 08/09/19 at 12:17 PM Physician J stated she was not made aware of ants being found on Resident #1 or Resident #1 having a change in condition. She stated she expected facility staff to notify her of changed in condition and incidents, including changes or injuries to a resident's skin, even if the resident was on hospice. She stated she liked to know what was going on with her patients. Physician J stated she thought the staff was required to inform her and that it was not just a general preference. In an interview on 08/09/19 at 12:29 PM the ESD stated the aides informed him about ants in Resident #1's room about two weeks ago. He stated he could not recall the date. The ESD stated he sprayed Resident #1 room and the room next to hers the same day. He sated he had not seen ants in Resident #1's room. He stated the bed was cleaned and there was no sign of ants. The ESD stated he checked Resident #1's room for ants the day after he sprayed. The ESD stated if staff verbally told him about maintenance issues he may not document it. He stated it was possible there were pest issues on other days than what was documented in the maintenance log The ESD stated he was notified of an ant sighting in room [ROOM NUMBER] today. He stated there was no longer a resident in the room. In an interview in 08/09/19 at 12:50 PM CNA I stated she did care for Resident #1 even though LVN C indicated CNA I reported finding ants on Resident #1 on 07/30/19. She stated she did not report to LVN C an incident where Resident #1 had ants on her. Review of the daily staffing schedule, dated 07/29/19, for station 2 revealed CNA I was not listed as scheduled to work on the 6:00 PM (07/29/19) to 6:00 AM shift (07/30/19). In an interview on 08/09/19 at 1:24 PM CNA H stated she did bathe Resident #1 on Wednesday (07/31/19), but she did not notice any skin changes that she needed to report to the nurse. She stated when she came onto her shift no one reported to her that ants had been found in Resident #1's room the previous day. In an interview on 08/09/19 at 1:29 PM Hospice RN G stated Hospice Aide A took the pictures of the ants on Resident #1's bed and the ant bites and sent them to Hospice RN D. She stated Hospice RN D sent the pictures to her. Hospice RN G stated she called the facility ADM on 08/01/19 and sent him the pictures of Resident #1's back through text as they were talking. She stated she informed him of what she learned about the ant incident and resident's change of condition and he told her he would follow-up. In an interview in 08/09/19 at 2:58 PM the DON stated she did not check other rooms when she became aware of ants being found on Resident #1 The DON stated she did not know if the ADM conducted an investigation or documented anything. She stated he checked Resident #1's room but she did not know if he checked other resident rooms. The DON stated there was no staff training related to the incident after the incident occurred. In an interview on 08/09/19 5:05 PM Resident #1's RP stated she was not notified by the facility about ants being found on the resident or the ant bites. She stated the hospice nurse notified her on 08/01/19. Resident #1's RP stated she spoke with ADON [NAME] on 08/02/19 and asked why someone did not notify her of the incident and change in condition. She stated the ADON told her she had just found out that morning (08/02/19). Resident #1's RP stated she was told by the nursing staff the ADM was aware of what happened. She stated hospice showed her the picture of the resident's back. She stated Resident #1 did complain to her of the bites itching. She stated Resident #1 would not understand if she had an insect on her and would not be able to brush ants off of her back. In an interview on 08/10/19 at 11:24 AM the ADM stated that on 07/30/19 LVN C notified him via a secure communication app that ants were found in Resident #1's room and the resident was being moved. The ADM stated he thought he received the message from LVN C in the evening, but he was not sure and could have received the message in the morning. The ADM stated he told LVN C the room would be treated tomorrow by the ESD. He stated he wanted the resident moved out of the room right away. The ADM stated the room was treated, and he did not see any ants when he looked around the room. He stated staff ensured the room was free from ants for at least 24 hours before Resident #1 was moved back to the room. The ADM stated he was not sure if the resident's RP was notified. He stated it was the charge nurse's responsibility to notify the family and if ants were found on a resident the physician should be notified. The ADM stated Hospice RN G was at the facility on 08/01/19, but did not mention ants or ant bites. He stated he did not recall Hospice RN G calling him on 08/01/19. The ADM stated Hospice RN G sent him a picture of a resident's irritated skin that he assumed was Resident #1 through text around 4:51 PM on 08/01/19. He stated the text message did not specify who the picture was of. He stated he could not recall what he did once he received the picture. He stated he was sure they discussed the ant incident in the morning meeting and he had instructed the ESD to treat the room. The ADM stated he did not document what he did post incident. He stated they should follow up once ants are found on a resident and should monitor. There was not documented evidence of monitoring of ant sightings and no indication of other monitoring put into place. In a subsequent interview on 08/10/19 at 1:23 PM the ADM showed the surveyor the text message he received from Hospice RN G. The text message contained a picture of a resident's back with numerous red bumps to their upper right back, right rib area, and under arm area. He stated he assumed he was not the first person to receive that picture. He stated other staff at the facility might have received it as well. The ADM stated he was not sure if the DON or ADON [NAME] received the picture, and he could not recall if he showed the picture to either of them, but he assumed he did. The ADM stated when he examined the picture sent by hospice he saw skin that appeared irritated. He stated he was not trained to assess skin, but he could tell there was redness and approximately 30 bumps present. He stated he did not know when the picture was taken but assumed it was around the time the ants were found. In an interview on 08/12/19 at 9:07 AM Hospice Aide A stated she took the pictures of Resident #1's back and of the ants in the resident's bed. She stated the picture of Resident #1's back was taken on 08/01/19 and the picture of the ants in her bed was taken on 07/30/19. She stated she sent both pictures to her supervisor, Hospice RN D. Hospice Aide A stated when she was at the facility on 07/30/19 she was not informed ants were found on Resident #1 or in her bed previously Hospice Aide A stated on 08/01/19 she did not find ants in Resident #1's bed but found ant bites on her. In an interview and observation on 08/08/19 at 10:58 AM Resident #2's RP revealed she had seen ants in Resident #2's room, room [ROOM NUMBER], on Tuesday (08/06/19). She stated there were about 10 ants crawling around the pantry table. She stated she told a nurse but did not know the nurse's name. Resident #2's RP stated Resident #2 had not been affected by ants. Resident #2's RP showed the surveyor a live ant, similar to a fire ant, crawling on the floor (in the resident's room), left side of the room, near the pantry table. The ant's head and thorax was reddish brown and the abdomen was black. The ant was a

Based on observation, interview and record review it was determined the facility failed to maintain an effective pest control program to ensure the facility was free of pests for one (Resident #1) of 14 residents reviewed for pest control program. The facility failed to ensure Resident #1 was assessed, treated, and monitored after ants were discovered in her room, on her bed, on her body, and in her hair and multiple ant bites were observed on the resident on 07/30/19. On 08/01/19 Resident #1 continued to experience a significant change in condition and had over 20 red, raised [MEDICAL CONDITION] and pustules to the right upper side of her back, right side/ribs and right axilla (armpit) without facility intervention. The facility did not take action to address the change of condition, including notifying Resident #1's physician and responsible party, until Resident #1's hospice provider intervened on 08/02/19. The failure placed residents at risk for pain, itching, infections, allergic reactions, and death. An Immediate Jeopardy was identified on 08/09/19. While the Immediate Jeopardy was removed on 08/12/19, the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed residents at risk of serious physical harm from ant or other pest bites. Findings include: Review of Resident #1's face sheet, dated 08/09/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's quarterly Minimum Data Set (MDS) Assessment, dated 08/05/19, revealed Resident #1 had unclear speech, sometimes understood others, sometimes was understood by others, and her cognition was severely impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #1 was totally dependent on staff for locomotion on/off unit, toilet use, and bathing. The assessment reflected Resident #1's [DIAGNOSES REDACTED]., anxiety disorder, depression, muscle wasting and atrophy, chronic pain, muscle weakness, and abnormal posture. Observation on 08/08/19 at 11:18 AM revealed Resident #1 was sitting in her geri chair in the common area near station 2. An interview was attempted with Resident #1, but Resident #1 did not respond. Observation on 08/09/19 at 10:26 AM, with the DON and Treatment Nurse, of Resident #1's back revealed over 15 fading red spots to her upper right back, right rib area, and near her right armpit. Review of the facility's 24-Hour Report/Change of Condition Report, dated 07/30/19, revealed a handwritten note under Remarks (Night) for Resident #1: Ants on her side of the room, on wall, in bed, and on res (resident). Red, raised areas noted to R (right) side of back possibly due to scratching. No staff signature, staff initials, or time was documented. There was no documentation regarding monitoring, interventions, or assessment for Remarks (Day) and Remarks (Evening) for Resident #1. Review of the Maintenance Book revealed on 07/30/19 it was documented that room [ROOM NUMBER]A was full of ants. The ESD initialed on 07/31/19 with no further documentation. Review of Resident #1's Weekly Skin Assessment, dated 07/30/19, and signed by LVN C, revealed the following: right side of back area from top to bottom- red, raised areas. The assessment did not include any documentation about the ants found on Resident #1 and ants found in her bed. Review of Resident #1's Progress Notes (department notes) revealed no documentation on 07/30/19 or 08/01/19 of the incident related to the ants and ant bites. Review of pictures taken by Hospice Aide A on 08/01/19 (provided by Resident #1's hospice provider on 08/08/19 at 10:38 AM) revealed the following: one picture of approximately seven ants on Resident #1's bed; one picture of Resident #1's right upper back, right rib area, and towards her right armpit with over 20 red bumps, some with pustules. Review of Resident #1's hospice RN Recertification summary notes, completed by Hospice RN D and dated 08/02/19, revealed on 08/01/19 Hospice Aide A arrived at the facility to provide ADL care to Resident #1 and discovered ants on Resident #1's body, in her hair, and in her bed. Hospice Aide A reported Resident #1 had multiple ant bites on her right upper back, side and axilla (armpit). Hospice Aide A reported she notified LVN B (Resident #1's 6:00 AM to 6:00 PM charge nurse), as well as the off-going night shift nurse (no name documented). According to the summary notes, Hospice RN D discussed the incident with ADON [NAME] and RN F, Resident #1's nurse. ADON [NAME] and RN F stated they were not aware of the ant bites. RN F reviewed the nurses' notes in Resident #1's chart and said there was no mention of the incident and no record of treatment obtained for Resident #1. Both ADON [NAME] and RN F said ants were discovered in the resident's bed sometime last week and the resident was temporarily moved to another room while her room (room [ROOM NUMBER]) was treated. Resident #1 was subsequently returned to her room (room [ROOM NUMBER]). Hospice RN D advised ADON [NAME] and RN F that her supervisor, Hospice RN G notified the facility ADM of the incident on 08/01/19 and sent him pictures of the ants and the bites to Resident #1, taken by Hospice Aide [NAME] ADON [NAME] requested RN F and Hospice RN D assess Resident #1 together. Hospice RN D and RN F inspected Resident #1's bed and found no current evidence of ants. They conducted a head to toe skin assessment of Resident #1 and found Resident #1 had approximately 20 to 30 small, red, raised [MEDICAL CONDITION], some with small pustules, to her upper right back, right side/ribs, and right axilla. Resident #1 had several large patches of psoriasis in the same area and some of the [MEDICAL CONDITION] were on top of the psoriasis. Hospice RN D notified the hospice physician and obtained orders for oral [MEDICATION NAME] and topical [MEDICATION NAME] cream which were ordered from the hospice pharmacy for stat delivery. Hospice RN D instructed RN F to start new medications as soon as they arrived and to monitor for signs and symptoms of infection or any worsening of [MEDICAL CONDITION]. Hospice RN D called Resident #1's responsible party to advise her of situation and she said she had not been made aware of the incident last week or on 08/01/19. Review of Resident #1's Progress Notes (department notes), documented on 08/02/19 at 9:31AM by RN F, revealed the following, Did a skin assessment on pt (patient) with hospice nurse. Pt seen to have ant bites on her right posterior back, towards her under arm presented as pustules. New order given. Will continue to monitor. Review of Resident #1's physician orders [REDACTED]. Review of a facility grievance/concern report, dated 08/05/19, revealed Resident #1's hospice nurse filed a grievance related to Resident #1 being covered in ants and the daughter and doctor not being notified. Documentation of facility follow-up reflected the grievance was assigned to the DON to take action. The follow-up reflected the resident was moved to another room, pest control was notified, and the room was sprayed and inspected (no date documented). The resolution reflected rooms were inspected and sprayed (specific rooms not identified). There were no ant sightings and Resident #1 had been moved to another room. In an interview on 08/08/19 at 12:07 PM Hospice RN D stated Resident #1 was bedbound unless she was transferred to her geri chair. She stated the resident had [MEDICAL CONDITION] and dementia. She stated the resident was mostly nonverbal. Hospice RN D stated Resident #1 might mumble a bit, but could not answer direct questions. She stated Resident #1 was unable to utilize the call light. Hospice RN D stated on 08/01/19 Hospice Aide A informed her about ants in Resident #1's bed and the ant bites Resident #1 suffered. Hospice RN D stated Hospice Aide A told the nurses (not specified) at the facility what she (hospice aide) saw and they told her they would take care of it. Hospice RN D stated she went to the facility on [DATE] and spoke with RN F about the ant bites. Hospice RN D stated RN F told her she (RN F) was not made aware of Resident #1 having ants on her or having ant bites. Hospice RN D stated she was informed by RN F that there was no documentation of any treatment being ordered for Resident #1's ant bites (post incident). Hospice RN D stated she spoke with ADON [NAME] and she did not know anything about the ant incident or Resident #1's ant bites. Hospice RN D stated ADON [NAME] asked that RN F and she (Hospice RN D) assess Resident #1 together. She stated Resident #1 was still in the same room (room [ROOM NUMBER]). Hospice RN D stated she and RN F assessed Resident #1, and Resident #1 had 20 to 30 ant bites on her right upper back, her side and right armpit area. She stated the bites were very red, raised and some had pustules. She stated she could not imagine that (the bites) felt good. Hospice RN D stated she did not see any ants when she assessed Resident #1. Hospice RN D stated she notified Resident #1's responsible party (RP). She stated Resident #1's RP told her she had not been notified of the ant incident or skin change. Hospice RN D stated she (Hospice RN D) also was not notified by the facility. Hospice RN D stated ADON [NAME] and RN F told her that a week or two prior to this incident Resident #1 had been moved to another room because there had been ants in Resident #1's room. Hospice RN D stated she was told Resident #1's room was treated and the resident was moved back into her room, but was not provided with a date of when this previous incident occurred. In a telephone interview on 08/08/19 at 7:52 PM LVN C, who worked from 6:00 PM on 07/29/19 to 6:00 AM on 07/30/19, stated she was told by CNA I that there were ants in Resident #1's room and on the resident. Initially, LVN C stated she could not remember when she was told this , but then stated she had reviewed the 24 hour report and she believed she documented the incident on 07/30/19 at 4:30 AM. (Review of the 24 hour report revealed there was no staff signature, staff initials, or time documented for the entry of this incident). LVN C stated Resident #1 was in bed in room [ROOM NUMBER] at the time of the incident. She stated when she went to assess Resident #1 she observed ants on Resident #1's back, on her bed, and on the wall. LVN C stated Resident #1 was removed from bed, wiped down, and her clothes changed. She stated Resident #1's bedding was changed and she was removed from the room. LVN C stated she saw some red, raised areas on the right side of Resident #1's back. She stated the raised areas looked more like where the resident had been scratching and she could not tell if the red areas were bites. LVN C stated she notified ADON E, the DON, and the ADM of the incident, and they said they would take care of it as soon as possible. LVN C stated she did not document the incident in Resident #1's chart and did not have a specific reason why she did not. She stated she was waiting for further instruction from management (on how to proceed). LVN C stated according to the 24 hour report she did relay information to LVN B (on-coming day shift nurse). LVN C stated looking back it probably would have been better to document the incident in the resident's chart. She stated the attending physician was not notified at that time because she could not tell if Resident #1 had been bitten by the ants. She stated she did not notify Resident #1's RP and did not know if the day nurse (LVN B) had notified her. LVN C stated it was better to notify the attending physician and the RP to be on the safe side. When asked if the incident should have been documented in Resident #1's chart LVN C stated when she returned to work on Wednesday (07/31/19 at 6:00 PM) she did not see any more ants. She stated she saw bumps to Resident #1's right side of her back but could not recall if she saw them on Wednesday (07/31/19) or Thursday (08/01/19). LVN C stated she did not recall Hospice Aide A reporting to her on 08/01/19 that Resident #1 had additional ant bites. She stated it was possible Hospice Aide A told her, but she did not recall the conversation. LVN C stated when she first saw the bumps on Resident #1 there was not a treatment order in place. LVN C stated she was not sure where to document pest sightings/concerns. Observation on 08/08/19 at 10:52 AM of room [ROOM NUMBER] revealed Resident #3 still resided in the room. Attempted to interview the resident but she did not respond to surveyor questions. In an interview on 08/08/19 at 1:00 PM Hospice Aide A stated she worked with Resident #1 while the resident's usual aide was on leave. She stated her first time to work with Resident #1 was on 07/19/19, and at that time Resident #1 was in her usual room (room [ROOM NUMBER]). Hospice Aide A stated the next time she went to the facility on [DATE] Resident #1 was in a different room. She stated at that time she was told by facility staff Resident #1 was moved to a new room due to ants, but she could not recall who told her that. Hospice Aide A stated the resident did not have any ant bites at that time. She stated when she started providing care to Resident #1 on 07/30 /19 (review of her sign in sheet showed this to be at 6:55 AM) she found quite a few ants in Resident #1's bed and on the resident. Hospice Aide A stated she informed LVN B (Resident #1's charge nurse)of the ants in Resident #1's bed. Hospice Aide A stated she removed the sheets from the resident's bed, washed Resident #1's hair, and provided a bed bath. Hospice Aide A stated she could not recall informing her supervisor on 07/30/19 of ants being found on Resident #1. She stated the resident was fine at the time but she probably should have informed her supervisor. Hospice Aide A stated she did not see Resident #1's skin on 07/31/19 because the facility aide, CNA H, bathed the resident that day. She stated CNA H did not tell her about Resident #1 having any ant bites on 07/31/19. Hospice Aide A stated she worked with Resident #1 again on 08/01/19 (sign in sheet revealed she signed in at 6:15 AM)and at that time she saw bumps on the resident's skin. She stated there were approximately 15 to 20 bumps that were raised and some were pustules. Hospice Aide A stated she informed LVN B and the night nurse, but she could not recall the night nurse's name. Hospice Aide A stated LVN B said that she (LVN B) was not aware of Resident #1 having the bumps, and LVN B said the bumps were probably from the ants. Hospice Aide A stated the night nurse also said she (night nurse) was not aware of the bumps on Resident #1. In an interview on 08/08/19 at 11:24 AM LVN B said Resident #1 was non-verbal, but could understand some questions. LVN B stated Resident #1 recently had a change in condition and had bumps on her back along the rib area. She said the bumps were being treated with [MEDICATION NAME] cream and [MEDICATION NAME], but she was not sure who had ordered the medications. LVN B stated she did not know what the bumps were. LVN B stated LVN C told her Resident #1 was moved from her normal room to a different room, by the night nurse, because of ants. She stated she could not recall the exact date LVN C told her that but maybe it was last week (07/28/19-08/03/19). LVN B stated when she initially saw Resident #1's skin (could not recall date) she did not see any bumps, but when she returned to work on Thursday (08/01/19 at 6:00 AM) she noticed Resident #1 had red bumps on her back. LVN B stated on 08/01/19 Hospice Aide A reported to her a concern about a change in Resident #1's skin and asked her to look at the resident's back, but did not say anything about finding ants on Resident #1 or in her bed. LVN B stated she when she assessed Resident #1 she did see red bumps on the resident but could not say how many. LVN B stated findings from skin assessment should be documented in the resident's electronic medical record, but she could not recall if she documented her assessment of Resident #1's skin. She stated if she recalled correctly Resident #1 had an order for [REDACTED].#1's room. She stated the ADM and DON also checked the resident's room. She stated if a resident had a change in condition the physician, supervisors and the family would be notified upon the change. LVN B stated she was not certain if there was a place to document pest sightings or concerns but maybe in the maintenance log at the nurses' station. In an interview on 08/08/19 at 2:15 PM LVN B stated she did not recall Hospice Aide A telling her on 08/01/19 that she (hospice aide) saw ants on Resident #1. LVN B stated she thought she recalled Hospice Aide A removing Resident #1's sheets but Hospice Aide A did not mention seeing ants to her. LVN B stated either LVN C or RN F notified the responsible party of Resident #1's change in condition related to her skin. LVN B stated she assessed Resident #1's skin along with Hospice Aide A, but she did not notify the resident's responsible party because she thought someone else had. In an interview on 08/08/19 at 2:59 PM ADON [NAME] stated Resident #1 was on hospice, was bed bound, and total care. She stated the ADM told her on 08/01/19 that ants had been found in Resident #1's room. ADON [NAME] stated on 08/01/19 she inspected Resident #1's bed, the floor the roommate's side of the room, but she did not see any ants. She stated she believed on 08/01/19 the ESD checked Resident #1's room and treated the room. ADON [NAME] stated Resident #1's responsible party came to the facility . She stated she told the RP she did not see any ants but the RP wanted Resident #1 moved to another room. ADON [NAME] stated she did not speak with Hospice RN D about ants being found on Resident #1 or the resident having bites. She stated Hospice RN G showed her a picture of Resident #1's skin with a moderate amount of ant bites on the right side of Resident #1's back, and she (Hospice RN G) had reported the issue to the ADM. She stated she could not recall when she was shown the picture. ADON [NAME] stated after she saw the pictures she did not assess Resident #1, and had not observed Resident #1's skin since becoming aware of the ant bites. ADON [NAME] stated she was not shown any pictures of ants in Resident #1's bed. ADON [NAME] stated she thought hospice notified the RP of the ant incident and change of condition. She stated she did not know if the facility nurses knew about ants being found on Resident #1 and/or Resident #1's change in condition because they did not tell her about it. ADON [NAME] stated she was not aware of ants being found in Resident #1's room on a previous date in (MONTH) (2019). ADON [NAME] stated if staff saw ants they should inform the charge nurse and the ESD. She stated if they saw ants on a resident the nurse should be informed and a change of condition (form) should be completed in the electronic chart. She stated a skin assessment should be conducted, the resident should be removed from the situation, and the family should be informed as well. In an interview on 08/08/19 at 3:32 PM CNA H stated in (MONTH) (2019) she assisted Resident #1 to bed and saw an ant by Resident #1's knee and it alarmed her. She stated she turned the resident's covers back and saw a couple more ants. She stated she brushed the ants away and told the nurse. CNA H could not recall the date of the incident or the nurse she told, but she thought it was on a Saturday. She stated the resident was put into a clean bed and moved to another room. She stated she did not know if the nurse assessed the resident. CNA H stated that was the only incident involving ants and Resident #1 of which she was aware. In an interview on 08/09/19 at 8:47 the DON stated the ADM and she received a message from LVN C on 07/30/19 or 07/31/19 through an app they used for secure conversations saying ants were found in Resident #1's room. The DON stated she saw the message early in the morning. She stated she did not recall the message saying ants were found on Resident #1 or in her bed. The DON stated LVN C checked Resident #1's clothes, stripped the bed, checked her bed and moved her to another room. The DON stated when she got to the facility in the morning, same day she received notification from LVN C, and the ADM and the ESD had been to Resident #1's room and did not see any ants. The DON stated the ADM, ADON E, and she went to Resident #1's room, room [ROOM NUMBER], and they did not see any ants. The DON stated she did not assess Resident #1 at that time because the resident was already in the dining room eating breakfast. The DON stated she asked LVN B if she had seen any ants in Resident #1's room and if she (LVN B) had a chance to look at the resident's skin. She stated LVN B said she (LVN B) assessed Resident #1 and saw a couple of small, red, raised areas near her rib area. The DON stated she could not recall which side of the resident's body LVN B said the bites were located. The DON stated there was an order to apply [MEDICATION NAME] cream, but she was not sure if that was a new order. She stated Resident #1 was moved back to her room the same day and she had not heard any more reports of ants. The DON stated she believed LVN C notified Resident #1's RP of the incident on 07/30/19 or 7/31/19, but she had not specifically talked to LVN C about the situation. The DON stated the ADM told her Hospice Aide A took a picture of Resident #1's ant bites. She stated she did not know if the ADM saw the picture but she (DON) did not see it. The DON stated she had not seen Resident #1's skin on 08/01/19 or 08/02/9. The DON stated if a resident had a skin change the ADM, DON, ADON, physician, and RP should be notified. She stated staff should fill out a change of condition (form) for skin under risk management in the electronic chart. The DON stated she was not aware of any other ant incidents. She stated staff should document pest signings and any maintenance issues in the maintenance log at the nurse's stations. In an interview on 08/09/19 at 10:46 AM RN F (6:00 AM to 6:00 PM charge nurse for Resident #1) stated on 07/31/19 CNA H did not report Resident #1 having a change of condition. She stated on Friday (08/01/19) Hospice RN D came to the facility. She stated Hospice RN D asked her if Resident #1 had bugs on her bed, and she told the hospice nurse, no. RN F stated Hospice RN D showed her a picture of Resident #1. RN F stated she reviewed Resident #1's chart for documentation related to an incident involving ants, but did not find anything. She stated Hospice RN D spoke with ADON E. RN F stated Hospice RN D and she conducted a skin assessment on Resident #1 and she (RN F) documented what she saw. She stated Resident #1 had over 15 pustules to her right back and axilla that looked pretty fresh. She stated Hospice RN D notified Resident #1's RP of the resident's condition and she also notified the hospice physician. RN F stated she did not see a treatment ordered for Resident #1's ant bites prior to 08/02/19. RN F stated on 07/31/19 CNA H did not report to her that Resident #1 had experienced a change of condition. RN F stated when Resident #1's RP came to the facility she told RN F the hospice nurse contacted her about the ants. RN F stated the RP told her she was not notified and did not understand why facility staff had not notified her. RN F stated the hospice nurse told her pictures of Resident #1's ant bites were forwarded to facility management on 08/01/19. RN F stated she was told Resident #1 was moved to another room due to ants found in her room and that the ESD was made ware. She stated she could not recall the date or who told her, but did recall it was prior to 07/30/19. In an interview on 08/09/19 at 12:17 PM Physician J stated she was not made aware of ants being found on Resident #1 or Resident #1 having a change in condition. She stated she expected facility staff to notify her of changed in condition and incidents, including changes or injuries to a resident's skin, even if the resident was on hospice. She stated she liked to know what was going on with her patients. Physician J stated she thought the staff was required to inform her and that it was not just a general preference. In an interview on 08/09/19 at 12:29 PM the ESD stated the aides informed him about ants in Resident #1's room about two weeks ago. He stated he could not recall the date. The ESD stated he sprayed Resident #1 room and the room next to hers the same day. He sated he had not seen ants in Resident #1's room. He stated the bed was cleaned and there was no sign of ants. The ESD stated he checked Resident #1's room for ants the day after he sprayed. The ESD stated if staff verbally told him about maintenance issues he may not document it. He stated it was possible there were pest issues on other days than what was documented in the maintenance log The ESD stated he was notified of an ant sighting in room [ROOM NUMBER] today. He stated there was no longer a resident in the room. In an interview in 08/09/19 at 12:50 PM CNA I stated she did care for Resident #1 even though LVN C indicated CNA I reported finding ants on Resident #1 on 07/30/19. She stated she did not report to LVN C an incident where Resident #1 had ants on her. Review of the daily staffing schedule, dated 07/29/19, for station 2 revealed CNA I was not listed as scheduled to work on the 6:00 PM (07/29/19) to 6:00 AM shift (07/30/19). In an interview on 08/09/19 at 1:24 PM CNA H stated she did bathe Resident #1 on Wednesday (07/31/19), but she did not notice any skin changes that she needed to report to the nurse. She stated when she came onto her shift no one reported to her that ants had been found in Resident #1's room the previous day. In an interview on 08/09/19 at 1:29 PM Hospice RN G stated Hospice Aide A took the pictures of the ants on Resident #1's bed and the ant bites and sent them to Hospice RN D. She stated Hospice RN D sent the pictures to her. Hospice RN G stated she called the facility ADM on 08/01/19 and sent him the pictures of Resident #1's back through text as they were talking. She stated she informed him of what she learned about the ant incident and resident's change of condition and he told her he would follow-up. In an interview in 08/09/19 at 2:58 PM the DON stated she did not check other rooms when she became aware of ants being found on Resident #1 The DON stated she did not know if the ADM conducted an investigation or documented anything. She stated he checked Resident #1's room but she did not know if he checked other resident rooms. The DON stated there was no staff training related to the incident after the incident occurred. In an interview on 08/09/19 5:05 PM Resident #1's RP stated she was not notified by the facility about ants being found on the resident or the ant bites. She stated the hospice nurse notified her on 08/01/19. Resident #1's RP stated she spoke with ADON [NAME] on 08/02/19 and asked why someone did not notify her of the incident and change in condition. She stated the ADON told her she had just found out that morning (08/02/19). Resident #1's RP stated she was told by the nursing staff the ADM was aware of what happened. She stated hospice showed her the picture of the resident's back. She stated Resident #1 did complain to her of the bites itching. She stated Resident #1 would not understand if she had an insect on her and would not be able to brush ants off of her back. In an interview on 08/10/19 at 11:24 AM the ADM stated that on 07/30/19 LVN C notified him via a secure communication app that ants were found in Resident #1's room and the resident was being moved. The ADM stated he thought he received the message from LVN C in the evening, but he was not sure and could have received the message in the morning. The ADM stated he told LVN C the room would be treated tomorrow by the ESD. He stated he wanted the resident moved out of the room right away. The ADM stated the room was treated, and he did not see any ants when he looked around the room. He stated staff ensured the room was free from ants for at least 24 hours before Resident #1 was moved back to the room. The ADM stated he was not sure if the resident's RP was notified. He stated it was the charge nurse's responsibility to notify the family and if ants were found on a resident the physician should be notified. The ADM stated Hospice RN G was at the facility on 08/01/19, but did not mention ants or ant bites. He stated he did not recall Hospice RN G calling him on 08/01/19. The ADM stated Hospice RN G sent him a picture of a resident's irritated skin that he assumed was Resident #1 through text around 4:51 PM on 08/01/19. He stated the text message did not specify who the picture was of. He stated he could not recall what he did once he received the picture. He stated he was sure they discussed the ant incident in the morning meeting and he had instructed the ESD to treat the room. The ADM stated he did not document what he did post incident. He stated they should follow up once ants are found on a resident and should monitor. There was no documented evidence of other monitoring of ant sightings and no indication of monitoring put into place. In a subsequent interview on 08/10/19 at 1:23 PM the ADM showed the surveyor the text message he received from Hospice RN G. The text message contained a picture of a resident's back with numerous red bumps to their upper right back, right rib area, and under arm area. He stated he assumed he was not the first person to receive that picture. He stated other staff at the facility might have received it as well. The ADM stated he was not sure if the DON or ADON [NAME] received the picture, and he could not recall if he showed the picture to either of them, but he assumed he did. The ADM stated when he examined the picture sent by hospice he saw skin that appeared irritated. He stated he was not trained to assess skin, but he could tell there was redness and approximately 30 bumps present. He stated he did not know when the picture was taken but assumed it was around the time the ants were found. In an interview on 08/12/19 at 9:07 AM Hospice Aide A stated she took the pictures of Resident #1's back and of the ants in the resident's bed. She stated the picture of Resident #1's back was taken on 08/01/19 and the picture of the ants in her bed was taken on 07/30/19. She stated she sent both pictures to her supervisor, Hospice RN D. Hospice Aide A stated when she was at the facility on 07/30/19 she was not informed ants were found on Resident #1 or in her bed previously. Hospice Aide A stated on 08/01/19 she did not find ants in Resident #1's bed but found ant bites on her. In an interview and observation on 08/08/19 at 10:58 AM Resident #2's RP revealed she had seen ants in Resident #2's room, room [ROOM NUMBER], on Tuesday (08/06/19). She stated there were about 10 ants crawling around the pantry table. She stated she told a nurse but did not know the nurse's name. Resident #2's RP stated Resident #2 had not been affected by ants. Resident #2's RP showed the surveyor a live ant, similar to a fire ant, crawling on the floor (in the resident's room), left side of the room, near the pantry table. The ant's head and thorax was reddish brown and the abdomen was black. The ant was approximately a quarter of an inch in length. The floor was clean with no food debris observed. Review of the pest control provider receipts of service revealed the following: -07/03/19: fire ants were noted during service and the exterior of the building was treated. -06/05/19: f