**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews; the facility's Administrator failed to follow up on reported rodent sightings in a timely manner and address them immediately, failed to ensure the designated Infection Preventionist who is responsible for the facility's Infection, Prevention and Control Program (IPCP) had completed specialized training in infection prevention and control. The facility's administrative staff failed to ensure that their policies for pest control services were followed, coordinate with other department heads, failed to contact the appropriate local agencies regarding the rodent infestation. The facility's failure to immediately implement an effective pest control program to eradicate and contain the rodents identified in residents' areas had the potential to spread diseases to residents and potentially affect 111 residents residing in this 120 bed facility. Rats and mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. The system failure to ensure pest control/infection control and prevention interventions and services were effective and implemented resulted in the likelihood for serious injury and/or death. This failure resulted in the determination of Immediate Jeopardy on 06/27/2024. The findings of Immediate Jeopardy were determined to be ongoing on 8/30/2024. The findings included: A review of the facility's Administrator's job description signed on 04/04/2022 revealed the following: Delegate the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility, and ensures compliance with all state and federal regulations. Provide leadership to all facility staff to meet the goal of providing quality resident care. Schedule regular meetings with direct report staff to provide supervision, ensure communication, and monitor the facility. Ensure a safe, clean and comfortable environment for residents, visitors and staff. Maintain effective relationships and open communication with residents, families, staff, contractors, and the outside community. A chart review revealed that Resident #9 (room [ROOM NUMBER]) was initially admitted to the facility on [DATE] with diagnoses of Hemiplegia, Muscle Weakness, and Gout. The last Minimum Data Set (MDS), dated [DATE], section C, revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated that she was cognitively intact and able to communicate. Section GG of the MDS revealed that Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a wheelchair. In an interview conducted on 08/26/24 at 11:24 AM, Resident #9, stated that for the last 4 Saturdays there has not been any housekeeping services and the place was dirty. The facility's Supervisors were aware that there were pests, roaches, and mice/rodents in the facility. When asked how often she has seen any, she said, They practically live here. Resident #9 then pointed at a flat, sticky trap (with a rat picture on the label) used for mice/rats in her room that was still in an unused packet sitting on top of her belongings. Resident #9 reported that these traps were used for mice/rats sighting in her room near the air-conditioning area. In this interview, the Surveyor observed a white boxed container, which was located by the air-conditioning unit and was labeled for pests and roaches. According to Resident #9, the white box used for trapping pests did not work for rats or rodents, and this was why she kept requesting the pest control technician to get her the unused designated mice trap that was seen earlier on top of her belongings. During this entire interview, the Surveyor noted that food packaging that were opened on the over bed table, and other unsealed food items were around the bed. In an interview conducted on 08/29/24 at 7:20 AM with Staff OO, the Pest Control Technician stated that the facility does not have a Pest Control Log that he checks every time he comes into the facility for the specific locations and rooms that need treatments. The facility's Administrator reports all pest sightings verbally to him. The facility's Administrator only told him of rodent sightings for the first time last week. In an interview conducted on 08/26/24 at 1:30 PM with the facility's Administrator, she stated she was not aware of any rodents sighting in the facility and reported that any residents or staff members had not told her of any rodents in the facility. She further stated that Pest Control Services are here once a week, and she is in constant contact with the pest control technician. In an interview conducted on 08/29/24 at 7:53 AM, the Director of Nursing (DON) stated that he had never seen any rodents or rats in the facility but was told by Staff RR, a Registered Nurse who saw three rodents in room [ROOM NUMBER] which was on 06/27/24. The DON sent a message to the Administrator letting her know of the sighting which was reported by Staff RR. The Administrator told him that she would let Staff PP, the Former Maintenance Director who is no longer an employee with the facility, to take care of the issue According to the DON, he received multiple complaints of rodent sightings in the last six months from various staff members. Some staff members reported rodents coming out of the air-conditioning unit, but this was never verified. He always discussed these sightings in the department heads' meetings that are conducted daily, and the Administrator was aware of the rodent issue for the last six months. He was told by the facility's Administrator that the rodent issue would be handled in-house by the Maintenance Department rather than called a Pest Control Company. He did not document any of the reports or sightings from staff members and did not report the dates and times of the sightings. The DON stated that he expected the Administrator to take care of the rodent issue immediately, but she did not. Since he expected the Administrator to take care of the rodent concern, he did not notify the Health Department of the rodent infestation. He further reported that he is responsible for ensuring that the residents are kept in a safe, clean environment. He even discussed with the Administrator why she did not call the Pest Control Company but decided to take care of it in-house by the Maintenance Director. The Director of Nursing said that the Administrator was not overly concerned and said that she would have the in-house team take care of the rodents' sightings. In an interview with the Administrator on 08/29/24 at 8:00 AM, she revealed being was aware that Resident #9 reported seeing rodents in her room last Thursday and she told the pest control technician to treat Resident #9's room. The Administrator said they were going to deep clean the room and put all the food items in the room in tight plastic containers. In a phone interview conducted on 08/29/24 at 8:40 AM with Staff PP, who started working in the facility in December of 2023 and left a month ago( July).; revealed the Administrator was aware of the rodent issue in the facility and was very involved in the pest control area before he was even hired. Around March of this year, he started getting reports of rodents sighting around the facility. He was not sure as to what arrangements were made with the Staff OO, the Pest Control Technician, and the Administrator, but Staff OO did not know of the rodent infestation in the facility. Staff OO visited the facility weekly, and they always discussed pest control issues. Staff OO never mentioned any rodent sightings reported to him by the Administrator. Staff PP received multiple complaints of rodents sighting by staff members which were not documented or written down in a pest control log. Most of the rodent's sightings were reported on the 2nd floor [NAME] Wing. He further revealed he never felt the support or leadership skills from the facility's Administrator. There were no systems in place to control the rodent's problem from the source. The in-house treatments that were done in some of the rooms did not resolve the problem and were only a temporary fix. Staff PP advised the Administrator to close the [NAME] Wing unit to treat the entire wing and eradicate the issue, which she refused. A chart review revealed Resident #36 (room [ROOM NUMBER]) was admitted to the facility on [DATE] with diagnoses of Dementia and Bipolar Disorder. The Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 12 which is mild cognitive impairment. In an interview conducted on 08/29/24 at 9:38 AM with Staff RR, Registered Nurse stated she has worked in the facility for the last 13 months. Around two months ago, she came down to the Director of Nursing (DON) office and told him that she saw three rodents running around in Resident #36's room; it was during medication administration, it was late in the evening when she noticed the rodents located at the end of the room. The DON told her that he would let management know of the rodent's sighting. A few days later, the DON told her that rodent traps would be placed in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, the Administrator failed to follow up on reported rodent sightings in a timely manner and address them immediately, the administrative staff failed to follow infection preventions and control techniques and CDC (Centers for Disease Control) guidelines for How to Control Wild Rodent Infestations, the facility's administration staff failed to ensure that their policies for pest control services were followed, coordinate with other department heads; failed to contact the appropriate local agencies regarding the rodent infestation. The facility's failure to immediately implement an effective pest control program to eradicate and contain the rodents. The facility's failure to properly inspect, clean and remove food sources identified in 2 of 17 Residents' rooms (Resident #9 and Resident #36). Rats and mice are known to carry many diseases. This can cause a severe life-threatening disease, Mpox (virus that affects rodents, and causes a painful rash, enlarged lymph nodes and fever in humans), and rat-bite fever (causes fever, vomiting, headache, muscle, and joint pain, and rash in humans) which has the potential to affect 111 residents residing in the 120-bed facility. The facility failed to ensure that infection control procedures and guidelines were followed to properly handle the Glucometer for 1 of 1 resident reviewed for Blood Glucose Monitor Testing (Resident #48). The facility failed to ensure proper hand hygiene and Enhanced Barrier Precautions (EBP) guidelines were followed during wound care treatment for 1 of 1 resident observed for wound care (Resident #307). The facility failed to ensure a clear separation between the soiled linen area and the clean laundry areas to prevent cross-contamination during 2 of 2 observations of the laundry room. Facility failed to ensure designated Infection Preventionist who is responsible for the facility's Infection, Prevention and Control Program (IPCP) had completed specialized training in infection prevention and control. The system failure to ensure pest control/infection control and prevention interventions and services were effective and implemented resulted in the likelihood for serious injury and/or death. This failure resulted in the determination of Immediate Jeopardy on 06/27/2024. The findings of Immediate Jeopardy were determined to be ongoing on 8/30/2024. The findings included: 1) The Surveyor requested to review completed copy of specialized training in infection prevention and control from the Director of Nursing (DON), who was also assigned the infection Preventionist (IP). No certificate of completion was provided. Review of job description for DON/IP dated 10/31/23 sign by the DON/IP revealed that the Certification in Infection Control as specified by Appendix PP at 880 is required or must obtain within the first 90 days of employment. An interview was conducted on 08/30/24 at 11:45 AM with the DON/IP. He stated he has worked at the facility since 10/31/23 and that he was not aware that he was assigned as the infection Preventionist until 2 months ago when the Administrator informed him to start the infection Preventionist modules. When asked if he had completed the entire IPCP training program and had a certificate, he stated that he started the modules but has not finished and has not obtained a certificate. Review of the facility's job description titled, Infection Preventionist, included the following: The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Infection Control and Prevention Program in accordance with current federal, state, and local standards, guidelines, and regulations that govern our center and as may be directed by the Medical Director or Director of Nursing (DON) to ensure that the center provides a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections. Experience: Certification in Infection Control as specified by Appendix PP at 880 is required or must obtain within the first 90 days of employment. 2) During an observation conducted on 08/26/24 at 11:50 AM, two Surveyors were on the 2nd floor [NAME] Wing hallway across from Resident #9's room. Upon exiting the room across, they observed a rodent running in the [NAME] Wing hallway toward Resident #9's room. Further observation revealed Resident #9 was sitting in her wheelchair in the hallway. She was noted lifting one leg to avoid touching the rodent with her feet. Resident #9 then said to the Surveyors, There it is. Did you see it? as she pointed at the rodent running into her room. Record review for Resident #9 revealed that the resident was admitted to the facility on [DATE] with diagnoses that include: Hemiplegia, Muscle Weakness, and Gout. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated that she was cognitively intact and able to communicate. Section GG of the MDS revealed that Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a wheelchair. During an interview conducted on 08/26/24 at 11:24 AM with Resident #9, she stated that for the last 4 Saturdays, there had not been any housekeeping services and that the place was dirty. The facility's Supervisors were aware that there were pests, roaches, and mice/rodents in the facility. When asked how often she has seen any, she said, They practically live here. During this entire interview, the Surveyor noted that food packaging was opened and laying on the overbed table, and other unsealed food items were around the bed and on the bedside table. During an interview conducted on 08/29/24 at 7:53 AM with the DON/IP, he stated that he had never seen any rodents in the facility but was told by Staff RR, a Registered Nurse who saw rodents in a resident's room on 06/27/24 and reported it to him. Staff RR reported seeing rodents in room [ROOM NUMBER] running around by the window. She further said to him that she witnessed 2 out of 3 medium-sized rodents who were not fully grown and who went by her very fast. This sighting was passed to the Administrator, who said she would handle the issue. During an interview with the Administrator on 08/29/24 at 8:00 AM, she stated that she was aware that Resident #9 reported seeing rodents in her room last Thursday. The Administrator stated that they are going to treat the entire room, take all furniture and belongings out, and look for possible openings and holes. According to the facility's administration, Resident #9 has been in the facility for 20 years, and her family brings her groceries every week, which are stored all around her room. During an interview conducted on 08/29/24 at 9:38 AM with Staff RR, the Registered Nurse reported around two months ago, she came down to the Director of Nursing (DON) office and told him that she saw three rodents running around in Resident #36's room. It was late in the evening, during medication administration, when she noticed the rodents were located at the end of the room. The DON told her that he would let management know of the rodent's sighting. A few days later, the DON told her that rodent traps would be placed in the resident's room. Any rodents or pest sightings are documented on the pest control log in the nurse's station. When asked if she had documented the sighting in the pest control log, she said no. Record review for Resident #36 revealed that the resident was admitted to the facility on [DATE] clinical diagnoses include: Dementia, Bipolar Disorder. Review of the MDS dated [DATE] revealed a BIMS score of 12, which was slight cognitive impairment. Review of the CDC's How to Control Wild Rodent Infestations, 01/03/23, https://www.cdc.gov/healthy-pets/rodent-control/index. html included in part the following: Rodents, such as rats, mice, and chipmunks, are known to carry many diseases. These diseases can spread to people directly, through: Handling of rodents. Contact with rodent droppings (poop), urine, or saliva. Rodent bites. Rodent droppings, urine, and saliva can spread by breathing in air or eating food that is contaminated with rodent waste. Rodents can also carry ticks, mites, or fleas that can spread diseases. Review of the facility's policy titled, Pest Control Services, dated 12/08/23, included the following: A program will be established for the control of insects and rodents within the facility. Procedure: 1. The Administrator coordinates with the Maintenance Department to arrange pest control services on a monthly basis, or as needed. 2. Food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin 3) Record review for Resident #48 revealed that the resident was admitted to the facility on [DATE] diagnoses that include: Metabolic Encephalopathy. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #48 had a Brief Interview for Mental Status of 07, which indicated that he was severely cognitively impaired. Review of the Physician's Orders showed that Resident #48 had an order dated 04/24/24 for Humalog KwikPen Subcutaneous Solution Pen-injector 100 Unit/ml (Insulin Lispro), Inject as per sliding scale before meals and at bedtime for DM. Injector 1 Fingerstick blood glucose monitoring QID (four times a day) before meal and at bedtime for Diabetes Mellitus (DM). On 08/27/24 at 4:00 PM observation of blood glucose monitoring test (Accu-Chek) conducted by Staff WW, Licensed Practical Nurse (LPN) Staff WW gather all the following supplies: Glucometer, 2 alcohol wipes, lancet, a container of blood glucose test strips, and placed them all on a foam tray. She entered the room for Resident #48, washed her hands, donned gloves, placed the foam tray on the bedside table, and performed the Accu-Chek on Resident #48. She then, placed the dirty Glucometer and the container of blood glucose strips back on the foam tray and walked outside of the room to discard the used lancet into the sharp's container. Staff WW returned to Resident #48's bedside table, placed the dirty Glucometer and the container of blood glucose strips into her uniform pocket and threw away the foam tray, then walked to the bathroom and washed her hands. She exited Resident #48's room and removed the dirty Glucometer and the container of blood glucose strips from her pocket and placed them on top of her medication cart. Staff WW donned gloves, bleach wipes and cleaned the dirty Glucometer and sat it on top of Medication cart to dry. When asked why she placed the dirty Glucometer in her pocket, Staff WW stated that she had no place to carry it, and she needed to wash her hands. Review of the CDC's Infection Prevention during Blood Glucose Monitoring and Insulin Administration, 02/06/13, https://www.cdc.gov/celiac/docs/addenda/celiac/07b_celiac_2013march_glucose_monitoring Blood Glucose Meters: General: Whenever possible, blood glucose meters should be assigned to an individual person, and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment (e.g., glucose meters). Do not carry supplies and medications in pockets. 4) Record review for Resident #307 revealed that the resident was admitted to the facility on [DATE], clinical diagnoses include but not limited to: Type 2 Diabetes Mellitus with other Specified Complication; Pressure Ulcers. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #307 had a Brief Interview for Mental Status of 11, which indicated moderate cognitive impairment. Review of the Physician's Orders showed that Resident #307 had an order dated 07/04/24 for Enhanced Barrier Precautions every shift for Wounds PPE (Personal Protective Equipment) required; Wound care Cleanse the wound with Dakins and pat dry with gauze. Apply Santyl to the wound bed followed by alginate. Cover with foam with silicone bordered dressing daily and PRN (as needed) for soiled or loose dressing. Collagenase Ointment 250 Unit/GM, apply to Left Posterior Groin topically as needed for Wound care Cleanse the wound with Dakins and pat dry with gauze. During a wound care observation conducted on 08/28/24 at 2:48 PM, Staff XX, Licensed Practical Nurse (LPN) noted she has been working at the facility for 3-4 months as the wound care nurse. Staff XX was observed gathering the following supplies from the wound care cart: a hand sanitizer pump, gloves (placed on a foam tray), gauzes, a cup of the powered medication (alginate), and a cup of clear liquid (Dakin's solution). She entered Resident #307's room and set-up the supplies on the over-bed table that was covered with a chuck pad. Staff XX went to the bathroom, washed her hands and returned to the bedside and donned on double gloves (no gown was donned). She soaked gauze with the Dakin's solution and cleaned the groin area, removed the top pair of gloves, leaving bottom pair of gloves on and donned a new clean pair of gloves over dirty pair that remained on her hands. Staff XX continued to double glove and don clean gloves over the dirty pair of gloves at least six times during the wound treatment procedure. In addition, Staff XX was observed in the bathroom washing her hands, used a small bottle (which she thought it was soap, however it was labeled hand sanitizer) to wash her hands. She then stated that the soap dispenser has not been working. Review of the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), 04/02/24, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html included in part the following: Enhanced Barrier Precautions (EBP) Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requiring a dressing. Review of the CDC's Clinical Safety: Hand Hygiene for Healthcare Workers, 02/27/24, https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html included in part the following: Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. During an interview conducted on 08/28/24 at 3:00 PM, Staff XX was asked why she did not wear a gown during the wound treatment, she just lowered her head and shrugged her shoulders. In addition, she was asked why she did not perform hand hygiene after removing her gloves, Staff XX stated that the hand sanitizer dries her hands, so she does not use it and that's why she wore double gloves. Review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, dated April 2013, included the following: To provide guidelines for general infection control while caring for residents. General Guidelines: 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents. d. after removing gloves. 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not 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. f. Before moving from a contaminated body site to a clean body site during resident care. j. After removing gloves. 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. 5) An observation was conducted on 08/26/24 at 10:48 AM of Staff I, Certified Nursing Assistant (CNA) dumping an open bag of dirty laundry down the 3rd floor laundry chute. During an interview conducted on 08/26/24 at 10:49 AM, Staff I was asked if she just dumped dirty laundry down the chute in an open bag, she stated yes. She acknowledged that sometimes she does dump dirty laundry down the laundry chute in an open bag and sometimes she does not. During this interview, the Assistant Director of Nursing (ADON) approached Staff I and stated that the dirty laundry should always be in a closed bag before dumping it down the laundry chute. Review of the facility's policy titled, Laundry Services- Handling/Storing/Transporting Linen, dated 12/08/23, included the following: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Procedure: Standard Precautions 1. Separate soiled and clean linen at all times. Bagging and Handling/Sorting Soiled Linen: 1. All soiled linen must be placed directly into a covered container designated for soiled linen and/or plastic bag which can contain the moisture. 4. Handle soiled linen as little as possible to prevent agitation. 5. Employees sorting or washing linen must wear a gown and gloves. Washing Linen and other Soiled Items: 5. Keep soiled and clean linen, their respective hampers and laundry carts, separate at all times. 7. Wash mops separately from linens, using bleach/EPA registered germicidal A tour of the facility's laundry room was conducted on 08/30/24 at 10:20 AM with the Maintenance Director and the Environmental Director. Upon entering the laundry room, it was noted that Staff EE, laundry aide, was not wearing personal protective equipment (PPE) and she was about to load soiled linen into the washer. She realized that the surveyor had entered the laundry and donned on a gown. The laundry was a small room that had 2 washers and 2 dryers (no separation between the contaminated linens and the clean laundry areas). There was an attached room for receiving the soiled laundry via the chute from the 2nd and 3rd floor, and another room where residents' clean clothing is sorted and stored; both room doors were propped open. In addition, there were 4 labeled laundry carts used to transfer linens between the soiled room, the washers, the dryers and the clean clothing room. Further observation revealed one of the carts was filled with clean dry residents' clothing, however, the cart was labeled for soiled linens. During an interview conducted on 08/30/24 at 10:30 AM, Staff EE stated she sorts the soiled linens and residents' clothing by color in the container in the soiled/chute room (the clothing are left inside the container until enough accumulate of the same color). Observation of the soiled room revealed that the chute and container were filled with soiled linen and residents' clothing; some of the clothing were in plastic bags and some were not. Staff EE acknowledged that the space is small and not divided, however, the staff is aware which cart to use for soiled linen versus clean linen since they are labeled. On 08/30/24 at 3:15 PM, a 2nd visit to the laundry room was conducted; only one laundry aide was observed in the room, Staff K, housekeeping and laundry aide. The surveyor noted a laundry basket overflowing with wet clean linens (hanging out of the basket and very close to the floor). Staff K stated that she was not sure why the other dryer was not working and was waiting for the one dryer currently working. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility's administrative staff failed to implement, maintain, and measure an effective pest control program to eradicate and contain rodent infestation. Facility administrative staff was unable to address rodent sightings in a timely manner. The facility's administrative staff failed to follow their own policy for pest control and educate staff members appropriately. These diseases can spread to people directly through the handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. This had the potential to affect 111 residents residing in this 120-bed capacity facilities. The system failure to ensure pest control/infection control and prevention interventions and services were effective and implemented resulted in the likelihood for serious injury and/or death. This failure resulted in the determination of Immediate Jeopardy on 06/27/2024. The findings of Immediate Jeopardy were determined to be ongoing on 8/30/2024. The findings included: A review of the facility policy titled Pest Control Services dated 12/08/23 showed the following: A program will be established to control insects and rodents within the facility. The Administrator coordinates with the Maintenance Department to arrange pest control services monthly or as needed. Staff should report to the Administrator and Maintenance Department sightings of live pests, which are documented in the pest control log. Food preparation, service, and storage areas will be monitored regularly for any signs of pests or vermin. The Administrator and Maintenance Department will be notified immediately of any concerns. A chart review revealed that Resident #9 (room [ROOM NUMBER]) was initially admitted to the facility on [DATE] with diagnoses of Hemiplegia, Muscle Weakness, and Gout. The last Minimum Data Set (MDS), dated [DATE], section C, revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated that she was cognitively intact and able to communicate. Section GG of the MDS revealed that Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a wheelchair. A chart review revealed that Resident #36 (room [ROOM NUMBER]) was admitted to the facility on [DATE] with diagnoses of Dementia, Bipolar Disorder. The MDS dated [DATE] revealed a BIMS score of 12, which was slight cognitive impairment. In an interview conducted on 08/26/24 at 11:24 AM, Resident #9 stated that for the last 4 Saturdays, there had not been any housekeeping services and that the place was dirty. The facility's Supervisors were aware that there were pests, roaches, and mice/rodents in the facility. When asked how often she has seen any, she said, They practically live here. Resident #9 then pointed at a flat, sticky trap (with a rat picture on the label) used for mice/rats in her room that was still in an unused packet sitting on top of her belongings. Resident #9 reported that these traps were used for mice/rats sighting in her room near the air-conditioning area. In this interview, the Surveyor observed a white boxed container, which was located by the air-conditioning unit and was labeled for pests and roaches. According to Resident #9, the white box used for trapping pests did not work for rats or rodents, and this was why she kept requesting the pest control technician to get her the unused designated mice trap that was seen earlier on top of her belongings. During this entire interview, the Surveyor noted that food packaging was opened over the bed table, and other unsealed food items were around the bed. In an observation conducted on 08/26/24, at 11:50 AM, Two Surveyors were on the 2nd floor [NAME] Wing hallway across from Resident #9' room. Upon exiting the room across, they observed a rodent running in the [NAME] Wing hallway toward Resident #9's room. Resident #9, who was sitting in her wheelchair in the hallway, lifted one leg to avoid touching the rodent with her feet. Resident #9 then said to Surveyors, There it is. Did you see it? as she pointed at the rodent running into her room. In an interview conducted on 08/26/24 at 1:30 PM, with the facility's Administrator, she stated she was not aware of any rodents sighting in the facility and reported that she was not told by any residents or staff members of any rodents in the facility. A chart review revealed Resident #9's roommate, Resident #96, was admitted to the facility on [DATE] with diagnoses of Altered Mental Status, Dementia, and Cerebral infarction. The MDS dated [DATE] showed a BIMS score of 14, which was cognitively intact. In an interview conducted on 08/26/24 at 12:10 PM with Resident #96, she was not able to answer any of the Surveyor's questions regarding the rodent sighting. In an interview conducted on 08/26/24 at 1:07 PM with Staff PP, the Psychologist stated that she had not seen any rodents in the facility but was told by several residents that they observed rodents in the facility. A review of the Pest Control service reports showed the following: On 02/1/24, a pest control service report showed that a routine rodent control service was provided. On 03/7/24, a pest control service report that showed a routine rodent control service was provided. On 4/4/24, a pest control service report that showed a routine rodent control service was provided. On 05/02/24, the pest control service report showed that a routine rodent control service was provided. On 06/6/24, a pest control service report that showed a routine rodent control service was provided. On 07/11/24, a pest control service report showed that a rodent control service was provided for exterior perimeter rodent control for roof rats. On 08/01/24, the pest control service report showed that a routine rodent control service was provided. In an interview conducted on 08/29/24 at 6:28 AM with Staff OO, Pest Control, he stated that he had been coming to the facility four times a week for the last seven months. When asked if he had seen any rodents in the facility, he said no and that he had not seen any rodent droppings. Staff OO stated that Resident #9 told him that she saw a rodent in her room near the window by the air-conditioning unit last Thursday. He then placed two glue traps in the room by the air-conditioning unit. Staff OO stated that during the above routine rodent control services conducted monthly, he checks on the five black rodent control boxes that are placed outside the facility perimeter. These boxes are checked once a month for any activities or sighting of rodents. He never found any rodents inside the black boxes, but he did see some activities inside the boxes indicating that rodents took the bates that were placed in these boxes. The rodent trap boxes are part of a routine service for preventative measures. According to Staff OO, once a week for his visits is sufficient, but twice a week would be better. He had reports of rodents being seen in the main kitchen about two months ago, and he placed traps. Staff OO did not see any rodent activities or capture any rodents from the traps that he placed in the main kitchen. According to Staff OO, the facility does not have a Pest Control Log that he checks every time he comes into the facility to review the areas and rooms that need to be sprayed or treated. The staff tells him verbally about the areas that need treatment when he comes into the facility. In an interview conducted on 08/29/24 at 7:53 AM with the Director of Nursing (DON), he stated that he had never seen any rodents in the facility but was told by Staff RR, a Registered Nurse who saw rodents in a resident's room on 06/27/24 and reported it to him. Staff RR reported seeing rodents in room [ROOM NUMBER] running around by the window. She further said to him that she witnessed 3 medium-sized rodents who were not fully grown and who went by her very fast. This sighting was passed to the Administrator, who said she would handle the issue. An overnight staff member whose name he did not know told Staff SS, Medical Records, that she saw a rodent on the 2nd floor but did not give any specific room or location of this sighting. In an interview with the Administrator on 08/29/24 at 8:00 AM, she stated that he verbally tells Staff OO of pest control issues and sightings when he comes for his weekly visits. According to the Administrator, it is not written on any pest control logs. She was aware that Resident #9 reported seeing rodents in her room last Thursday, and she told Staff OO to treat the room. The Administrator stated that they are going to treat the entire room, take all furniture and belongings out, and look for possible openings and holes. According to the facility's administration, Resident #9 has been in the facility for 20 years, and her family brings her groceries every week, which are stored all around her room. In a phone interview conducted on 08/29/24 at 8:40 AM with Staff PP, the Former Maintenance Director stated that he started working in the facility in December of last year and left the facility a month ago. He was told by Staff QQ, Maintenance Staff, that Resident #36 had rodents running around her room. Staff QQ placed glue traps in Resident #36's room to try to trap the rodents, but this did not work since rodent sightings were still noted in the room. In March of 2024, he started getting multiple complaints of rodents around the facility from multiple staff members who reported sighting, but none of the sightings were documented in a pest control log. Most of the rodent sightings were coming from the 2nd floor [NAME] Wing. In an interview conducted on 08/29/24 at 9:38 AM with Staff RR, the Registered Nurse reported that she has been working in the facility for the last 13 months. Around two months ago, she came down to the Director of Nursing (DON) office and told him that she saw three rodents running around in Resident #36's room. It was late in the evening, during medication administration, when she noticed the rodents were located at the end of the room. The DON told her that he would let management know of the rodent's sighting. A few days later, the DON told her that rodent traps would be placed in the resident's room. Any rodents or pest sightings are documented on the pest control log in the nurse's station. When asked if she had documented the sighting in the pest control log, she said no. In an interview conducted on 08/29/24 at 9:52 AM with Staff SS, Medical Records stated that she was unaware of any rodents sightings in the facility or any other staff members reporting sighting of rodents. She denied any staff telling her verbally or via text messages of any rodents sightseeing in the facility. When asked about the policy for pest sightings, she said that she would tell the Administrator and Maintenance staff. When asked if she was part of any group chat regarding the facility, she said yes. In an interview conducted on 08/29/24 at 10:04 AM with Staff QQ, Maintenance staff reported that he has been working in the facility since 2001. He has never seen any rodents around the facility and was never told by any staff members or residents of any rodent sighting. Staff PP never told him about the rodents that were sighted in Resident #36's room. Staff QQ stated that he looks at the pest control log located on each unit for any pest control issues or sightings from staff. He knows that the Pest Control technician comes into the facility once a week but does not know what was treated and which areas. In another interview conducted on 08/29/24 at 10:10 AM with Staff SS, she reported that after she was done with the earlier interview on 08/29/24 at 9:52, she suddenly remembered that a staff member said to her that they saw a rodent on the unit which was on 08/20/24. She did not know the name of the staff member who told her but knew that they worked the night shift. Staff SS sent the information to the facility's group chat. In an interview conducted on 08/29/24 at 10:18 AM with Staff TT, Physical Therapy Assistance stated that she had never seen any rodents in the facility. This week, she was told of a rodent sightseeing, which was observed by Surveyors and Resident #9. She is part of a group chat from the facility by all department heads. She read on the group chat that a rodent was seen by a staff member last week, on 08/20/24. The facility's Administrator was aware of these sightings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation,and interviews, the facility failed to prevent the neglect of one (Resident #1) out of six residents sampled documented for elopement risk. The facility's failure in ensuring an adequate alert monitoring system was in place and staff's negligence in ensuring supervision and failure in implementing measure to prevent the elopement of Resident #1 who was care planned as an elopement risk. Resident #1's exited the facility undetected on 07/17/2024 through the facility's laundry room door that was not latched by staff. Resident #1 who was last seen between 7:00 PM and 7:30 PM was located at approximately 2:30 AM by local law enforcement at the county dump site one and a half miles (1.5) from the facility). The facility is a three-story building with residents rooms on the second and third floor; located in an area that has high traffic volume, busy intersections and is in a residential area. The county dump site (1.5 miles from the facility) has 2-way traffic, with a 40 miles per hour speed zone traffic. The resident has risk factors that that could likely have resulted in an adverse outcome based on the resident's clinical diagnoses The findings included. Records reviewed revealed on 07/17/2024 Resident #1 who has exit seeking behavior and wanders was not adequately supervised and left his room on the second floor, took the elevator to the first-floor laundry room and exited the facility through the unlocked door in the laundry room. On 07/29/2024 at 10:25 AM Resident #1 was observed in his room seated on his wheelchair in his room watching television with assigned one to one (1:1) Certified Nursing Assistant (CNA) Staff A. Interview on 07/29/2024 at 10:26 AM; Staff A reported the resident is not agitated and she will take the resident to activities. On 07/30/2024 at 10:45 AM; Resident#1 was sleeping, and no distress was noted. Staff A reported the resident requested to be in bed and at lunch time she will wake up the resident. Review of Resident #1's clinical records revealed, an initial admission to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include, but not limited to, Alzheimer's Disease with Late Onset; Altered Mental Status; Dementia; Restlessness and Agitation. Resident #1 who was listed as an elopement risk had was being monitored for behaviors that were being documented on the Medication Administration Records (MAR) by the day and night shift. The Quarterly Minimum Data Set (MDS) 07/05/2024 documentation indicated a Brief Interview of Mental Status (BIMS) score of 00 out of 15 to suggest the resident has severe cognitive impairment; Section E for Behaviors documented the resident exhibited wandering behaviors. Review of Resident #1's Care Plan initiated on 2/21/2024 with next review date 10/5/2024 revealed: The resident is an elopement risk/wanderer related to History of Elopement, Dementia, Disoriented to Place, History of Attempts to Leave Facility Unattended, Impaired Safety Awareness, Resident Wanders Aimlessly, Significantly Intrudes Privacy or Activities. Goal: The resident will not leave facility unattended through the review date. The residents' safety will be maintained through the review date. Interventions: Distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Increased supervision (Resident is on 1:1 supervision always). Monitor location frequently. Document wandering behavior and attempted diversional interventions. Place resident's picture, and information in Elopement Book. Review of the Federal Report #644710 revealed: On 07/17/2024 between 7:00 PM to 7:30 PM Resident #1 was seen by Staff D Certified Nursing Assistant, after she provided care for him. She reported she took the resident downstairs from the third floor to the second floor to get him ready for bed, after she gave him care, she left, and he left his room shortly afterwards. He usually can be found walking up and down slowly on the second-floor hallway. He sometimes wanders into other resident rooms, but he is easily redirected when that occurs. He sometimes sits on the floor and was once found hiding in a closet in a resident room. When the nurse went to give him his medications between 8:00 PM and 8:30 PM she noticed that he was not in his room, and she began to look for him throughout the second floor. When he could not be located, she called the third floor and asked for them to look for him. 9:00 PM Staff were looking for the resident for 30-40 minutes. Once everywhere was checked and he still could not be located, the nurse notified the Registered Nurse (RN) Supervisor who was onsite at around 9:00 PM. The RN supervisor then began to search for him. He looked in every room, bathroom, office, dining room, break room, daycare, laundry, therapy, etc. He then got in his car and drove around the area. The facility then called the police and notified the resident's son and physician. The police showed up at around 12:00 AM. While onsite the police got a call over the radio at about 2:30 AM that he was located at the county dump. The security guard at the dump observed him enter the property on foot. He approached him and noticed the resident was confused. The security guard asked the resident his name and Resident # 1 gave his name the security guard gave the police officer the name. The police already had patrol cars in the area looking for him, so they went there and picked him up. They brought him back to the facility at about 2:45 AM. During an interview on 07/29/2024 at 3:40 PM the Chief Nursing Officer revealed, the Administrator texted her on 07/17/2024 at 11:17 PM. The Administrator informed her one resident was missing and all-staff member were looking for him, they were looking in all rooms in the facility, the lobby dining rooms etc. The Administrator called the police department, and a police officer arrived at the facility; and the resident was found around one and a half miles from the facility at the county dump site. The police took the resident back to the facility. The Administrator informed her when the resident was taken back to the facility. The administrator decided to send the resident to the hospital for further evaluation. She stated the resident come back from the hospital on the same date with no injuries, Interview with Staff C Registered Nurse/Supervisor (RN) on 07/29/2024 at 3:56 PM. He reported the nurse approached him and informed him [Resident # 1] was missing they started to search for the resident on every floor. They search all rooms, under the bed and in the closets because the resident has a tendency to hide under the beds and inside the closets. When they finished looking for the resident on the second and third floors, they came down to the lobby and realized the laundry room was not latched. They went to the laundry room and saw the exit door open, that exit door goes to the parking lot and the street. He then called the Director of Nursing and the Administrator. They search around the area outside the facility. When the resident was not found the police was called and the resident was reported missing. Interview on 08/01/2024 at 3:45 PM the Director of Nursing (DON) reported; the Nurse Supervisor called him at approximately 10:00 PM and he was informed that a resident was missing, and staff were looking for the resident in all areas of the facility, and outside the facility. When he arrived at the resident eloped through the laundry room door that was not latched. The DON reported he went around the area in his car looking for the resident. The police found the resident and took him back to the facility around 2:45 AM and the resident was transferred to the hospital for evaluation. The back to the facility the same date with no injuries. He reported Immediate Jeopardy removal plan included unannounced elopement drills every other day in different shifts and in-services education for the staff. All residents were reassessed for risk of elopement initiated 7/17/2024 and completed 7/18/2024. There was a facility wide head count of current residents completed 7/17/2024. One resident eloped and was unaccounted for until 7/18/2024. All the facility doors were immediately checked to ensure proper functioning by the Administrator on 7/17/2024. All doors are checked 7 days a week to ensure proper functioning by a department head initiated 7/18/2024. The resident was placed on 1:1 supervision as of 7/18/2024 and will remain on 1:1 supervision until further assessment by the physician and psych services. The laundry staff who did not latch the door properly was educated by the Administrator 7/18/2024. Residents at risk for elopement have names and photos in a binder at the front desk and nursing stations are at 100% as of 7/17/2024. Care Plans were reviewed for current residents at risk for elopement and will have individualized interventions as of 7/17/2024. There is a dedicated staff member to monitor the front lobby area 24 hours 7 days a week with documentation that was initiated on 07/17/2024 and ongoing, hourly checks are being done for all elopement risk residents initiated 7/18/2024. The department manager will complete a head count of all residents upon arrival and before leaving five times a week to ensure all residents are accounted for was initiated on 7/18/2024. A screamer alarm was placed on the identified laundry room door 7/18/2024. The facility's Immediate Jeopardy Removal Plan was verified through records reviewed and interviews. The removal plan included: The immediate actions taken to remove the Immediate Jeopardy related to F600 based upon root cause analysis: 1-100% of all current residents reassessed for risk of elopement initiated 7/17/2024 and completed 7/18/2024. 2-100% facility head count of current residents completed 7/17/2024. One resident eloped and was unaccounted for until 7/18/2024. 3-All facility doors were immediately checked to ensure proper functioning by the Administrator on 7/17/2024. 4-Doors are checked 7 days a week to ensure proper functioning by a department head initiated 7/18/2024. 5-Resident was placed on 1:1 supervision as of 7/18/2024 and will remain on 1:1 supervision until further assessment by the physician and psych services. 6-Facility to conduct unannounced drills 4 x a week to include off shifts and weekends initiated 7/17/2024. 7- Laundry staff who did not latch the door properly was educated by the administrator 7/18/2024. 8-Residents at risk for elopement have names and photos in a binder at the front desk and nursing stations are at 100% as of 7/17/2024. 9-Care Plan reviewed and current for residents at risk for elopement to include individualized interventions as of 7/17/2024 10-Dedicated staff member to monitor the front lobby area 24/7 with documentation initiated 07/17/2024 and ongoing. 11-Hourly checks for all elopement risk residents initiated 7/18/2024. 12-A department manager to complete a head count of all residents upon arrival and before leaving five times a week to ensure all residents are accounted for initiated 7/18/2024. Staff to be educated upon hire, annually and as indicated based on facility need related to the Elopement and Abuse / Neglect policies. Quote initiated for a keypad type system for the elevator 7/29/2024. [Wander management alarm] vendor contacted, and initial phase of quotes and equipment needed initiated 7/31/2024. Residents identified as at risk for elopement will be monitored by the electronic tracking system. The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring r/t the above listed elements of F600 Abuse and Neglect to maintain compliance. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings. Verification of the facility's education related to the elopement revealed all staff members were educated Licensed Nurses 100 percent (%) of 07/8/2024 received education. Certified Nursing Assistant 100% as of 7/18/ 2024 Dietary 100% as of 7/18/2024 Maintenance 100% as of 7/18/ 2024 Environment 100% as of 7/18/ 2024 Laundry 100% as of 7/18/ 2024 Therapy 100% as of 7/18/ 2024 Department Heads 100% as of 7/18/ 2024 Review of the facility's Policies and Procedures for Abuse, Neglect, Exploitation and Misappropriation effective date 11/30/2014 revised on 11/29/2017 revealed: Policy It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be from abuse, neglect, mistreatment, exploitation and or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free form abuse, neglect, mistreatment, and /or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Neglect: is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include, but are not limited to. Failure to adequately supervise a resident known to wander form the facility without the staff knowledge.