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

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

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

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

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

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policies and procedures, record review and staff interview, the facility failed to implement their policy and honor the resident's right to receive cardiopulmonary resuscitation (CPR) in the event of cardiac and/or respiratory arrest for 1 (Resident #1) of 3 residents reviewed for care at the end of life. On [DATE] shortly after midnight, Resident #1 was found without a pulse or respiration. The facility failed to initiate CPR despite the resident's Power of Attorney directive to do everything that can be done. Resuscitation efforts, if successful, may have prolonged Resident #1's life. On [DATE] at 3:40 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. Cross reference: F678 and F835. The findings included: The facility's policy regarding Treatment and Advance Directives, revised 1/2022 noted, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Closed record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of schizophrenia, dementia, coronary artery disease, emphysema, and atrial fibrillation. The admission Minimum Data Set with an Assessment Reference Date of [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 0 which meant Resident #1 was rarely/never understood. A valid Power of Attorney (POA) for healthcare decision was executed appointing Resident #1's sister as the POA on [DATE]. On [DATE] in a discussion with the facility social worker, the POA stated, Do everything that can be done, meaning full code status (initiate cardiopulmonary resuscitation (CPR) in the event of cardiac and/or respiratory arrest). Closed record review revealed a physician's order for full code was written on [DATE] and a care plan initiated on [DATE] which noted Resident #1 had an established CPR (Full code) order in place. Closed record review revealed on [DATE], a little after 12:00 a.m., Certified Nursing Assistant (CNA) Staff C entered Resident #1's room and he did not seem to be breathing. The CNA asked Licensed Practical Nurse (LPN) Staff A to come to his room. LPN Staff A nurse entered the room, checked pulse and respirations, and determined Resident #1 was not breathing and did not have a pulse. This occurred at 12:20 a.m. LPN Staff A exited the room and returned to the nursing station. She did not check for code status, start CPR or call 9-1-1. LPN Staff A asked LPN Staff B to contact the physician and family to let them know the resident had expired. Review of the facility investigation revealed a witness statement from LPN Staff A dated [DATE] noting: Resident expired after midnight. During rounds I found the resident to be deceased . He still had the oxygen on, but he was not breathing there was no pulse . Once I saw he was deceased , I came to the desk at the nurse's station and notified the family and the MD (Physician). I didn't check to see that he was a full code. I didn't initiate CPR. The resident was mottled (patchy, irregular colors), and his extremities were cold, but his body was warm. I made a mistake. On [DATE] at 9:30 a.m., the Administrator and Director of Nursing (DON) confirmed LPN Staff A did not follow Resident #1's Power of Attorney's expressed advance directive for a full code and did not initiate CPR. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after verification of an acceptable removal plan, and the scope and severity reduced to D (No actual harm with potential for more than minimal harm that is not immediate jeopardy). The removal plan submitted by the facility and verified by the survey team included: [DATE] - The Licensed Nurse who did not perform CPR on the full code status resident was suspended pending investigation. The DON or designee initiated education with the licensed nurses on the facility's policy and procedure for responding to a medical emergency, validating code status, resident rights regarding advanced directives, and abuse and neglect. By end of day, education was completed with 23 of 65 facility licensed nurses and CNAs (35% completion). An ad hoc (unplanned) QAPI (Quality Assurance Performance Improvement) Committee meeting was held with the Medical Director in attendance. Root Cause Analysis was performed. A Performance Improvement Project (PIP) was implemented. DON/designee conducted a quality review of residents who coded in the last 6 months to ensure advanced directives were followed as ordered by the physician. In addition to Resident #1, 2 of 19 residents reviewed were full code, CPR was performed, and emergency medical personnel was contacted. The DON or designee initiated quality review of advanced directive orders for current residents residing in the facility. Physician orders for advance directives were confirmed present. For residents with DNR (Do Not Resuscitate) orders in place, the Florida DNR form was confirmed to be present in the medical records and care plans related to advanced directives were reviewed/updated accordingly. HR (Human Resources) or designee initiated audit of licensed nurses' CPR certification. DON or designee conducted Code Blue drills with licensed nursing staff. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. By end of day, 21 of 65 licensed nursing staff participated in drills (33% completion). [DATE] - Employment terminated with licensed nurse who did not initiate CPR on the full code resident (Resident #1). Nurse license reported to Florida Department of Health. HR or designee completed audit of licensed nurses' CPR certification. CPR certification current for 19 of 19 licensed nurses consisting of 8 RNs (Registered Nurses) and 11 LPNs (100% validated). The DON or designee initiated education with licensed nurses on the facility's policy and procedure for responding to a medical emergency, validating code status, resident rights regarding advanced directives, and abuse and neglect. By end of day, education completed with 64 of 65 facility licensed nurses and CNAs (98% completion). 1 CNA not yet educated will not be permitted to work until education has been received. Any new hires will receive education prior to providing resident care. The DON or designee completed the quality review of advanced directive orders for current residents residing in the facility. Physician orders for advance directive were confirmed present. For residents with DNR orders in place, the Florida DNR form was confirmed to be present in the medical records. Care plans related to advanced directives were reviewed/updated accordingly. DON or designee conducted Code Blue drills with licensed nursing staff. By end of day, 47 of 65 licensed nursing staff had successfully participated in Code Blue drills (72% completion). Licensed nursing staff will not be permitted to provide direct care to residents until he/she has participated in a code blue drill and has shown competency in implementing the emergency medical response policy. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. Ongoing monitoring to ensure compliant practice remains in place: DON or designee to conduct Code Blue drills weekly on each shift for four weeks, then 2 times monthly on each shift for 2 months to ensure licensed nursing staff respond as per federal regulation and facility policy and procedure. DON or designee to conduct competencies with 10 licensed nursing staff weekly for 3 months regarding following advanced directives and responding to medical emergencies to include identifying when CPR should be performed, and emergency medical personnel contacted. Findings will be reported at monthly QAPI committee meeting. Findings will be reported to QAPI committee monthly. Ongoing quality review schedule may be modified based on findings to ensure compliance practice remains in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility failed to provide cardiopulmonary resuscitation (CPR) in accordance with the resident's documented wishes and physician's order for 1 (Resident #1) of 3 sampled residents reviewed for emergency care. Resident #1 had a full code status effective [DATE]. On [DATE] shortly after midnight, the resident was unresponsive and had no pulse or respiration. The staff nurse on duty did not perform CPR or call 9-1-1. Resident #1 expired at the facility without receiving CPR as per expressed wishes and physician's order. The facility's failure to initiate CPR in accordance with the resident's expressed wishes and physician's order resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on [DATE]. On [DATE] at 3:40 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after implementation of an acceptable removal plan was verified, and the scope and severity was reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). There were 59 residents with full code status at the time of the event. Cross reference: F578 and F835. The findings included: A Center for Clinical Standards and Quality/Survey & Certification (S&C) letter on Cardiopulmonary Resuscitation (CPR) in Nursing Home: 14-01-NH, revised [DATE] includes the following: The American Heart Association (AHA) has established evidenced-based decision-making guidelines for initiating CPR when cardiac arrest occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place. 2) obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. Facility policy should specifically direct staff to initiate CPR when cardiac arrest occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines. Review of the facility policy Medical Emergency Response revised 1/2022 noted, The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate. The admission Minimum Data Set with an Assessment Reference Date of [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 0 which meant Resident #1 was rarely/never understood and had severe cognitive impairment. A valid Power of Attorney (POA) for healthcare decision was executed appointing Resident #1's sister as the POA on [DATE]. On [DATE] in a discussion with the facility social worker, the POA stated, Do everything that can be done meaning full code Status. Closed record review revealed a physician's order for full code was written on [DATE]. A care plan noting Resident #1 has an established CPR (full code) order in place was initiated on [DATE]. Closed record review revealed on [DATE], a little after 12:00 a.m., Certified Nursing Assistant (CNA) Staff C entered Resident #1's room and he did not seem to be breathing. The CNA asked LPN Staff A to come to the resident's room. LPN Staff A nurse entered the room, checked pulse and respirations, and determined Resident #1 was not breathing and did not have a pulse. This occurred at 12:20 a.m. LPN Staff A exited the room and returned to the nursing station. She did not check for code status, did not start CPR, and did not call 9-1-1. LPN Staff A asked LPN Staff B to contact the physician and family to let them know the resident had expired. Review of the facility investigation revealed a witness statement from LPN Staff A dated [DATE] noting: Resident expired after midnight. During rounds I found the resident to be deceased . He still had the oxygen on, but he was not breathing there was no pulse . Once I saw he was deceased , I came to the desk at the nurse's station and notified the family and the MD (Physician). I didn't check to see that he was a full code. I didn't initiate CPR. The resident was mottled (patchy, irregular colors), and his extremities were cold, but his body was warm. I made a mistake. Review of the facility generated report submitted to the Florida Agency for Healthcare Administration on [DATE] noted Resident #1 was a long-term resident admitted to the facility on [DATE]. On [DATE] staff nurse observed Resident #1 unresponsive and without a pulse. The nurse did not verify the code status and CPR was not initiated. The facility completed a thorough investigation including, but not limited to resident interviews, staff interviews and medical record review. The facility substantiated the allegation of neglect and noted in the conclusion based on the facility investigative findings, it had been validated that the LPN did not initiate CPR when Resident #1 was observed without a pulse or respiration on [DATE]. The resident's care plan and physician orders for advanced directives were not followed. On [DATE] at 9:30 a.m., in an interview with the Administrator and Director of Nursing (DON), they confirmed LPN Staff A did not follow Resident #1's Power of Attorney's expressed advance directive for a full code and did not initiate CPR. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after verification of an acceptable removal plan, and the scope and severity reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). The removal plan submitted by the facility and verified by the survey team included: [DATE] - The Licensed Nurse who did not perform CPR on the full code status resident (Resident #1) was suspended pending investigation. The DON or designee initiated education with the licensed nurses on the facility's policy and procedure for responding to a medical emergency, validating code status, resident rights regarding advanced directives, and abuse and neglect. By end of day, education was completed with 23 of 65 facility licensed nurses and CNAs (35% completion). An ad hoc (unplanned) QAPI (Quality Assurance Performance Improvement) Committee meeting was held with the Medical Director in attendance. Root Cause Analysis was performed. A Performance Improvement Project (PIP) was implemented. DON/designee conducted a quality review of residents who coded in the last 6 months to ensure advanced directives were followed as ordered by the physician. In addition to Resident #1, 2 of 19 residents reviewed were full codes and CPR was performed and emergency medical personnel was contacted. The DON or designee initiated quality review of advanced directive orders for current residents residing in the facility. Physician orders for advance directives were confirmed present. For residents with DNR (Do Not Resuscitate) orders in place, the Florida DNR form was confirmed to be present in the medical records and care plans related to advanced directives were reviewed/updated accordingly. HR (Human Resources) or designee initiated audit of licensed nurses' CPR certification. DON or designee conducted Code Blue drills with licensed nursing staff. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. By end of day, 21 of 65 licensed nursing staff participated in drills (33% completion). [DATE] - Employment terminated with licensed nurse who did not initiate CPR on the full code resident (Resident #1). Nurse license reported to Florida Department of Health. HR or designee completed audit of licensed nurses' CPR certification. CPR certification current for 19 of 19 licensed nurses consisting of 8 RNs (Registered Nurses) and 11 LPNs (100% validated). The DON or designee initiated education with licensed nurses on the facility's policy and procedure for responding to a medical emergency, validating code status, resident rights regarding advanced directives, and abuse and neglect. By end of day, education was completed with 64 of 65 facility licensed nurses and CNAs (98% completion). 1 CNA not yet educated will not be permitted to work until education has been received. Any new hires will receive education prior providing resident care. The DON or designee completed the quality review of advanced directive orders for current residents residing in the facility. Physician orders for advance directive were confirmed present. For residents with DNR orders in place, the Florida DNR form was confirmed to be present in the medical records. Care plans related to advanced directives were reviewed/updated accordingly. DON or designee conducted Code Blue drills with licensed nursing staff. By end of day, 47 of 65 licensed nursing staff had successfully participated in Code Blue drills (72% completion). Licensed nursing staff will not be permitted to provide direct care to residents until he/she has participated in a code blue drill and has shown competency in implementing the emergency medical response policy. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. Ongoing monitoring to ensure compliant practice remains in place: DON or designee to conduct Code Blue drills weekly on each shift for four weeks, then 2 times monthly on each shift for 2 months to ensure licensed nursing staff respond as per federal regulation and facility policy and procedure. DON or designee to conduct competencies with 10 licensed nursing staff weekly for 3 months regarding following advanced directives and responding to medical emergencies to include identifying when CPR should be performed, and emergency medical personnel contacted. Findings will be reported to QAPI committee monthly. Findings will be reported at monthly QAPI committee meeting. Ongoing quality review schedule may be modified based on findings to ensure compliance practice remains in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility administration failed to utilize its resources effectively to ensure licensed staff were competent to perform emergency response and provide life saving measures, including cardiopulmonary resuscitation for residents requiring such emergency care. This has the potential to negatively impact all 59 residents in the facility who may require emergency services. Resident #1 had a full code status effective [DATE]. On [DATE] shortly after midnight, the resident was unresponsive and had no pulse or respiration. The staff nurse on duty did not perform CPR or call 9-1-1. Resident #1 expired at the facility without receiving CPR as per expressed wishes and physician's order. The failure of the facility's administration to ensure staff training and competency for emergency response resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on [DATE] when the licensed nurse failed to initiate CPR when Resident #1, who had a full code status, was found without a pulse or respiration. On [DATE] at 3:40 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after implementation of an acceptable removal plan was verified, and the scope and severity reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). Cross reference: F578 and F678. The findings included: The Administrator's job description which he signed on [DATE] revealed, Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents. The Director of Nursing's job description which she signed on [DATE] included, To manage the overall operations of the Nursing Department in accordance with company policies, standards of nursing practices and governmental regulations to maintain excellent care of all residents' needs. Review of the facility policy Residents' Rights Regarding Treatment and Advance Directives revised 1/2022 noted, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Review of the Medical Emergency Response revised 1/2022 noted, The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate . Review of the closed clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of schizophrenia, dementia, atrial fibrillation, emphysema, and coronary heart disease. The admission Minimum Data Set with an Assessment Reference Date of [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 0 which meant Resident #1 was rarely/never understood. A valid Power of Attorney (POA) for healthcare decision was executed appointing Resident #1's sister as the POA on [DATE]. On [DATE] in a discussion with the facility social worker, the POA stated, Do everything that can be done meaning full code Status. Closed record review revealed a physician's order for full code was written on [DATE] and a care plan noting Resident #1 had an established CPR (full code) order was initiated on [DATE]. Review of the closed clinical record revealed on [DATE], shortly after midnight, Resident #1 was unresponsive and had no pulse or respiration. Resident #1 expired at the facility without receiving CPR as per expressed wishes and physician's order. Licensed Practical Nurse (LPN) Staff A, the staff nurse on duty, did not perform CPR or call 9-1-1. LPN Staff A asked LPN Staff B to contact the physician and family to let them know the resident had expired. Review of the facility investigation revealed a witness statement from LPN Staff A dated [DATE] noting she did not check the code status and did not initiate CPR. LPN Staff A documented in the statement, I made a mistake . Closed record review revealed no evidence LPN Staff A had been assessed for competency in medical emergency response or trained in resident's rights regarding treatment and advance directives. On [DATE] at 9:30 a.m., the Administrator and Director of Nursing confirmed LPN Staff A did not follow Resident #1's expressed advance directive for a full code and did not initiate CPR. On [DATE] at 2:10 p.m., the Director of Clinical Services provided documentation of training dated [DATE] to 17 licensed nurses. The training consisted of a 25-page presentation with two lines that included the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. The Director of Clinical Services also provided proof of training related to residents' rights dated [DATE] for LPN Staff B. She said the facility did not have documentation of assessment of clinical competencies for all 19 licensed nurses related to emergency response. On [DATE] at 7:00 p.m., the Immediate Jeopardy was removed after verification of an acceptable removal plan, and the scope and severity reduced to D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). The removal plan submitted by the facility and verified by the survey team included: By [DATE], the facility DON or designee conducted Code Blue drills with licensed nursing staff to include 4 CNAs who had not yet participated in a code blue drill and prior to providing direct patient care. By the end of day, 51 of 65 licensed nursing staff had participated in Code Blue drills (78% completion). Licensed nursing staff will not be permitted to provide direct care to residents until he/she has participated in a code blue drill and has shown competency in implementing the emergency medical response policy. Licensed nursing staff who fail to perform code as per the emergency response policy during the drill will be re-educated and be required to participate in additional code blue drill(s) until competent to carry out emergency medical response policy. Ongoing monitoring to ensure compliant practice remains in place: DON or designee to conduct Code Blue drills weekly on each shift for four weeks, then 2 times monthly on each shift for 2 months to ensure licensed nursing staff respond as per federal regulation and facility policy and procedure. DON or designee to conduct competencies with 10 licensed nursing staff weekly for 3 months regarding following advanced directives and responding to medical emergencies to include identifying when CPR should be performed, and emergency medical personnel contacted. Regional Operations and/or Clinical Consultants to review education and competencies on emergency medical response policy and advanced directives that has been completed with facility staff to include newly hired licensed nurses and CNAs every other week for 4 weeks, then a minimum of monthly to ensure administration is effective in ensuring staff implement their emergency response policy. Chart reviews will be conducted by the DON/designee within 24 hours of a resident coding within the facility to verify the emergency response policy was implemented and advanced directives followed as per their wishes. Findings will be presented to QAPI (Quality Assurance and Performance Improvement) committee monthly. Ongoing quality review schedule may be modified based on findings to ensure to ensure compliance practice remains in place.