**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to: 1. Ensure ants were not found on Resident #1's body on 08/13/25 and 08/15/25 which caused large papules (small bumps on the skin that contain fluid or pus) from his right shoulder to elbow, right hip to mid-thigh, abdomen, and between the toes of his feet.2. Accurately document in Resident #1's EMR regarding the presence of ants/ant bites on his body.3. Ensure Resident #1 was moved to a different room after ants were found on his body on 08/13/25 until 08/15/25.This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/25/25 at 7:10 PM and a template was provided. While the IJ was removed on 08/26/25 at 7:06 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of discomfort, pain, worsening skin impairment issues, and a decreased quality of life. Findings included:Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, dysphagia (difficulty swallowing), muscle weakness, and need for assistance with personal care. Review of Resident #1's quarterly MDS assessment, dated 07/22/25, reflected a BIMS score of 00, indicating he had a severe cognitive deficit. Review of Resident #1's quarterly care plan, dated 07/06/25, reflected he had skin tears related to fragile skin, aging, medication effects, or mobility with an intervention of making sure his environment was safe. Review of Resident #1's NP assessment, dated 08/13/25, reflected the following: [Resident #1] is seen today for a report of possible ant bites to the right arm and right leg. Small red lesions noted to [Resident #1]'s right arm and leg. Review of Resident #1's hospice note, dated 08/13/25 at 12:57 PM and documented by HN D, reflected the following: PC from [LVN A] at (facility) requesting order for Benadryl RN due to ant bites on [Resident #1]'s arm and itching. Verbal order given per s/sx management for Benadryl 25mg 1-2 tablets every 6 hours as needed for itching. Review of Resident #1's progress note, dated 08/13/25 at 3:09 PM and documented by LVN A, reflected the following: [Resident #1] continues with red raised rash to right upper arm and a few patchy areas to the right thigh. He has no complaints of pain or itching at this time. Received PRN order for Benadryl from hospice. Review of Resident #1's physician order, dated 08/13/25, reflected Benadryl Oral Tablet 25 MG - Give 1 tablet by mouth every 6 hours as needed for rash. Review of Resident #1's skin assessment, dated 08/13/25 and completed by LVN A, reflected a rash to his right upper arm. There were no further skin assessments conducted. Review of the facility's pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait was placed in the restroom and bedroom as a precaution. Review of Resident #1's HN B's skin assessment, dated 08/15/25 at 10:44 AM, reflected he had generalized ant bites that were not healing and were pink and beefy red pustules. Review of Resident #1's HN B's progress note, dated 08/15/25 from 10:40 AM - 11:40 AM, reflected the following: [HN B] entered [Resident #1]'s room and found pt awake in bed, [HN B] noted ants crawling on pt's bedding. [HN B] returned to nurses station to tell [LVN C] that the pt needed to be moved to a new room and they needed to contact an exterminator, as ants were in pt's bed. [LVN C] offered for facility aides to change pt bedding. [HN B] stated she would change the bedding, but ants need to be addressed as pt had ant bites on Wednesday (08/13/25). [LVN C] stated the assessment from Wednesday stated pt had a rash. [HN B] went back to pt room, took a picture of ant bites on pt's arm and showed them to [LVN C] who stayed at the nurses station. [HN B] returned to change pt bedding and noted at least 100 ants in pts bed and on pt. [HN B] returned to nurses station to tell [LVN C] that there is a serious issue and pt need to be moved immediately. [HN B] returned to pt room to find [LVN C] had not followed her and was still at nursing station. [HN B] stated loudly that [LVN C] needed to get the DON or the administrator into the patient's room immediately. Multiple HCAs showed up to help [HN B], and eventually [LVN C] did too. [HN B] showed all staff members the multitude of ants in pt's bed. Ants were in between the pt's toes, and on his body from his right leg up to stomach, also removed ants from under pt's scrotum. [LVN C] stated that she was on her first day and was unaware. [The ADM] showed up and said, these [NAME] fire ants, I was told they were fire ants. [HN B] replied, I dont care what they are, this is unacceptable. [The ADM] stated that a pest control person treated the room yesterday and said he left live traps for ants, so it would be normal to see ants going to the live traps. [HN B] asked [The ADM] if the pest control person put live traps in the pt's bed, as that is where the majority of the ants are. [The ADM] did not answer, but stated that the bird feeder outside of the pt's window was a big problem and a cause of ants. [HN B] asked [The ADM] if the facility staff was putting bird feed underneath the pt. Again, [The ADM] did not answer. [HN B] showed everyone in the room the pt's right upper arm, which was covered in ant bites, [LVN C] stated that the patient's arm did not look like that on Wednesday. [HN B] asked [LVN C] how she knows what patient's arm looked like if today was her first day, no one answered. [HN B] stated that staff needed to get the hoyer lift so that pt can be transferred out of his bed to high back WC immediately. WC, in pt's bathroom, also found to have ants on it. [The ADM] left and came back several minutes later stating that pt would be moved to another room, but instructed facility aides to just get pt to high back WC and take him to the cafeteria for lunch, not to move his belongings at this time. SKIN: Skin is thin/fragile with Ecchymosis to BUE, with ruddy BLE. Pt has generalized ant bites all over his body. Pt's right arm from shoulder to elbow is approximately 85% covered in numerous erythematous papules (red lesions on the skin that may resemble elevated rashes) and vesiculopustular lesions that range from 1-5mm in diameter. Many with vesicopustule (a vesicle which is developing pus) formation with erythema (redness or discoloration of the skin) at the base. Similar lesions are present from pt's right hip to mid thigh, covering approximately 30-40% of the surface area and multiple lesions are also present between the toes of bilateral feet. Facility staff reports pt's itching has been controlled with PRN Benadryl and Hydrocortisone cream.Please ensure that pt has been moved to new room and that no ants or other insects are present in pt's bed. I did not leave medihoney in pt room so that Administrator could not blame ants on medihoney. Review of Resident #1's progress note, dated 08/15/25 at 11:09 AM and documented by LVN A, reflected the following: Notified [Resident #1's RP] and [Resident #1] that he is moving to 214 (room) today. Review of Resident #1's HN B's progress note, dated 08/18/25 at 12:07 PM, reflected he had generalized ant bites that were not healing with raised heads. Review of maintenance log requests, from 07/01/25 - 08/20/25, reflected ants were found in resident's rooms on 07/11/25, 07/22/25, 07/24/25, and 07/25/25.Review of a pest control invoice, dated 07/14/25, reflected they spot treated a proximity [sic] a dozen fire ant mounds. Review of a pest control invoice, dated 07/29/25, reflected the following: (Pest control company) responded to an emergency call regarding ant activity in rooms [ROOM NUMBERS]. Upon arrival, I met with the social worker at the front desk. We first inspected room [ROOM NUMBER], where staff reported ant activity throughout the room and restroom. During my inspection, I confirmed the presence of fire ants in the restroom and along the baseboards near the dresser. I applied a liquid treatment around all baseboards in the room and restroom. Next, we proceeded to room [ROOM NUMBER], which previously housed the resident from room [ROOM NUMBER]. Although no live ant activity was observed during the inspection, I performed a preventative treatment by baiting the restroom baseboards and the sink area. Afterward, I met with the [MAINTD], to access the courtyard and inspect for ant mounds near the affected units. Several mounds were located and treated. I recommended a long-term control solution, and the [ADM] requested a quote. I will be contacting my superiors to have this quote forwarded to her.Reported ants in room [ROOM NUMBER]. Facility has made multiple requests for ants. Please evaluate if larger scale of services needed. Review of pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait eas [sic] placed in the restroom and bedroom as a precaution. After this I made my way outside for an exterior inspection and granular perimeter application. Active ant mounds were treated with a bait application. A liquid residual perimeter application was performed on entry ways to aid in control of ants. I spoke with the administrator to wrap up the service. She was notified that our products take a few days to achieve full effect. During an observation on 08/20/25 at 10:52 AM revealed Resident #1 asleep in his bed and was unable to arouse. Visible beneath the right sleeve of his hospital gown revealed approximately 50 dark pink/red ant-like bites on his upper arm/shoulder. There were no visible ants in his bed, room, or bathroom. During a telephone interview on 08/20/25 at 12:04 PM, Resident #1's NP stated she was notified of redness to his arm on 08/13/25. She stated she looked at it but could not determine what it was, it was too difficult to say. She stated she wrote an order for Benadryl for dermatitis (a skin condition that causes redness, irritation, or rash). She stated he was on hospice services, so they oversaw his care. During an interview on 08/2025 at 12:55 PM, CNA E stated Resident #1 had recently been moved to her hall (200) but was not sure why. She stated she was not told what happened. She stated he had redness to his arms and stomach. During an interview on 08/20/25 at 1:03 PM, LVN C stated she was not working the day Resident #1 appeared with a rash. She stated she first saw it the following day, 08/14/25 and was asked if she would describe it. She stated she would not be able to because she was not a doctor. During an interview on 08/10/25 at 1:10 PM, the ADM stated on 08/13/25 she was grabbed by an aide stating Resident #1 had ants in his bed. She stated they had already cleaned up his bed but was shown a picture and they looked like sugar ants and sugar ants did not bite. She stated she told them to get him up and asked the housekeepers to clean his room. She stated she had the NP and her ADON assess his skin and the ADON said it looked more like a rash. She stated the NP looked at it and said she did not think they were ant bites by the way they were raised up from his skin and that it may be a reaction to something or a rash. She stated she contacted pest control, and they came the following day, 08/14/25, to treat his room. She stated on 08/15/25, HN B pulled back his covers on his bed and found ants on his abdomen. She stated she had not moved him rooms because pest control had already treated the room and the ADON and NP had told her it was a rash, not ant bites. She stated she called the pest control company again and they told her it could take up to a week before all the ants were killed. She stated she had not known that before. She stated she had not seen his skin since 08/13/25 and was shown a current picture. When she saw the picture, she stated it did look like they could be bites. During a telephone interview on 08/25/25 at 11:50 AM, HN B stated she found out ants were in Resident #1's bed on 08/13/25 when LVN A contacted their agency requesting Benadryl for ant bites and him itching. She stated on 08/15/25, when she arrived, she could not believe what she saw. She stated there were hundreds of ants all over him actively biting and she had to remove them from his right arm, right leg, abdomen, and under his scrotum. She stated his bites had little white heads and she had no doubt they were from the ants. She stated she even found ants on his wheelchair in his bathroom. She stated she went to tell LVN C who blew her off and kept telling her it was a rash. She stated she finally got the ADM in the room and showed her the ants and told her to get her staff to move him rooms as it was completely unacceptable. She stated her HCAs provided him with a shower and removed his linens to be laundered. During an interview on 08/26/25 11:57 AM, LVN C stated she worked the 6:00 AM - 6:00 PM shift on 08/15/25. She stated when HN B came in to do wound care on Resident #1, she was shown a picture of his skin, and she believed it was a rash. She then stated HN B found the ants on him and in his bed. She stated they then removed all of his linens and took them to the laundry room and moved him to a room on the 200 hall. She stated she did see the ants in his bed but did not perform a skin assessment because she saw one had already been done that day and a rash was noted. She stated the importance of skin assessments was to make sure the skin was good, for skin integrity, and to ensure there was no skin breakdown. During an interview on 08/26/25 at 12:10 PM, the ADM stated the pest control company they used brought up doing extra services on the grounds (outside of facility) but not the inside of the facility. She stated she asked for a quote but never received one. She stated a negative outcome of not following up with the pest control company would be that you could have pests in the building that could contribute to negative outcomes for the residents. She stated they could be a nuisance, could carry germs, or they could bite the residents which could lead to more negative outcomes. She stated the importance of accurate nursing documentation was so there was a clear picture of what was happening with the resident. She stated her expectations on nursing documentation was that all issues and concerns of the residents were documented. She stated if the documentation was not accurate, the resident could have an issue or concern that the nurses were not aware of, and it would not get addressed. She stated a skin assessment should have been conducted by the nurses every day after Resident #1 acquired his rash to ensure they were assessing the area and to ensure the MD was notified if there was a change. During a telephone interview on 08/26/25 at 12:46 PM, the ADON stated he was told by LVN A that Resident #1 had a skin impairment issue (could not remember the date). He stated he went and assessed him but did not see anything visible at that time. He stated he did not see anything that was consistent with bite marks. He stated he had ben out sick so he had not assessed Resident #1 since 08/13/25. He stated even though he was under hospice's care, they (facility staff) were still responsible for the welfare of the resident. He stated the importance of accurate skin assessments were to ensure there were no areas on the residents and to make sure there were no skin issues going unaddressed. During a telephone interview on 08/26/25 at 1:18 PM, LVN A stated she was working on Resident #1's hall on 08/13/25. She stated CNAs F and G came to her and told her he had raised areas to his right arm. She stated there was mention of ant this and ant that but when she inspected his room, she saw no ants. After the NP assessed him and did not note ant bites, she completed her skin assessments and documented a rash to his right arm. During a telephone interview on 08/26/25 at 4:25 PM, CNA G stated she worked on Resident #1's hall on 08/13/25. She stated she had worked with him for 3-4 years and he was unable to use his call light, so when he was in distress or needed something, he would whistle. She stated on 08/13/25, she heard him whistling so she went to his room with CNA F. She stated they pulled back his covers and saw about 15 ants or more crawling on his right thigh. She stated there were bites all over his legs, stomach, and right arm. She stated there the bites were blotchy red spots. She stated she and CNA G told LVN A that they needed to get the ADM to his room. She stated the ADM told them to give him a shower and she would call for pest control to come and treat the room. She stated the HCAs provided the shower while they removed the linens to be laundered. During an interview on 08/26/25 at 4:40 PM, CNA F stated she worked on Resident #1's hall on 08/13/25. She stated she and CNA G uncovered him, and they saw ants and ant bites on his right side, right arm, right upper thigh, and on his stomach. She stated the bites looked red like little dots and she estimated there were 15-20 ants on him. She stated his body was moving in frustrated movements, which was not normal. She stated she and CNA G reported it to LVN A. Review of the facility's Pest Control Policy, revised May 2008, reflected the following: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's Charting and Documentation Policy, dated July 2017, reflected the following: The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the facility's Pressure Injury Risk Assessment, dated March 2020, reflected the following: Documentation:The following information should be recorded in the resident's electronic health record utilizing facility forms.:.4. Any change in the resident's condition, if identified.5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. Review of the facility's Skin System Process Policy, dated May 2025, reflected the following: PCC Skin and Wound Total Body Skin Assessment: assessment is completed weekly until pressure injury or skin issue (skin tears, lacerations, abrasions, surgical incisions, diabetic, arterial, stasis, venous ulcers) is resolved. The ADM was notified on 08/25/25 at 7:10 PM that an IJ had been identified and an IJ template was provided at that time.The following Plan of Removal submitted by the facility was approved accepted on 08/26/25 at 12:30 PM: Resident #1 was assessed for skin alterations by the Director of Nursing on 08/25/2025. An entire building skin sweep was initiated and completed on 8/25/25 by the Director of Nursing to ensure no more residents had skin alterations from possible ant bites. Skin assessments on all residents are documented in the electronic health record of the individual residents. On 8/25/25, the regional nurse consultant educated the administrator, business office manager, and the director of nursing on abuse, neglect, identifying pest control issues, skin abnormalities in regards to insect bites. The Business Office Manager searched all residents' rooms on 08/25/25 for any evidence of ants, no concerns were notes. Interviewable residents were asked if they had noticed any ants or pests in their rooms, on 08/25/25By the Business Office Manager. All residents interviewed stated they had not seen any ants or pests. This was documented on a facility form. The charge nurse that did not report the alleged neglect, was counseled by the director of nursing on 08/25/25 on the Abuse and Neglect policy, documentation, assessment, physician notification of change, skin assessment, immediately moving a resident if pests are found in room, notification of RP for change in condition, rounding, documentation in medical record. Charge nurse signature on in-service indicates understanding. The pest control company was at facility to exterminate inside and outside for ants on 8/14/25. The pest control company was at the facility on 8/26/25 to exterminate inside and outside the facility. This will be documented in the pest control book. All staff were in-serviced on Abuse, Neglect, and Exploitation, and reporting Abuse and Neglect to the abuse coordinator/facility administrator immediately, beginning on 8/25/25 and will be completed on 8/26/2025. In-services were completed per the Director of Nursing. Any new staff or agency staff will be in-serviced by the DON on Abuse, Neglect, and Exploitation policy before the start of their first shift. Verification of education will be completed by administrator/designee, three (3) times a week for thirty (30) days and randomly thereafter. Results will be kept on a facility audit form. Department heads will round in the morning all resident rooms. Focus will be ensuring there is no evidence of ants or pests in the resident rooms, daily M-F X3 months. Dept heads will be educated on this practice by the administrator on 08/26/2025. Results will be kept on a facility rounding form. DON and the Administrator will interview 3 staff daily related to their understanding of the in-service education provided, for the next 4 weeks. Results will be kept on a facility audit form. An Ad Hoc QAPI was held by the Facility Administrator, Director of Nursing, , and Asst. Director of Nurses on 08/25/2025 at 8:30 PM to review the alleged deficiency and plan. The surveyor monitored the POR on 08/26/25 as followed: Observations made on 08/26/25 from 12:45 PM - 1:18 PM revealed six randomly picked resident rooms without any ants/pest sightings. The residents that occupied these rooms denied seeing any pests/ants. During interviews on 08/26/25 from 3:18 PM - 6:20 PM, the following staff were interviewed from all shifts: CNA E, CNA F, CNA G, the DM, HSK H, HSK I, DA J, MA K, CNA L, LVN M, MA N, CNA O, MA P, CNA Q, LVN R, and LVN S. All stated they were in-serviced on abuse and neglect and pest control prior to their shift. The nurses stated they were also interviewed on documentation and skin assessments. All staff stated their ADM was the abuse and neglect coordinator and they should report to her immediately if they heard of or saw any allegation of abuse or neglect. They were able to give examples of abuse such as verbal, physical, or emotional. They all stated if they saw any pests, such as roaches, ants, or flies, they would immediately notify the ADM and MAINTD and fill out the pest control log that was located at the nurse's station. They all stated if a pest was found on a resident they needed to be showered, moved to another room, an all their linens and clothes would need to be laundered. The CNAs stated they would notify the nurses immediately if they saw any bites on a resident during personal care. The nurses stated the importance of skin assessments were to give an accurate depiction of the resident's skin, such as potential bug bites. The nurses stated they were to document all skin impairments along with the size/measurements (if applicable), color, and any other indications. The nurses stated anything that happened to a resident medically or physically should be accurately documented in the resident's chart to paint a clear picture of what was going on with them. All nursing staff stated residents should be rounded on at least every two hours to ensure their safety and health needs were being met. During an interview on 08/26/25 at 3:02 PM, the PCS stated the facility contacted his company on 08/25/25 and requested service as soon as possible. He stated he treated the facility inside and outside on 08/26/25. He stated he did not observe any ants inside the facility. During an interview on 08/26/25 at 4:54 PM, the RNC stated she in-serviced the ADM and DON on 08/25/25 regarding staff rounding, reporting pests, abuse and neglect, skin assessments, nursing documentation, and moving residents to a pest-free room if pests were observed in their room. During an interview on 08/26/25 at 5:14 PM, the ADM stated she and the DON were in-service by the RNC prior to in-servicing staff on pest control, what to do when pests were located, and skin assessments prior to a resident being potentially bitten. She stated they were also in-serviced on abuse and neglect, reporting/investigation time frames, skin assessments, and nursing documentation. She stated when pests/ants were observed in a resident's room, they should be moved immediately, showered, and linens laundered. She stated pest control would be contacted immediately for service. During an interview on 08/26/25 at 5:32 PM, MAINTD stated he completed a thorough assessment of the perimeter and the inside of the facility that day (08/26/25) and he brought up concerns of wasp nests to the attention of the PCS for mitigation. Review of the facility's QAPI meeting agenda, dated 08/25/25, reflected the ADM, the MD, the DON, the ADON, the RVP, and the BOM were in attendance. Review of an in-service entitled Pest Control and Resident Assessment/Safety, dated 08/25/25 and conducted by the RNC, reflected the ADM and DON were in-serviced on the facility's pest control policy. The in-service also covered abuse and neglect, accurate skin assessments, and nursing documentation. Review of Resident #1's skin assessment, on 08/25/25, reflected multiple scabs to his right elbow, abdomen, chest, right thigh, and right antecubital (inner arm). Review of skin assessments conducted on all residents, dated 08/25/25, reflected no new skin issues (including bites). Review of the facility's document for checking for pests, dated 08/25/25 and documented by the BOM, reflected she interviewed 11 residents who were asked if they saw any pests of any kind and all residents stated they had not. Review of room rounds, dated 08/26/25, reflected all residents' rooms were searched for pests and none were observed. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on abuse and neglect. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on safety and supervision of residents. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on moving residents to a pest-free room should pests be identified in their room that could/would bite.[TF1] Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on the facility's pest control policy. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all nurses were in-serviced on skin assessments: Skin assessments should be completed no less than weekly and should reflect all skin impairments and documented in the resident's chart and notification of any new skin impairments should be communicated to the RP, physician, and DON.The ADM was notified on 08/26/25 at 7:20 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one (Resident #1) of five residents reviewed for physical environment. The facility failed to ensure ants were not found on Resident #1's body on 08/13/25 and 08/15/25 which caused papules (small bumps on the skin that contain fluid or pus) from his right shoulder to elbow, right hip to mid-thigh, abdomen, and between the toes of his feet. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/25/25 at 7:10 PM and a template was provided. While the IJ was removed on 08/26/25 at 7:06 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of discomfort, pain, or infection. Findings included:Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, dysphagia (difficulty swallowing), muscle weakness, and need for assistance with personal care. Review of Resident #1's quarterly MDS assessment, dated 07/22/25, reflected a BIMS score of 00, indicating he had a severe cognitive deficit. Review of Resident #1's quarterly care plan, dated 07/06/25, reflected he had skin tears related to fragile skin, aging, medication effects, or mobility with an intervention of making sure his environment was safe. Review of Resident #1's NP assessment, dated 08/13/25, reflected the following: [Resident #1] is seen today for a report of possible ant bites to the right arm and right leg. Small red lesions noted to [Resident #1]'s right arm and leg. Review of Resident #1's hospice note, dated 08/13/25 at 12:57 PM and documented by HN D, reflected the following: PC from [LVN A] at (facility) requesting order for Benadryl RN due to ant bites on [Resident #1]'s arm and itching. Verbal order given per s/sx management for Benadryl 25mg 1-2 tablets every 6 hours as needed for itching. Review of Resident #1's progress note, dated 08/13/25 at 3:09 PM and documented by LVN A, reflected the following: [Resident #1] continues with red raised rash to right upper arm and a few patchy areas to the right thigh. He has no complaints of pain or itching at this time. Received PRN order for Benadryl from hospice. Review of Resident #1's physician order, dated 08/13/25, reflected Benadryl Oral Tablet 25 MG - Give 1 tablet by mouth every 6 hours as needed for rash. Review of Resident #1's skin assessment, dated 08/13/25 and completed by LVN A, reflected a rash to his right upper arm. There was no documented evidence of further skin assessments conducted. Review of the facility's pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait was placed in the restroom and bedroom as a precaution. Review of Resident #1's HN B's skin assessment, dated 08/15/25 at 10:44 AM, reflected he had generalized ant bites that were not healing and were pink and beefy red pustules. Review of Resident #1's HN B's progress note, dated 08/15/25 from 10:40 AM - 11:40 AM, reflected the following: [HN B] entered [Resident #1]'s room and found pt awake in bed, [HN B] noted ants crawling on pt's bedding. [HN B] returned to nurses station to tell [LVN C] that the pt needed to be moved to a new room and they needed to contact an exterminator, as ants were in pt's bed. [LVN C] offered for facility aides to change pt bedding. [HN B] stated she would change the bedding, but ants need to be addressed as pt had ant bites on Wednesday (08/13/25). [LVN C] stated the assessment from Wednesday stated pt had a rash. [HN B] went back to pt room, took a picture of ant bites on pt's arm and showed them to [LVN C] who stayed at the nurses station. [HN B] returned to change pt bedding and noted at least 100 ants in pts bed and on pt. [HN B] returned to nurses station to tell [LVN C] that there is a serious issue and pt need to be moved immediately. [HN B] returned to pt room to find [LVN C] had not followed her and was still at nursing station. [HN B] stated loudly that [LVN C] needed to get the DON or the administrator into the patient's room immediately. Multiple HCAs showed up to help [HN B], and eventually [LVN C] did too. [HN B] showed all staff members the multitude of ants in pt's bed. Ants were in between the pt's toes, and on his body from his right leg up to stomach, SN also removed ants from under pt's scrotum. [LVN C] stated that she was on her first day and was unaware. [The ADM] showed up and said, these [NAME] fire ants, I was told they were fire ants. [HN B] replied, I dont care what they are, this is unacceptable. [The ADM] stated that a pest control person treated the room yesterday and said he left live traps for ants, so it would be normal to see ants going to the live traps. [HN B] asked [The ADM] if the pest control person put live traps in the pt's bed, as that is where the majority of the ants are. [The ADM] did not answer, but stated that the bird feeder outside of the pt's window was a big problem and a cause of ants. [HN B] asked [The ADM] if the facility staff was putting bird feed underneath the pt. Again, [The ADM] did not answer. [HN B] showed everyone in the room the pt's right upper arm, which was covered in ant bites, [LVN C] stated that the patient's arm did not look like that on Wednesday. [HN B] asked [LVN C] how she knows what patient's arm looked like if today was her first day, no one answered. [HN B] stated that staff needed to get the hoyer lift so that pt can be transferred out of his bed to high back WC immediately. WC, in pt's bathroom, also found to have ants on it. [The ADM] left and came back several minutes later stating that pt would be moved to another room, but instructed facility aides to just get pt to high back WC and take him to the cafeteria for lunch, not to move his belongings at this time. SKIN: Skin is thin/fragile with Ecchymosis to BUE, with ruddy BLE. Pt has generalized ant bites all over his body. Pt's right arm from shoulder to elbow is approximately 85% covered in numerous erythematous papules (red lesions on the skin that may resemble elevated rashes (and vesiculopustular lesions that range from 1-5mm in diameter. Many with vesicopustule (a vesicle which is developing pus) formation with erythema (redness or discoloration of the skin) at the base. Similar lesions are present from pt's right hip to mid thigh, covering approximately 30-40% of the surface area and multiple lesions are also present between the toes of bilateral feet. Facility staff reports pt's itching has been controlled with PRN Benadryl and Hydrocortisone cream.Please ensure that pt has been moved to new room and that no ants or other insects are present in pt's bed. SN did not leave medihoney in pt room so that Administrator could not blame ants on medihoney. Review of Resident #1's progress note, dated 08/15/25 at 11:09 AM and documented by LVN A, reflected the following: Notified [Resident #1's RP] and [Resident #1] that he is moving to 214 (room) today. Review of Resident #1's HN B's progress note, dated 08/18/25 at 12:07 PM, reflected he had generalized ant bites that were not healing with raised heads. Review of maintenance log requests, from 07/01/25 - 08/20/25, reflected ants were found in resident's rooms on 07/11/25, 07/22/25, 07/24/25, and 07/25/25.Review of a pest control invoice, dated 07/14/25, reflected they spot treated a proximity [sic] a dozen fire ant mounds. Review of a pest control invoice, dated 07/29/25, reflected the following: (Pest control company) responded to an emergency call regarding ant activity in rooms [ROOM NUMBERS]. Upon arrival, I met with the social worker at the front desk. We first inspected room [ROOM NUMBER], where staff reported ant activity throughout the room and restroom. During my inspection, I confirmed the presence of fire ants in the restroom and along the baseboards near the dresser. I applied a liquid treatment around all baseboards in the room and restroom.Next, we proceeded to room [ROOM NUMBER], which previously housed the resident from room [ROOM NUMBER]. Although no live ant activity was observed during the inspection, I performed a preventative treatment by baiting the restroom baseboards and the sink area. Afterward, I met with the [MAINTD], to access the courtyard and inspect for ant mounds near the affected units. Several mounds were located and treated. I recommended a long-term control solution, and the [ADM] requested a quote. I will be contacting my superiors to have this quote forwarded to her. Reported ants in room [ROOM NUMBER]. Facility has made multiple requests for ants. Please evaluate if larger scale of services needed. Review of pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait eas [sic] placed in the restroom and bedroom as a precaution. After this I made my way outside for an exterior inspection and granular perimeter application. Active ant mounds were treated with a bait application. A liquid residual perimeter application was performed on entry ways to aid in control of ants. I spoke with the administrator to wrap up the service. She was notified that our products take a few days to achieve full effect. During an observation on 08/20/25 at 10:52 AM revealed Resident #1 asleep in his bed and was unable to arouse. Visible beneath the right sleeve of his hospital gown revealed approximately 50 dark pink/red ant-like bites on his upper arm/shoulder. There were no visible ants in his bed, room, or bathroom. During a telephone interview on 08/20/25 at 12:04 PM, Resident #1's NP stated she was notified of redness to his arm on 08/13/25. She stated she looked at it but could not determine what it was, it was too difficult to say. She stated she wrote an order for Benadryl for dermatitis (a skin condition that causes redness, irritation, or rash). She stated he was on hospice services, so they oversaw his care. During an interview on 08/2025 at 12:55 PM, CNA E stated Resident #1 had recently been moved to her hall (200) but was not sure why. She stated she was not told what happened. She stated he had redness to his arms and stomach. During an interview on 08/20/25 at 1:03 PM, LVN C stated she was not working the day Resident #1 appeared with a rash. She stated she first saw it the following day, 08/14/25 and was asked if she would describe it. She stated she would not be able to because she was not a doctor. During an interview on 08/10/25 at 1:10 PM, the ADM stated on 08/13/25 she was grabbed by an aide stating Resident #1 had ants in his bed. She stated they had already cleaned up his bed but was shown a picture and they looked like sugar ants and sugar ants did not bite. She stated she told them to get him up and asked the housekeepers to clean his room. She stated she had the NP and her ADON assess his skin and the ADON said it looked more like a rash. She stated the NP looked at it and said she did not think they were ant bites by the way they were raised up from his skin and that it may be a reaction to something or a rash. She stated she contacted pest control, and they came the following day, 08/14/25, to treat his room. She stated on 08/15/25, HN B pulled back his covers on his bed and found ants on his abdomen. She stated she had not moved him rooms because pest control had already treated the room and the ADON and NP had told her it was a rash, not ant bites. She stated she called the pest control company again and they told her it could take up to a week before all the ants were killed. She stated she had not known that before. She stated she had not seen his skin since 08/13/25 and was shown a current picture. She stated what she saw in the picture did look like they could be bites. During a telephone interview on 08/25/25 at 11:50 AM, HN B stated she found out ants were in Resident #1's bed on 08/13/25 when LVN A contacted their agency requesting Benadryl for ant bites and him itching. She stated on 08/15/25, when she arrived, she could not believe what she saw. She stated there were hundreds of ants all over him actively biting and she had to remove them from his right arm, right leg, abdomen, and under his scrotum. She stated his bites had little white heads and she had no doubt they were from the ants. She stated she even found ants on his wheelchair in his bathroom. She stated she went to tell LVN C who blew her off and kept telling her it was a rash. She stated she finally got the ADM in the room and showed her the ants and told her to get her staff to move him rooms as it was completely unacceptable. She stated her HCAs provided Resident #1 a shower and his linens were removed to be laundered. During an interview on 08/26/25 11:57 AM, LVN C stated she worked the 6:00 AM - 6:00 PM shift on 08/15/25. She stated when HN B came in to do wound care on Resident #1, she was shown a picture of his skin by HN B, and she believed it was a rash. She then stated HN B found the ants on him and in his bed. She stated they then removed all of his linens and took them to the laundry room and moved him to a room on the 200 hall. During an interview on 08/26/25 at 12:10 PM, the ADM stated the pest control company they used brought up doing extra services on the grounds (outside of facility) but not the inside of the facility. She stated she asked for a quote but never received one. She stated a negative outcome of not following up with the pest control company would be pests in the building that could contribute to negative outcomes for the residents. She stated they could be a nuisance, could carry germs, or they could bite the residents which could lead to more negative outcomes. During a telephone interview on 08/26/25 at 12:46 PM, the ADON stated he was told by LVN A that Resident #1 had a skin impairment issue (could not remember the date). He stated he went and assessed him but did not see anything visible at that time. He stated he did not see anything that was consistent with bite marks. He stated he was off since the incident and had not assessed his skin since. He stated even though he was under hospice's care, they (facility staff) were still responsible for the welfare of the resident. During a telephone interview on 08/26/25 at 1:18 PM, LVN A stated she was working on Resident #1's hall on 08/13/25. She stated CNAs F and G came to her and told her he had raised areas to his right arm. She stated there was mention of ant this and ant that but when she inspected his room, she saw no ants. After the NP assessed him and did not note ant bites, she completed her skin assessments and documented a rash to his right arm. During a telephone interview on 08/26/25 at 4:25 PM, CNA G stated she worked on Resident #1's hall on 08/13/25. She stated she had worked with him for 3-4 years and he was unable to use his call light, so when he was in distress or needed something, he would whistle. She stated on 08/13/25, she heard him whistling so she went to his room with CNA F. She stated they pulled back his covers and saw about 15 ants or more crawling on his right thigh. She stated there were bites all over his legs, stomach, and right arm. She stated there the bites were blotchy red spots. She stated she and CNA G told LVN A that they needed to get the ADM to his room. She stated the ADM told them to give him a shower and she would call for pest control to come and treat the room. She stated the HCAs provided Resident #1 with a shower and they removed his linens. During an interview on 08/26/25 at 4:40 PM, CNA F stated she worked on Resident #1's hall on 08/13/25. She stated she and CNA G uncovered him, and they saw ants and ant bites on his right side, right arm, right upper thigh, and on his stomach. She stated the bites looked red like little dots and she estimated there were 15-20 ants on him. She stated his body was moving in frustrated movements, which was not normal. She stated she and CNA G reported it to LVN A. Review of the facility's Pest Control Policy, revised May 2008, reflected the following: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.The ADM was notified on 08/25/25 at 7:10 PM that an IJ had been identified and an IJ template was provided.The following Plan of Removal submitted by the facility was accepted on 08/26/25 at 12:30 PM: F925 Pest Control The facility failed to check the other residents' rooms 08/13/25. The facility staff failed to notify management that ants had been discovered 08/13/25. The facility failed to ensure that the unit was free from fire ants. The facility failed to assess other residents on the unit when Resident #1 was identified to have ant bites on 08/13/25. The facility failed to ensure Resident #1 was kept free of harm when they were found to have ants on their body, sheet and room. The facility did not move resident to another room when ants were found on the resident skin on 08/13/25 The facility failed to protect Resident #3 from potential harm as resident was left in the same room on 08/13/25. Identify residents who could be affected All Residents have the potential to be affected. Identify responsible staff/ what action taken The facility administrator requested Pest Control to visit the facility as soon as possible on 8/25/25. On 8/25/25, the regional nurse consultant educated the director of nursing regarding staff rounding, reporting pests in the facility immediately to the administrator/maintenance, skin assessments and notifications to MD/RP, and removing residents from their room if pests are found and showering of the resident who has any evidence of bites from pests. On 8/25/25, the director of nursing began education to direct care staff (RN, LVN, CNA, CMA, RNA), housekeeping, laundry, dietary, maintenance, office staff, and rehabilitation staff. Any agency staff utilized by facility or staff who did not receive the in-service on 8/25/25 will receive in-services prior to starting their assigned shift. The in-service addresses proper notifications when pest/ants are identified inside or outside the facility. Any resident that is identified as exposed to ants will immediately be removed from that area, head to toe assessment completed, will receive a shower and then proper notifications will be made to the responsible party, attending physician, the administrator, the director of maintenance and the director of nursing. The in-service also included conducting proper skin assessments on residents and complete rounds on all rooms/areas that pests or ants have been identified. If the administrator, director of maintenance or director of nursing did not answer the staff must continue to call department managers until they are able to reach someone. This in-service was started on 08/25/25 and will be completed on 08/26/25. Any staff who are unable to attend will receive the in service prior to beginning their shift and will not work until they receive the in service. New hires will receive same in service as part of their onboarding and will not work the floor until in service completed. Resident #1 was moved to another room on 08/15/25. A head-to-toe assessment was completed on 08/25/25 and residents' skin is clear. The maintenance director, completed a thorough assessment of the perimeter of the facility on 08/25/25. Any concerns identified were brought to the attention of pest control for mitigation. This will be documented in the pest control binder. Implementation of Changes Pest Control will service the facility weekly x4 weeks and then monthly and as needed thereafter. The maintenance director/designee will conduct thorough rounds throughout the facility QDay x30days and then prn thereafter to monitor for any pest/ant activity. This will be documented on a form in the pest control binder. The maintenance director/designee will round daily and ensure all food items are stored properly to prevent pest/ant activity daily x 30days and prn. This will be documented on a form in the pest control binder. During morning meeting TELS will be reviewed for any new concerns regarding pest/ant activity and that appropriate interventions have been implemented daily x 30days and prn. Perimeter checks of the facility will be conducted twice a day x 30days and prn to monitor for pest/ant mounds by the maintenance director/designee. This will be documented on a form in the pest control binder. During clinical morning meeting and during clinical stand down the Director of nursing/Assistant Director of Nursing will discuss with each charge nurse regarding any pest/ant activity x30days and prn. This will be documented on the room rounds form. Pest Control will service the facility weekly x4 weeks and then monthly and as needed thereafter. This will be documented in the pest control binder. All monitoring and any negative findings will be reported to QAPI monthly. The Director of Nursing/Assistant Director of Nursing/Designee will conduct five staff interviews, three (3) times a week for thirty (30) days to validate staff knowledge of education. This will be documented on interview questionnaire. Involvement of Medical Director The facility held an ad.hoc QAPI with the medical director to discuss a plan of removal on 08/25/25 at 8:30PM Who is responsible for implementation of process? The Administrator will be responsible for implementation of New Process. The New Process/ system will be started on 08/25/25. Please accept this letter as our plan of removal for the determination of revised Immediate Jeopardy issued on 08/25/25. Starting 8/26/25, education understanding will be completed with 3 staff members, three (3) times a week for one (1) month by the administrator/designee by questioning the facility staff about what they do if ants/pests are observed in the facility, to notify the administrator immediately. The Regional VP of Operations will ensure the administrator understands the directive to notify pest control, move the resident, direct nursing to complete skin assessment and notify the Rp and provider immediately. This will be documented on an audit flow sheet. The Surveyor monitored the POR on 08/26/25 as followed: Observations made on 08/26/25 from 12:45 PM - 1:18 PM revealed six randomly picked resident rooms without any ants/pest sightings. The residents that occupied those rooms denied observing any pests/ants. During interviews on 08/26/25 from 3:18 PM - 6:20 PM, the following staff were interviewed from all shifts: CNA E, CNA F, CNA G, the DM, HSK H, HSK I, DA J, MA K, CNA L, LVN M, MA N, CNA O, MA P, CNA Q, LVN R, and LVN S. All stated they were in-serviced on pest control issues prior to their shift. They all stated if they saw any pests, such as roaches, ants, or flies, they would immediately notify the ADM and MAINTD and fill out the pest control log that was located at the nurse's station. They all stated if a pest was found on a resident they needed to be showered, moved to another room, an all their linens and clothes would need to be laundered. The CNAs stated they would notify the nurses immediately if they saw any bites on a resident during personal care. During an interview on 08/26/25 at 3:02 PM, the PCS stated the facility contacted his company on 08/25/25 and requested service as soon as possible. He stated he treated the facility inside and outside on 08/26/25. He stated he did not observe any ants inside the facility. During an interview on 08/26/25 at 4:54 PM, the RNC stated she in-serviced the ADM and DON on 08/25/25 regarding staff rounding, reporting pests, and moving residents to a pest-free room if pests were observed in their room. During an interview on 08/26/25 at 5:14 PM, the ADM stated she and the DON were in-serviced by the RNC prior to in-servicing staff on pest control, what to do when pests were located (remove the resident from the room, provide a shower, and wash their linens), and skin assessments prior to a resident being potentially bitten. During an interview on 08/26/25 at 5:32 PM, MAINTD stated he completed a thorough assessment of the perimeter and the inside of the facility that day (08/26/25) and he brought up concerns of wasp nests to the attention of the PCS for mitigation. There was no documentation of ant mounds. Review of the facility's QAPI meeting agenda, dated 08/25/25, reflected the ADM, the MD, the DON, the ADON, the RVP, and the BOM were in attendance. Review of an in-service entitled Pest Control, dated 08/25/25 and conducted by the RNC, reflected the ADM and DON were in-serviced on the facility's pest control policy. Review of Resident #1's skin assessment, on 08/25/25, reflected multiple scabs to his right elbow, abdomen, chest, right thigh, and right antecubital (inner arm). Review of skin assessments conducted on all residents, dated 08/25/25, reflected no new skin issues (which included bites). Review of the facility's document for checking for pests, dated 08/25/25 and documented by the BOM, reflected she interviewed 11 residents who were asked if they saw any pests of any kind and all residents stated they had not. Review of room rounds, dated 08/26/25, reflected all residents' rooms were searched for pests and none were observed. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on moving residents to a pest-free room should pests be identified in their room that could/would bite. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on the facility's pest control policy.The ADM was notified on 08/26/25 at 7:20 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.