**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment for secure unit dining room, main dining room and for 14 of 27 residents (Resident #2, Resident #39, Resident #12, Resident #13, Resident #14, Resident #17, Resident #22, Resident #25, Resident #28, Resident #34, Resident #35, Resident #43, Resident #47, Resident #48) reviewed for environment and resident rights, in that, The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and did not ensure resident rooms were clean, sanitary and free of food debris and drink spills to prevent ants, gnats and flies. There were ants, gnats, flies in resident rooms and resulted in 102 ant bites on Resident #2's upper middle chest, over the right breast, right side of the neck, right shoulder, right arm, and right elbow. An IJ was identified on 08/08/24. The IJ template was provided on 08/08/24 at 4:11 PM. While the IJ was removed on 08/12/24, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm because all staff had not been trained on clean, sanitary, and homelike environment. These failures placed residents at risk of living in an unsanitary and unhomelike environment. Findings included: 1. Review of Resident #2's face sheet, dated 08/07/24, revealed she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Hypertension (high blood pressure), diabetes mellitus, Acute and chronic respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), Quadriplegia (paralysis of all four limbs), Cognitive communication deficit, aphasia following cerebral infarction (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain), chronic pain, and adult failure to thrive. Review of Resident #2's MDS quarterly assessment, dated 04/28/24 revealed Resident#2's BIMS score of 00 indicating severe cognitive impairment. Resident #2 had a feeding tube with over 51% or more received through tube feeding. Review of Resident #2's care plan, dated 03/29/23, and updated 08/08/24, reflected the following Problems: Resident #2 has scattered insect bites (ant bites) on her right neck, right shoulder, right arm, and right breast. Goal: Resident #2 insect bites will heal without complications over the next 90 days. Approach: Monitor for s/s of infection and report findings to MD. Treatment as ordered. Record review of Resident #2's weekly skin assessment, dated 07/29/2024, revealed Resident #2's skin was intact. Record review of Resident #2's skin assessment, dated 07/30/2024, revealed Resident #2 had redness, bites/welts on the right shoulder, and right arm. Record review of Resident #2's physician order dated 07/30/2024 revealed Resident #2 had an order for, Kenalog cream apply to right of neck and right forearm three time a day till healed. Record review of Resident #2's nursing progress note, dated 07/30/2024 at 06:00 p.m., revealed a note reflecting Resident #2 . Approximately 06:00 pm walked into resident's room to administer medication via G tube (gastrostomy tube is a tube that is surgically inserted through the abdominal wall and into the stomach to provide an alternative way to deliver nutrition, fluids, and medications directly to the stomach) and noted ants on resident R arm/elbow, and right side of her face. Removed ants as quickly as possible, assessing resident and noted resident to have reddened welts to R elbow, and bend of AC (Antecubital - the area on the front side of the upper part between the arm and forearm) and to the right side of her neck. Notified Doctor (Resident primary doctor) new order received to apply Kenalog three time a day. Resident moved to another bed in another room. Notified DON. Notified resident representative . Vital signs: Blood pressure: 118/75, Heart rate, Temperature: 98.2 F, Respiratory rate: 20. Record review of Resident #2's nursing progress note dated 07/31/2024 at 01:00 am., revealed a note stating Resident #2 currently in bed resting no signs and symptoms of pain or discomfort noticed, small bites to right inner elbow, no edema (swelling caused by too much fluid trapped in the body's tissues) noted to the areas. Record review of Resident #2's nursing progress note, dated 08/01/2024 at 09:00 a.m., revealed a note reflecting Resident #2 . new order Benadryl 25 mg via peg tube bid for 7 days . Record review of Resident #2's nursing progress note, dated 08/7/2024 at 10:00 a.m., revealed a note reflecting Resident #2 . day 7/7 Benadryl r/t insect bites Record review of Resident #2's Doctor orders revealed Resident #2 had an order dated 06/01/2024 for Tylenol-Codeine #3 (Acetaminophen with codeine, pain medication) one tablet every four hours as needed for pain via G-tube feeding. Record review of Resident #2's MAR revealed Resident #2 received Tylenol-Codeine #3 (prescription drug used to relieve mild to moderately severe pain that is not well-controlled with over-the-counter medication) one tablet on 07/31/24 at 08:00 a.m., 08/01/24 at 08:00 a.m., and 08/02/2024 at 08:00 a.m. via G-tube feeding, with the note of pain level 6/10, and pain reassessment after medication revealed effectiveness. Observation on 08/06/2024 at 09:13 AM of Resident #2's room revealed Resident #2's bed was located next to the window. Resident#2 was up in the wheelchair and connected to G-tube feeding. Ant bites were visible on Resident#2's right side of her neck, and right arm around the anti-cubital fossa (the area on the anterior side of the upper part between the arm and forearm). Observation revealed the ants bites were either clear fluid filled raised areas and/or scabbed raised areas in the affected area. Resident #2's G tube had feeding formula spots on the floor, and the on the G tube pump pole, and electric wire. Observation and Interview with the ADON on 08/06/24 at 4:13 PM revealed skin assessment with ADON on Resident #2. Resident had multiple healing ant bites on her right arm, upper chest, neck and face. ADON stated when she came in that night (07/30/24) after the incident it broke her heart to think of Resident #2 lying there, not being able to speak, not being able to call out for help. She stated the ants were crawling on the resident and crawling in the bed linens. She stated the ants were everywhere. Observation on 08/07/2024 at 10:07 am of Resident #2's Skin assessment by LVN B with the help of CNA I revealed : 8 ant bites at the middle chest by the neck; 9 ant bites over the right breast; 15 ant bites on the right side of resident neck; 25 ant bites on the right shoulder; 30 ant bites in top of the right arm in front of the elbow; 15 ant bites on the resident's right elbow. Observation and interview revealed Resident # 2 sustained a total of 102 ant bites. Resident #2's G tube feeding formula pole was next to resident's bed with drip spots on the floor, and on the G tube pump support, pole, and power cord. Interview on 08/07/2024 at 10:16 AM with LVN B revealed Resident #2's equipment looked like it needed cleaning from the G Tube formula drip stain, and it was the responsibility of everyone to clean the formula drips stain, CNAs, nurses, and housekeeper. She stated was going to clean it right way. Interview on 08/07/2024 at 10:18 AM with CNA I revealed Resident #2's equipment needed good cleaning and did not know whose responsibility it was to do it. She stated she mentioned it to the housekeeper few days ago, but the housekeeper replied that it was the nurses' responsibility to clean residents' equipment. Telephone Interview on 08/07/2024 at 11:13 am over the phone with Resident #2's family member revealed she saw ants in the resident room on 07/21/24. Interview revealed she asked a facility staff member to clean the dirty floor and clean up the G-Tube formula drip stains on the floor. The family member stated the facility did not do anything on 07/21/24. The family member stated on 07/26/24, she saw ants in the resident room. Interview revealed she asked a housekeeping staff member to clean up the floor and the floor mat to remove the G Tube formula drip stains. The family member stated housekeeping did not clean the floor. The family member stated she moved the resident bed , kneeled to clean up the floor and floor mat on 07/26/24. Interview with the family member revealed she visited the resident on the day of the incident, 07/30/24 for about 30 minutes. She stated she did not uncover the resident to look at the resident. The family member stated she saw G Tube feeding formula drip stains on the floor and feeding tube equipment each time she visited the resident. Interview revealed she did not inform the Administrator about the ants, the dirty floor and dirty resident equipment. Interview over the phone on 08/07/2024 at 1:22 pm with agency LVN M revealed she saw G Tube formula drip stains on the floor and G Tube equipment. She stated it was not her responsibility to clean the floor and equipment. Interview revealed she did not know whose responsibility it was to clean the floor and resident equipment. Agency LVN M stated at around 6:00PM on 07/30/24, she went to Resident #2's room to administer scheduled medications to Resident #2. Interview revealed she noted ants crawling on the right side of Resident #2's face. She uncovered the resident and there were ants crawling on Resident #2's right arm and right leg. Agency LVN M stated she saw ant bites around Resident #2's neck and arm. Agency LVN M stated she saw black big ants and black small ants crawling on the resident and ants crawling in the linens. She stated she removed the top linens off the resident. Agency LVN M stated she used her hands to remove the ants that were crawling on the resident. Agency LVN M stated she called CNA H to help her. Interview on 08/08/2024 at 2:45 PM with the Administrator revealed the G-tube feeding formula spill spots on the resident's linen, floor, and the pump pole was a food source for ant and gnats, and the facility reeducated the staff to clean the area and keep G tube feeding residents' rooms free of any G tube feeding formula dripping spots. An interview with LVN B on 08/09/24 at 01:20 p.m., revealed, she stated on 07/31/2024 at 08:00 am she noticed Resident #2 grimacing and grinding her teeth. She said she assessed her pain, called Resident #2's primary doctor and got orders for Benadryl 25 mg via G-Tube feeding to ease the skin irritation related to ant bites, apply Kenalog to the affected area three times a day, and continuous with pain medication order Acetaminophen with codeine one tablet via G tube feeding every four hours as needed for pain. An interview with Resident #2's primary doctor on 08/09/24 at 01:35 PM, revealed, he stated he was notified of Resident #2's ant bites incident on July 30, 2024, and ordered Kenalog cream to apply to the affected area three times a day to ease the skin irritation from the ant bites. He stated the Nurse Practitioner assessed Resident #2 the next day after the incident (07/31/2024) of ant bites. He stated he saw Resident #2 on 08/01/24 and noted small red ant bites on Resident #2's right shoulder, right arm, and elbow. 2.Review of Resident #39's undated face sheet reflected a [AGE] year-old female with and admission date 03/01/23 and a re-admission date of 12/13/23. Diagnoses included dehydration, dysphagia (difficulty swallowing), cerebral vascular accident (stroke), contractures, and unspecified severe protein-calorie malnutrition. Review of Resident #39's quarterly MDS assessment, dated 04/26/24, reflected Resident #39 had BIMS score of 0 which indicated she was severely cognitively impaired. She was totally depended on all ADLs and always incontinent of bowel and bladder and she received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #39's care plan with a revision date of 07/01/24 reflected, .[Resident #39] require PEG feeding . Observation and interview on 08/07/24 at 11:32 AM revealed three ants were in Resident #39's window blinds and 1 brown/black ant on window seal crawling. Resident #39 was connected to g-tube feeding while lying in her bed next to window where brown/ black ants were located. LVN A was notified by surveyor about the brown/black ants in Resident #39's room. LVN A moved Resident #39's bed away from the window. Resident #39's g-tube pole had drops of feeding on the middle of pole and along the bottom of the pole and stand along with 4 to 5 drops of feeding to the right of the g-tube pole on the floor next to resident's bed. Interview with LVN A revealed the g-tube feeding pole did have drops of feeding on the g-tube pole and it needed to cleaned along with the floor. LVN A stated she would move Resident #39 to another room due to ants in the resident window. Observation on 08/08/24 at 10:43 AM revealed Resident #39 was in the new room. She was lying in bed and her g-tube pole had drops of feeding on the pole and on the bottom of the g-tube pole. 3) Review of Resident #28's face sheet undated reflected Resident #28 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Bipolar disorder, Dysphagia (Swallowing disorder), Cognitive Communication deficit, Chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), Respiratory Failure, Schizoaffective disorder (mental health condition combining symptoms of schizophrenia and mood disorders), diabetes and heart failure. Review of Resident #28's Quarterly MDS assessment dated [DATE] reflected Resident #28 had a BIMS score of 12 indicating he was moderately cognitively impaired. Observation and interview on 08/06/24 at 9:26 AM revealed Resident # 28 was in his room lying across his bed dressed. Resident #28 was surrounded by clutter. There were numerous gnats noted swarming around his chest of drawers and bedside table. There was a dirty sheet wadded up on the floor with brown substance. Resident #28 stated he had spilt some of his coffee on the floor. Resident #28's room smelled of urine. There was a milk crate with dirty clothes. Interview on 08/06/24 at 9:32AM with Contract Housekeeping Supervisor S revealed housekeeping had Resident # 28's room on their high priority cleaning schedule. She stated he hoarded a lot of paper and other stuff. She stated they clean the Resident #28's room twice a day and deep cleaned it once a week. She stated she knew there were gnats in his room. Observation on 08/06/24 at 10:52 AM of Resident #28's room revealed there was a strong smell of urine and a swarm of small flying insects on the resident's privacy curtain, on his bedside table, his dresser top and on his bed. There was a swarm of flying insects on soiled linens tangled and lying on the floor. There were over 25 small flying insects on Resident #28's bedside table with sticky residue and crumbs of food and debris. Observation of Resident #28's bathroom revealed his toilet had a yellow liquid that smelled strongly of urine. Interview on 08/06/24 at 10:54 AM with LVN A revealed she was aware of the state of Resident #28's room and that he commonly clogged the toilet and hoarded food and trash in his room. Observation on 08/08/24 at 9:17 AM in Resident #28's room revealed there was soiled linen wrapped and lying on the floor with 5 small flying insects on top. There were large crumbs of food on his bed spread with two flies on top. Observation on 08/09/24 at 2:22 PM of Resident #28's room revealed he was still in the same room and there was a sticky residue on the bedside table with 18 small flying insects on the bedside table. Observation on 08/11/24 at 2:25 PM of Resident #28's room revealed he had been moved to a different room. Resident #28 was not in his room, and it had a bed that was placed away from the wall and window with a privacy curtain, night stand, bedside table with mini soda's, instant coffee and a loveseat on the wall next to the entry door. Observation of the floor under Resident #28's loveseat revealed food crumbs and paper trash. Interview on 08/11/2024 at 2:30 PM with CNA X, revealed it was her first day at the facility and she worked for a staffing agency. She stated she had been in-serviced on pests and cleaning of resident rooms and knew there was a binder they put any pest sightings or housekeeping concerns in. She stated that she observed what looked to be food residue on Resident #28's bed spread, a live fly on the bed spread, and that it did not look like the floor under the loveseat had been swept,- there were food crumbs and small paper trash. She stated she had not looked at the windowsills of the resident's room yet and planned to at the end of her shift. 4. Review of Resident #25's face sheet dated 08/08/24 reflected Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems), Dysphagia (Swallowing disorder), Hemiplegia (Paralysis) on left side, End Stage Renal Disease, Seizure Disorder, Heart Failure and Legal Blindness. Review of Resident #25's quarterly MDS assessment dated [DATE] reflected Resident #25 had a BIMS score of 15 indicating he was cognitively intact. It reflected Resident #25 required substantial/maximal assistance with toileting. Review of Resident #25's Comprehensive Care Plan last updated 06/24/24 reflected Resident #25 was at risk for falling R/T (related to) impaired mobility and impaired vision. Has left bka (below knee amputation) with prothetic. Intervention included Assure the floor is free of glare, liquids, foreign objects. Observation and interview on 08/06/24 at 12:01 PM revealed Resident #25's room had a yellowish stain on the floor from the closet and inside closet there was wetness on closet floor with Resident #25's clothing on floor. There was a strong odor in the resident room and 2 flies on bedside table and landed on his bed while Resident #25 was sitting in the middle of the bed. There was bubbling paint on the wall between window and the closet. There was bubbling paint on walls between closet and bathroom door for Resident #25. Resident #25's bed was next to window and window seal had particles and small dead black bugs on the window sill Resident #25 revealed he was blind and could not see if there were any ants in his room. He stated he had flies and gnats in his room and knew they were there because the flies landed on him and his face. He stated he knew there had been a leak recently in his room from the closet but did not know what they had done. Observation on 08/06/24 at 12:04 PM of Resident #25's bathroom revealed sink was dripping into a plastic cup with spoon in it and his toilet had yellowish/brownish stains in the toilet with floor having yellowish/brownish stains around the toilet on the floor. Resident #25's bathroom floor was sticky with stains and wetness covering the floor. Observation on 08/08/24 at 9:40 AM revealed Resident #25's room had food debris noted on the floor, empty cracker wrapper on the floor and empty medication cup on the floor. 5. Review of Resident #17's face sheet undated reflected Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Emphysema (a lung condition that causes shortness of breath), Psychotic disorder, Neuropathy (nerve damage that causes weakness, numbness and pain, usually in your hands and feet), Stroke, Hemiplegia (Paralysis on right side), heart failure and schizoaffective disorder. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected Resident #17 had a BIMS score of 13 indicating he was cognitively intact. Resident #17 required supervision with ADLs. Resident #17 was continent with bowel and bladder. Observation on 08/06/24 at 11:54 AM revealed Resident #17's window was cracked open with windowsill next to his bed full of debris, dead black bugs, and crumbs. His bathroom had blackish stains on floor near toilet and around the toilet bowl. The wall in the bathroom had bubbling paint and was wet. Bathroom cabinet door was sitting on floor leaned against the wall below the toilet roll. Bathroom cabinet had no door with toilet seat lid sitting under the bathroom sink with yellowish/brownish stains along with black particles and bugs covering the toilet seat lid. Observation on 08/06/24 at 11:53 AM revealed Resident #13 shared a room with Resident #17 and was lying in his bed. Interview on 08/06/24 at 2:20 PM with Resident #17 revealed housekeeping did not clean his room including his bathroom on the weekends at all. He stated he had flies and gnats in his room. Interview on 08/07/24 at 2:31 PM with Contract Housekeeping Supervisor S revealed, Resident #28 stored and hoarded alot of stuff in his room and spilt drinks in his room. She stated Resident #17's bathroom had spills due to Resident #17 urinated on floor. She stated both Resident #17 and #28's rooms were required to be cleaned twice daily including bathrooms. She stated these rooms were to be cleaned first and then come back later in the day to follow up to look for spills, debris and clean. She stated Resident #17's bathroom floor was black and stained. She stated she spoke to Maintenance Director about a month ago about Resident #17's toilet seat lid needing to be replaced and bathroom cabinet door was off needing to be replaced. She stated she did not clean the toilet lid since it was off needing to be replaced by Maintenance. She stated she noticed the yellowish stain on Resident #25's bedroom floor near the closet about 2 weeks ago and it required more deeper cleaning. She stated they would have to have resident move out of room in order to clean up the floor of Resident #25. She stated the toilet stains required stronger cleaning supplies to get rid of stained inside toilet. She stated Resident #28's room had flies and gnats in his room since he hoarded food and other items in his room. She stated she had noticed the flies in Resident #17's room. She stated she would have to bring the mop and bucket to clean the secure unit common area and dining room floors in the secure units. She stated she had not cleaned the common areas of the secure unit yet. 6. Observation on 08/06/2024 at 11:25 AM of the outside of the secure unit (hall 200) and hall 100 revealed there was a flattened cardboard box approximately 2 feet wide by 4 feet long with one corner touching the foundation wall underneath the window of the secured unit's living room windows with improperly stored unused electrical equipment. Observation revealed a trail of ants crawled along the length of the foundation of Hall 100 to the secured unit foundation and up and along the window frame of the secured unit living room windows which were cracked open up to a half of an inch wide and a trail of ants crawled into inside of the window frame into the secure unit common area. Observation of a crepe [NAME] tree approximately 6 feet from the secure unit and Hall 100 revealed numerous ants of different types crawled around the perimeter of the tree and crawled up the trunk of the tree. Observation on 08/06/24 at 11:36 AM revealed the first window in the common area of the secure unit had ants coming in through one window. Ants were noted on inside of the window of secure unit common area and on the bottom of window and top of window near latch. Six residents were sitting in the common area. There was a brownish stain below this window in the common area. Observation on 08/06/24 at 11:40 AM of the Maintenance Director revealed he picked up the unused electrical equipment and there were hundreds of ants that crawled all over on the flattened cardboard box. He picked up the flattened cardboard box turning it on the side and shook off the ants and walked away with the flattened cardboard box. Interview on 08/06/2024 at 11:41 AM with the Maintenance Director revealed he stated the ants were sugar ants, they did not bite and were nothing to worry about. He stated they were not able to prevent ants or them coming into the building. The Maintenance Director stated Pest Control Company N came to the facility regularly and had already come out to spray for the ants. Observation and interview with the Maintenance Director in the secure unit living room revealed there were ants entering through the cracks in the window frame and the Maintenance Director stated he did not need to look because he was going to spray them and would see them when he sprayed. Observation of the main dining room on 08/06/2024 at 1:55 PM revealed all the dining room tables had various amounts of food crumbs, smears, and drink residue on their surfaces and there were 2 flies in the dining room. In confidential group interview on 08/06/2024 at 2:00 PM with 9 residents revealed their biggest concern regarded housekeeping which they had brought up in previous meetings with the Activity Director. Another resident stated that the gnats and flies were another concern and that the gnats really bothered her when they fly around her face or landed on her. Resident in the group stated that the flies bothered her a lot and that housekeeping had not wiped down the dining room tables after lunch, which was about 2 hours ago, and there was still food residue and crumbs and sticky drink residue on the tables. All of the residents stated there were numerous flies and gnats throughout the facility, in the common areas, and sometimes in their rooms but they had not observed ants. One resident stated that it seemed like the cleaning wasn't done on the weekend at all. Another resident agreed with the resident and stated that he observed a housekeeper clean his toilet with a rag and then wipe down his sink with the same rag. A resident stated the housekeeper did not understand English when he tried to tell her that it was unsanitary, and he complained to staff. Resident stated that he had someone help him make a sign in Spanish which told the housekeeper not to use the same rag used on the toilet in the sink and a staff member came and showed the housekeeper how to clean his bathroom properly but the door was closed and he did not see what they showed her-so he kept the sign up to be on the safe side. All residents in the confidential group meeting stated they felt that the lack of housekeeping quality and frequency bothered them greatly because it felt gross when things were dirty. Interview on 08/07/24 at 8:25 AM with Maintenance Director revealed he would attempt to contact the main number to get hold of Pest Control Service Tech P for surveyor. He stated Pest Control Company N was not scheduled to come out to the facility. Interview on 08/07/24 at 10:13 AM with Pest control Service Tech P revealed on 07/31/24 when he came to the facility Resident #28's room had stickiness and spilled soda on the floors. He did not see any ants in rooms but it was reported to him that ants had been seen in the room. He stated the risk to the residents for pests was the ants can bite if threatened. He stated the fire ants bite. He stated any type of ants can bite if threatened. He stated he was not made aware of ants being found in the facility yesterday (08/06/24). He stated he came out for his monthly visit on 08/03/24 and treated the kitchen drain for gnats. He stated the facility needed to treat the source of the gnats/flies to address the pests. He stated the gnats and flies have been an ongoing issue and he tried to knock it down. He stated the facility was not on a program for small flies. He stated the ongoing issues with lack of sanitation and cleanliness make it difficult to address the pests especially when going into resident rooms that had pest activity revealing food debris, food stickiness and drink spills. He stated he was aware of Resident #28's room having ants and gnat activity. He stated the ants were attracted to food and water sources. He was not aware of any ants in resident room currently and the facility had not notified him of ants coming inside. He treated on 07/31/24 and 08/03/24 but did not see any ants at this time. Interview on 08/07/24 at 4:35 PM with Pest Control Company O Service Tech revealed he did rounds with the Executive Director on 08/07/24. He stated in Resident #44's room he found about 6 fire ants near the window. He stated he treated Resident #44's window with sealant for the cracks inside and outside of resident rooms where he found trails of ants on the foundation. He stated he spot treated resident rooms and treated the outside of the facility for ants. He stated ants can bite. He stated he did not treat for gnats today. He stated he did not find ant activity in Resident #39's room. Record review of the grievance summaries revealed an undated document titled June Grievances that stated rooms were not being cleaned on the weekends and were not being cleaned thoroughly under beds and behind furniture. Grievance Summary revealed an incident dated 07/23/2024 and reported date 08/06/2024 revealed resident council had a grievance of rooms not cleaned on the weekends with no other details under the sections for resolved date, resolved note, summary of investigation, summary of findings, or summary of action taken. Record review of the resident council meeting notes dated 06/28/2024 revealed an issue of weekend housekeeping slacking. 7. Review of Resident #14's face sheet undated reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Cerebral palsy, protein-calorie malnutrition, Heart failure, and Dysphagia. Review of Resident #14's quarterly MDS assessment dated [DATE] reflected Resident #14's cognition was severely impaired and had a feeding tube. Resident #14 was dependent for all ADLs. Review of Resident #14's Comprehensive Care Plan with problem start date of 03/09/24 and revised on 08/09/24 reflected Resident #14 requires feeding tube R/T (related to) recurrent aspiration pneumonia. Observation on 08/08/24 at 10:45 AM revealed Resident #14's g-tube pole had drops of feeding and stained on bottom of g-tube pole while Resident #14 was connected via g-tube. Interview on 08/08/24 at 10:48 AM with the ADON revealed Resident #39 and #14's g-tube poles and floor should be free of spills from the feeding. She stated both residents were total dependent. She stated she expected nursing to clean the g-tube poles and floor when feeding spilled on it. She stated the g-tube poles not being cleaned placed residents at risk of attracting pests. She stated housekeeping should be cleaning the floor daily to ensure g-tube feeding not on floor. 8. Review of Resident #47's quarterly MDS assessment dated [DATE] reflected Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of heart failure, hypertension, Kidney Failure and Parkinson's Disease, Resident #47 had a BIMS score of 12 indicating she was moderately cognitively impaired. Resident #47 required partial/moderate assistance with most ADLs. Review of Resident #48's quarterly MDS assessment dated [DATE] reflected Resident #48 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension, diabetes and seizure disorder. Resident #48 had a BIMS score of 13 indicating she was cognitively intact. Resident #48 required supervision with ADLs. Interview with Resident #47 and Resident #48 on 08/06/24 at 2:20 PM revealed Resident #47 stated that she and Reside[TRUNCATED]

**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 to keep the facility free from pests for 16 of 26 residents (Resident #2, Resident #13, Resident #17, Resident #25, Resident #28, Resident #39, Resident#44 and 9 Confidential Group Residents) reviewed for pest control, in that: 1. The facility failed to ensure an effective pest control program was in place to keep ants out of resident rooms, resulting in 102 ant bites on Resident #2's upper middle chest, over the right breast, right side of the neck, right shoulder, right arm, and right elbow. 2. The facility failed to maintain an effective pest control to address the outside of hall 100 and hall 200 for ant activity. The facility failed to ensure resident secure unit common area windows were free of ants on 08/06/24 and 08/07/24. 3. The facility failed to ensure Resident #13 and #17's room was free of pests and failed to ensure their window was closed. 4. The facility failed to ensure Resident #28 room was free of gnats, flies, and ants. 5. The facility failed to ensure Resident #39's room was free of ants. 6. The facility failed to ensure Resident #25's room was free from flies and gnats. 7. The facility failed to ensure kitchen and dining room was free of flies and gnats. 8. The facility failed to ensure Resident #44's room was free of gnats and ants. On 08/08/2024 at 4:11 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/12/2024 at 4:20 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). These failures placed residents at risk for injury related to ant bites, and infection from pests. The findings included: 1. Review of Resident #2's face sheet, dated 08/07/24, revealed she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Hypertension (high blood pressure), diabetes mellitus, Acute and chronic respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), Quadriplegia (paralysis of all four limbs), Cognitive communication deficit, aphasia (a language disorder that affects a person's ability to communicate.) following cerebral infarction (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain), chronic pain, and adult failure to thrive (a syndrome that describes a decline in older adults that can be caused by many factors.) Review of Resident #2's MDS quarterly assessment, dated 04/28/24 revealed Resident#2's BIMS score of 00 indicating severe cognitive impairment. Review of Resident #2's care plan, dated 03/29/23, and updated 08/08/24, reflected the following Problems: Resident #2 has scattered insect bites (ant bites) on her right neck, right shoulder, right arm, and right breast. Goal: Resident #2 insect bites will heal without complications over the next 90 days. Approach: Monitor for s/s of infection and report findings to MD. Treatment as ordered. Record review of Resident #2's weekly skin assessment, dated 07/29/2024, revealed Resident #2's skin was intact. Record review of Resident #2's skin assessment, dated 07/30/2024, revealed Resident #2 had redness, bites/welts on the right shoulder, and right arm. Record review of Resident #2's physician order dated 07/30/2024 revealed Resident #2 had an order for, Kenalog cream apply to right of neck and right forearm three time a day till healed. Record review of Resident #2's nursing progress note, dated 07/30/2024 at 06:00 p.m., revealed a note reflecting Resident #2 . Approximately 06:00 pm walked into resident's room to administer medication via G tube (gastrostomy tube is a tube that is surgically inserted through the abdominal wall and into the stomach to provide an alternative way to deliver nutrition, fluids, and medications directly to the stomach) and noted ants on resident R arm/elbow, and right side of her face. Removed ants as quickly as possible, assessing resident and noted resident to have reddened welts to R elbow, and bend of AC (Antecubital - the area on the front side of the upper part between the arm and forearm) and to the right side of her neck. Notified Doctor (Resident primary doctor) new order received to apply Kenalog three time a day. Resident moved to another bed in another room. Notified DON. Notified resident representative . Vital signs: Blood pressure: 118/75, Heart rate, Temperature: 98.2 F, Respiratory rate: 20. Record review of Resident #2's nursing progress note dated 07/31/2024 at 01:00 am., revealed a note stating Resident #2 currently in bed resting no signs and symptoms of pain or discomfort noticed, small bites to right inner elbow, no edema (swelling caused by too much fluid trapped in the body's tissues) noted to the areas. Record review of Resident #2's nursing progress note, dated 08/01/2024 at 09:00 a.m., revealed a note reflecting Resident #2 . new order Benadryl 25 mg via peg tube bid for 7 days . Record review of Resident #2's nursing progress note, dated 08/7/2024 at 10:00 a.m., revealed a note reflecting Resident #2 . day 7/7 Benadryl r/t insect bites Record review of Resident #2's Doctor orders revealed Resident #2 had an order dated 06/01/2024 for Tylenol-Codeine #3 (Acetaminophen with codeine, pain medication) one tablet every four hours as needed for pain via G-tube feeding. Record review of Resident #2's MAR revealed Resident #2 received Tylenol-Codeine #3 (prescription drug used to relieve mild to moderately severe pain that is not well-controlled with over-the-counter medication) one tablet on 07/31/24 at 08:00 a.m., 08/01/24 at 08:00 a.m., and 08/02/2024 at 08:00 a.m. via G-tube feeding, with the note of pain level 6/10, and pain reassessment after medication revealed effectiveness. Observation of Resident #2's assigned room at the facility, on 08/06/2024 at 09:13 AM, revealed Resident #2's bed was located next to the window. Resident #2 was up in the wheelchair, cleaned, groomed, wearing appropriate attire, and connected to G-tube feeding. Ant bites were visible on Resident #2's right side of her neck, and right arm around the anti-cubital fossa (front of the elbow). There were G tube feeding formula spots on the floor, and on the G tube pump pole, and electric wire. No ants were observed in the room. Resident#2 was unable to participate in interview related to severe cognitive impairment. Observation and Interview with the ADON on 08/06/24 at 4:13 PM revealed skin assessment with ADON on Resident #2. Resident had multiple healing ant bites on her right arm, upper chest, neck and face. ADON stated when she came in that night (07/30/24) after the incident it broke her heart to think of Resident #2 lying there, not being able to speak, not being able to call out for help. She stated the ants were crawling on the resident and crawling in the bed linens. She stated the ants were everywhere. Interview on 08/07/24 at 09:51 AM with CNA I revealed she was assigned to care for Resident # 2 on the day of the incident (07/30/2024). CNA I stated during her last rounds on 07/30/24 around 1:00pm, Resident #2 was incontinent of bowel and bladder. CNA I stated she cleaned Resident #2. CNA I stated she did not see ants in Resident # 2's room and/or the Hall 300 hallway on 07/30/24. She stated she could not see if there were ants in the window because the resident's family member covered the window with a blanket. Interview on 08/07/2024 at 10:03 am of LVN B revealed at around 12:45 PM on 07/30/24, she administered routine medication via the G Tube to Resident #2. Interview revealed she pulled the linens away from the resident to administer the G-Tube medication. LVN B stated she did not notice anything on the resident. Observation on 08/07/2024 at 10:07 am of Resident #2's Skin assessment by LVN B with the help of CNA I revealed : 8 ant bites at the middle chest by the neck; 9 ant bites over the right breast; 15 ant bites on the right side of resident neck; 25 ant bites on the right shoulder; 30 ant bites in top of the right arm in front of the elbow; 15 ant bites on the resident's right elbow. Observation and interview revealed Resident # 2 sustained a total of 102 ant bites. Observation on 08/07/2024 at 10:07 am revealed Resident #2's G tube feeding formula drip spots on the floor, and on the G tube pump support, pole, and power cord. Interview on 08/07/2024 at 10:16 am of LVN B revealed Resident #2's equipment looked like it needed cleaning from the G Tube formula drip stains. LVN B said it was the responsibility of everyone to clean the formula drip stains, including CNAs, Nurses, and Housekeepers. She stated was going to clean it right way. Interview on 08/07/2024 at 10:18 am of CNA I stated Resident #2's equipment needed a good cleaning from the G tube formula drip stains. Interview revealed she did not know whose responsibility it was to clean the G tube formula drip stains on residents' equipment. She stated she mentioned it to the housekeeper a few days ago, but the housekeeper replied that it was the nurses' responsibility to clean residents' equipment. Interview on 08/07/2024 at 11:13 am over the phone with Resident #2's family member revealed she saw ants in the resident room on 07/21/24. Interview revealed she asked a facility staff member to clean the dirty floor and clean up the G-Tube formula drip stains on the floor. The family member stated the facility did not do anything on 07/21/24. The family member stated on 07/26/24, she saw ants in the resident room. Interview revealed she asked a housekeeping staff member to clean up the floor and the floor mat to remove the G Tube formula drip stains. The family member stated housekeeping did not clean the floor. The family member stated she moved the resident bed , kneeled to clean up the floor and floor mat on 07/26/24. Interview with the family member revealed she visited the resident on the day of the incident, 07/30/24 for about 30 minutes. She stated she did not uncover the resident to look at the resident. The family member stated she saw G Tube feeding formula drip stains on the floor and feeding tube equipment each time she visited the resident. Interview revealed she did not inform the Administrator about the ants, the dirty floor and dirty resident equipment. Interview on 08/07/2024 at 1:14 with CNA H revealed he did not see ants on Resident #2 during his initial rounds on 07/30/24 between 2:30 PM- 3:00PM. CNA H stated at around 4:00pm, he changed Resident #2's brief and that he did not see ants on the resident at that time. CNA H stated at around 6:00PM, the nurse called him to clean the resident and to move Resident # 2 to a different room. CNA H went to the room of Resident # 2 and saw black, tiny ants crawling on Resident # 2. He cleaned the ants off the resident and then moved the resident to a different room. Interview over the phone on 08/07/2024 at 1:22 pm with agency LVN M revealed she saw G Tube formula drip stains on the floor and G Tube equipment. She stated it was not her responsibility to clean the floor and equipment. Interview revealed she did not know whose responsibility it was to clean the floor and resident equipment. Agency LVN M stated at around 6:00PM on 07/30/24, she went to Resident #2's room to administer scheduled medications to Resident #2. Interview revealed she noted ants crawling on the right side of Resident #2's face. She uncovered the resident and there were ants crawling on Resident #2's right arm and right leg. Agency LVN M stated she saw ant bites around Resident #2's neck and arm. Agency LVN M stated she saw black big ants and black small ants crawling on the resident and ants crawling in the linens. She stated she removed the top linens off the resident. Agency LVN M stated she used her hands to remove the ants that were crawling on the resident. Agency LVN M stated she called CNA H to help her. Interview on 08/08/2024 at 08:16 am with contracted Housekeeper II via phone interpreter line with Spanish speaking interpreter revealed she did not see ants in the facility or resident rooms. She denied Resident #2's family member showing her the ants and the request to clean the resident room. Housekeeper II stated another housekeeper told her that in the past, she saw ants in the 200 and 300 Halls. Attempted interview on 08/08/2024 at 08:28 am with contracted Housekeeper HH via phone interpreter line with a Spanish speaking interpreter. There was no answer and a voicemail with instruction to call back was left. No call back received from Housekeeper HH by the date and time of exit. Interview on 08/08/2024 at 10:40 am with contracted Housekeeper Supervisor S stated she had never been notified by housekeeping staff or the other facility staff about ants in the building. She denied been notified of residents' rooms needing to be cleaned. She stated she was made aware of ants in the building on the day of the reported incident (07/30/2024). Interview on 08/08/2024 at 10:44 am with contracted Housekeeper JJ revealed she saw some ants in the last room by the emergency exit door in the Hall #100. She stated maybe there were ants because the resident in that room urinated on the floor sometimes. She stated she did not report it to Contract Housekeeping Supervisor S. Interview on 08/08/2024 at 2:45 pm with the Administrator revealed she did not personally see ants in the facility. The Administrator stated in April 2024, she and the Maintenance Director were notified about ants in the building. Interview revealed the facility called pest control and that pest control came in and treated the building. She stated after that the Maintenance Director would do spot treatments in the facility for pests if anybody reported ants to her. The Administrator stated no resident's family member asked for room cleaning or notified her of ants in the facility. Interview with the Administrator revealed Resident #2's bed was next to the window per the resident's family request. She stated that when she was notified of Resident #2's ant bites incident on 07/30/24, the facility conducted an incident internal investigation. The Administrator stated the investigation process included moving Resident #2 and her roommate to a clean room; notifying Resident #2's family, and primary doctor; and conducting a full skin sweep for all residents in Hall 300. She stated facility staff were in serviced on pest control. She stated the facility staff were instructed to make sure if they noticed ants or insects in the building to inform the management team; and make sure if there was food in the residents' rooms to seal it in a closed container. She stated the G-tube feeding formula spill spots on the resident's linen, floor, and the pump pole was a food source for ants and gnats, and the facility reeducated the staff to clean the area and keep the rooms of residents who had G tube feedings free of any G tube feeding formula dripping spots. Interview on 08/08/2024 at 03:09 pm with the DON revealed she denied seeing ants in the building or being notified by the staff, or residents' family member of the existence of ants. She stated the day of the incident (07/30/2024) Resident #2 was cleaned and removed with her roommate to a clean room. She stated skin, and pain assessments were done for the resident. She stated Resident #2's primary doctor was notified and ordered Kenalog cream to apply to the affected area to ease the skin irritation from ant bites, and continuous with the chronic pain medication order if any signs and symptom of pain and discomfort were noticed on Resident #2. She stated G Tube feeding formula drip spots on the resident's room floor could attract ants, and gnats. She stated she expected nurses, CNAs, and housekeepers to keep residents' rooms clean, and free of any kind of food that could attract ants and gnats. An interview with LVN B on 08/09/24 at 01:20 p.m., revealed, she stated on 07/31/2024 at 08:00 am she noticed Resident #2 grimacing and grinding her teeth. She said she assessed her pain, called Resident #2's primary doctor and got orders for Benadryl 25 mg via G-Tube feeding to ease the skin irritation related to ant bites, apply Kenalog to the affected area three times a day, and continuous with pain medication order Acetaminophen with codeine one tablet via G tube feeding every four hours as needed for pain. An interview with Resident #2's primary doctor on 08/09/24 at 01:35 PM, revealed, he stated he was notified of Resident #2's ant bites incident on July 30, 2024, and ordered Kenalog cream to apply to the affected area three times a day to ease the skin irritation from the ant bites. He stated the Nurse Practitioner assessed Resident #2 the next day after the incident (07/31/2024) of ant bites. He stated he saw Resident #2 on 08/01/24 and noted small red ant bites on Resident #2's right shoulder, right arm, and elbow. 2. Observation on 08/06/2024 at 9:55 AM revealed the living area in the secure unit had broken window blinds on the bottom 3 blinds of the right window and the window was cracked open about half an inch with about 6 residents in the room watching television. Observation on 08/06/2024 at 11:25 AM of the outside of the secure unit (hall 200) and hall 100 revealed there was a flattened cardboard box approximately 2 feet wide by 4 feet long with one corner touching the foundation wall underneath the window of the secured unit's living room windows with improperly stored unused electrical equipment. Observation revealed a trail of ants crawled along the length of the foundation of Hall 100 to the secured unit foundation and up and along the window frame of the secured unit living room windows which were cracked open up to a half of an inch wide and a trail of ants crawled into inside of the window frame into the secure unit common area. Observation of a crepe [NAME] tree approximately 6 feet from the secure unit and Hall 100 revealed numerous ants of different types crawled around the perimeter of the tree and crawled up the trunk of the tree. Observation on 08/06/24 at 11:36 AM revealed the first window in the common area of the secure unit had ants coming in through one window. Ants were noted on inside of the window of secure unit common area and on the bottom of window and top of window near latch. Six residents were sitting in the common area. There was a brownish stain below this window in the common area. Observation on 08/06/24 at 11:40 AM of the Maintenance Director revealed he picked up the unused electrical equipment and there were hundreds of ants that crawled all over on the flattened cardboard box. He picked up the flattened cardboard box turning it on the side and shook off the ants and walked away with the flattened cardboard box. Interview on 08/06/2024 at 11:41 AM with the Maintenance Director revealed he stated the ants were sugar ants, they did not bite and were nothing to worry about. He stated they were not able to prevent ants or them coming into the building. The Maintenance Director stated Pest Control Company N came to the facility regularly and had already come out to spray for the ants. Observation and interview with the Maintenance Director in the secure unit living room revealed there were ants entering through the cracks in the window frame and the Maintenance Director stated he did not need to look because he was going to spray them and would see them when he sprayed. Interview on 08/06/24 at 11:45 AM with LVN AA revealed the brownish stain below the secure unit window may be chocolate ensure. She stated housekeeping had not cleaned it yet nor the dining room. Observation on 08/06/24 at 5:08 PM revealed a trail of small ants crawled along the length of the foundation of Hall 100 with two windows cracked open and window screen bent near bottom of the windows. Observation of a crepe [NAME] tree approximately 6 feet from the secure unit and Hall 100 revealed numerous ants of different types crawled around the perimeter of the tree and crawled up the trunk of the tree. Observation on 08/07/2024 at 9:19 AM of the foundation line of Hall 100 revealed a line of small black ants that started from the middle of the building crawled up from cracks in the ground, along the concrete foundation of and below the first line of bricks. The ants entered into cracks in the concrete foundation and cracks between bricks and crawled along the foundation line along Hall 1 and the secure unit hall foundation. Observation on 08/07/24 at 9:29 AM of the outside of the secure unit living room second window revealed one of the secure unit's living room windows was opened and there was a trail of ants that crawled up and into both sides of the window frame. Observation on 08/07/24 at 9:30 AM revealed one resident window on the secure unit had the window opened about 1/8 of an inch, and 3 windows on Hall 100 had windows that were cracked open. Observation of one of the three windows on Hall 1 included window of Resident #13 and Resident #17's from outside revealed their window was cracked open with dead bugs between the window screen and window frame. 3. Review of Resident #28's face sheet undated reflected Resident #28 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Bipolar disorder, Dysphagia (Swallowing disorder), Cognitive Communication deficit, Chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), Respiratory Failure, Schizoaffective disorder (mental health condition combining symptoms of schizophrenia and mood disorders), diabetes and heart failure. Review of Resident #28's Quarterly MDS assessment dated [DATE] reflected Resident #28 had a BIMS score of 12 indicating he was moderately cognitively impaired. Observation on 08/06/24 at 9:26 AM revealed Resident # 28 was in his room lying across his bed dressed. Resident #28 was surrounded by clutter. There were numerous gnats noted swarming around his chest of drawers and bedside table. There was a dirty sheet wadded up on the floor with brown substance. Resident #28 stated he wasted some of his coffee. Resident #28's room smelled of urine. There was a milk crate with dirty clothes. Interview on 08/06/24 at 9:32AM with Contract Housekeeping Supervisor S revealed housekeeping had Resident # 28's room on their high priority cleaning schedule and it should be cleaned twice daily. She stated he hoarded a lot of paper and other stuff. She stated they clean the room twice a day and deep clean it once a week. She stated she knew there were gnats in his room. Observation on 08/06/2024 at 10:52 AM of Resident #28's room revealed there was a strong smell of urine and a swarm of small flying insects on the resident's privacy curtain, on his bedside table, his dresser top, on his bed, and on soiled linens tangled and laid on the floor. There were over 25 small flying insects on Resident #28's bedside table with sticky residue and crumbs of food and debris. Observation of Resident #28's bathroom revealed his toilet had a yellow liquid that smelled strongly of urine. Interview on 08/06/2024 at 10:54 AM with LVN A revealed she was aware of the state of Resident #28's room and that he commonly clogged the toilet and hoarded food and trash. Observation on 08/08/2024 at 9:17 AM of Resident #28's room revealed there was soiled linen wrapped and laid on the floor with 5 small flying insects on top. There were large crumbs of food on his bed spread with two flies on top. Observation on 08/09/2024 at 2:22 PM of Resident #28's room revealed he was still in the same room and there was a sticky residue on the bedside table with 18 small flying insects on the bedside table. Observation on 08/11/2024 at 2:25 PM of Resident #28's room revealed he had been moved to a different room. Resident #28 was not in his room and it had a bed that was placed away from the wall and window with a privacy curtain, night stand, and bedside table with mini sodas, instant coffee and a loveseat on the wall next to the entry door. Observation of the floor under Resident #28's loveseat revealed food crumbs and paper trash. Interview on 08/11/2024 at 2:30 PM with CNA X, revealed she had been in-serviced on pests and cleaning of resident rooms and knew there was a binder they put any pest sightings or housekeeping concerns in. She stated that she observed what looked to be food residue on Resident #28's bed spread, a live fly on the bed spread, and that it did not look like the floor under the loveseat had been swept as there were food crumbs and small paper trash. She stated she had not looked at the windowsills of the resident's room yet and planned to at the end of her shift. 4. Review of Resident #39's undated face sheet reflected a [AGE] year-old female with an admission date 03/01/23 and a re-admission date of 12/13/23. Diagnoses included dehydration, dysphagia (difficulty swallowing), cerebral vascular accident (stroke), contractures (abnormal and permanant shortening of muscle tissue resulting in reduces movement and flexibility of a part of the body), and unspecified severe protein-calorie malnutrition. Review of Resident #39's quarterly MDS assessment, dated 04/26/24, reflected Resident #39 had BIMS score of 0 which indicated she was severely cognitively impaired. She was totally dependent on all ADLs and always incontinent of bowel and bladder and she received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #39's care plan with a revision date of 07/01/24 reflected, .[Resident #39] require PEG feeding . Observation on 08/07/24 at 11:20 AM revealed while observing incontinent care of Resident #39 there was an ant crawling on the windowsill. Resident #39 was lying in her bed next to the windowsill. Observation on 08/07/24 at 11:25 AM revealed three ants were in Resident #39's open window blinds and 1 ant crawling on the windowsill. Resident #39 was connected to g-tube feeding while lying in her bed next to the window where ants were located. The surveyor notified LVN A about ants in Resident #39's room. LVN A moved Resident #39's bed away from window. Observation reveled Resident #39's g-tube pole had drops of feeding on the middle of the pole and on the bottom of the pole and stand along with 4 to 5 drops of feeding to the right of the g-tube pole on the floor. Interview on 08/07/24 at 11:32 AM with LVN A revealed the g-tube feeding pole did have drops of feeding on the g-tube pole and it needed to be cleaned along with the floor. LVN A stated she would move Resident #39 to another room due to ants in the resident's window. She stated she did not see any ants on the resident's bedding. 5. Review of Resident #25's face sheet dated 08/08/24 reflected Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Chronic Obstructive Pulmonary Disease, Dysphagia, Hemiplegia (Paralysis) on left side, End Stage Renal Disease, Seizure Disorder, Heart Failure and Legal Blindness. Review of Resident #25's quarterly MDS assessment dated [DATE] reflected Resident #25 had a BIMS score of 15 indicating he was cognitively intact. It reflected Resident #25 required substantial/maximal assistance with toileting. Review of Resident #25's Comprehensive Care Plan last updated 06/24/24 reflected Resident #25 was at risk for falling R/T (related to) impaired mobility and impaired vision. Has left bka (below knee amputation) with prosthetic. Intervention included Assure the floor is free of glare, liquids, foreign objects. Observation on 08/06/24 at 12:01 PM revealed Resident #25's room had a yellowish stain on the floor from the closet and inside the closet there was wetness on the closet floor with Resident #25's clothing on the floor. There was a strong odor in resident room and 2 flies on the bedside table and landing on his bed while Resident #25 was sitting in the middle of the bed. There was bubbling on the wall between the window and the closet. There was bubbling on the walls between the closet and bathroom door for Resident #25. Resident #25's bed was next to the window and the window sill had particles and dead bugs on it. Interview with Resident #25 revealed he was blind and could not see if there were any ants in his room. He stated he had flies and gnats in his room and knew they were there because the flies landed on him. Observation on 08/06/24 at 12:04 PM of Resident #28's bathroom revealed the sink was dripping into a plastic cup with a spoon in it and his toilet had yellowish/brownish stains in the toilet with the floor having yellowish/brownish stains around the toilet on the floor. Resident #28's bathroom floor was sticky with stains and wetness covering the floor. Interview on 08/07/24 at 2:31 PM with Contract Housekeeping Supervisor S revealed Resident #28 stored a lot of stuff, spilled drinks and spits on the floor. She stated Resident #28 had flies and gnats in his room. She stated Resident #17's bathroom had spills on it and Resident #17 urinated on the floor. She was aware of flies in Resident #17's room before. She stated Resident #28 had flies and gnats in his room. Interview on 08/07/24 at 3:20 PM with the Administrator revealed she was aware of the gnats in Resident #28's room but the resident hoarded and kept food in his room. She stated she was not aware of any ants coming in residents' rooms since Resident #2 had gotten bit by ants and ants were found on her and her bedding. She stated Maintenance sprayed the ants that evening on 07/30/24 and pest control came out on 07/31/24 to spray ants. She stated DON in-serviced the staff after the incident with Resident #2 having ant bites and ants found in her room on 07/30/24. She stated she had not in-serviced housekeeping about pests and cleanliness. She stated Maintenance Director was addressing the pest control. 6. Observation and Interview on 08/06/24 at 10:02 AM revealed Resident #4 had noticed the flies and the gnats in her room since it had gotten warmer especially with her food left in her room. Gnat flying around landing on her styrofoam cup. Her breakfast tray was still in her room. 2 Flies noted in resident room landing on bedside table and bedding. Observation of the main dining room on 08/06/2024 at 1:55 PM revealed all the dining room tables had various amounts of food crumbs, smears, and drink residue on their surfaces and there were 2 flies in the dining room. In confidential group interview on 08/06/2024 at 2:00 PM with 9 residents revealed their biggest concern regarded housekeeping and they had brought up the concern in previous meetings with the Activity Director. Residents stated that the gnats and flies were another concern and that the gnats really bothered them when they flew around their face or landed on them. Residents stated that the flies bothered them a lot and that housekeeping had not wiped down the dining room tables after lunch, which was about 2 hours ago, and there was still food residue and crumbs and sticky drink residue on the tables. The residents stated there were numerous flies and gnats throughout the facility, in the common areas, and sometimes in their rooms. They stated they had not observed ants. All residents in the confidential group meeting stated they felt that the lack of housekeeping quality and frequency bothered them greatly because it felt gross when things were dirty. Interview on 08/07/24 at 8:25 AM with Maintenance Director revealed he would attempt to contact the main number to get hold of Pest Control Service Te[TRUNCATED]