**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and facility policy review it was determined that the facility failed to provide quality of care related to skin impairment and Activities of Daily Living for one of 33 sampled residents. (Resident #45 (R45)). On 07/15/2023 at 12:44 AM, nursing observed small white insects approximately 3 cm [centimeters] in size what appeared to look like small worms, in creases of resident's wound beds on both lower extremities. The resident had a temp of 101.6 and was complaining of chills and sweats. Resident 45 was sent to the emergency room for evaluation. Additionally, staff documented on 06/01/2024 and 06/02/2024 the resident had white particles on her outer thigh area of BLE (bilateral extremities), in the resident abdominal folds, and inner creases of BLE. In an interview with R45 on 06/24/2024 at 2:28 PM, she stated that she has had maggots on her legs at least two (2) times, but only went to the hospital for them once. R45 stated she had lots of flies in her room sometimes. The findings include: Review of the facility's policy titled, Resident Rights, revised 03/18/2024, revealed the resident had the right to a dignified existence, and the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health and safety of the resident or other residents. Review of the facility's policy titled, Activities of Daily Living (ADLs), revised 08/09/2023, revealed the facility will ensure a resident's abilities in Activities of Daily Living (ADLs) do not deteriorate unless deterioration was unavoidable. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Record review revealed the facility admitted Resident 45 on 12/16/2020 with diagnoses to include [NAME]-[NAME] Syndrome, Lymphedema, and Unspecified Intellectual Disabilities. Review of Resident #45's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 was assessed to have a Brief Interview for Mental Status (BIMS) Score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Observation of the facility on 06/23/2024 at 6:10 PM, revealed four (4) flies swarming on the 200 Hall and Dining Room area. On 06/24/2024 at 2:28 PM, observation revealed three (3) flies in R45's room and one (1) on the resident's bed. On 06/25/2024 at 10:00 AM, observation revealed three (3) flies swarming on the 200 Hall of the facility. Observation on 06/26/2024 at 1:27 PM, revealed several flies in R45's room with three (3) flies resting on the Resident's thigh area. Also, five (5) additional flies were noted swarming over the resident's bed. Further observation revealed nursing staff waving their hands to shoo the flies away. Observation on 06/27/2024 at 1:42 PM revealed flies in R45's room with one fly on the resident's face and one fly on the left side of the resident's neck. During an interview with R45 at this time, she stated that she did not like the flies on her and that they made her feel bad. Review of Resident 45's (R45) care plan revised 06/09/2023, revealed the facility care planned the resident for nutritional problems r/t [NAME]-[NAME] Syndrome which results in her not feeling full; morbid obesity with weight greater than 500 lbs; and weight gain since admission. Further review revealed R45 frequently refused to allow weight to be obtained. MD aware, with interventions to include CCHO Controlled Carbohydrate diet with HS (night time) snack, Dietary to provide low calorie dense food/snacks between meals upon resident's request, Educate/encourage family to bring resident healthy snacks instead of candy, chips, sugary drinks. Provide and serve diet as ordered. Regular Diet with thin liquids. Resident 45's last weight was 640 lbs on 06/11/2024. Review of Resident 45's shower schedule revealed the resident was scheduled on Mondays and Thursdays during dayshift for baths. Review of Activities of Daily Living (ADLs) documentation revealed Resident 45 was given a complete bed bath on 07/14/2023 by State Registered Nurse Aide #6 (SRNA6). Review of the Nursing Progress Note dated 07/15/2023 at 12:44 AM revealed the nurse was summoned to the resident's room. Further review revealed the nurse observed small white insects approximately 3 cm [centimeters] in size what appeared to look like small worms, in creases of resident's wound beds on both lower extremities. Nurse notified the DON [Director of Nursing], DON stated that she would contact the wound care nurse to get new orders. Resident had a temp of 101.6. Resident was complaining of chills and sweats. Nurse contacted on call services. The doctor on call gave order to send resident to ER. RP notified and arrived at the facility to escort resident to ER. Resident left facility via ambulance at approx 0030. Review of hospital records revealed a Skin Assessment documented by the emergency room Physician on 07/15/2023 at 2:01 AM revealed multiple areas of wetness especially noted in all of the resident's skin folds due to her weight. There was one maggot noted along the right side of the resident's body. Review of the facility's document titled, Pest Sighting Log, revealed twenty (20) flies were found and killed at the 200 Hall nurse's station and ten (10) flies were found and killed in R45's room on 05/21/2024 at 9:00 AM, also, ten (10) flies were found and killed in the same room on 06/01/2024 at 10:00 AM. Review of the Nursing Progress Note, dated 06/01/2024 at 11:45 AM, revealed the nurse was summoned by staff to R45's room r/t SRNA seeing white particles on the resident's outer right thigh. Further nursing assessment revealed white particles were noted coming out of the outer thigh area of BLE (bilateral extremities), in the resident abdominal folds, and inner creases of BLE. Review of the Nursing Progress Note, dated 06/02/2024 at 2:55 PM revealed, Complete bed bath given today x 4 staff members. [NAME] particles continue to right outer thigh area. None noted to abdominal folds or left thigh. Dakins and triad cream continues. In an interview with R45 on 06/24/2024 at 2:28 PM, she stated that she has had maggots on her legs at least two (2) times, but only went to the hospital for them once. R45 stated she had lots of flies in her room sometimes. In an interview with R45's mother on 06/25/2024 at 9:43 AM, she stated she felt that the facility was not providing quality care for the resident. She stated R45 called her and told her that she had laid and waited for someone to come and change her for hours and that it was mainly afternoon staff. She stated they use the resident's size and instances of care refusal as an excuse to not take care of her. She further stated R45 had had maggots on her at least twice that she knew of. She stated she got a call from a nurse around midnight on 07/15/2023 and the nurse reported she found maggots on R45 and was sending her to the hospital. She stated she met the resident at the hospital and the hospital emergency room (ER) staff informed her that they also had to clean maggots off the resident. She stated the Director of Nursing (DON) had told her they were working on a plan to get rid of the flies in the facility, but no one had followed up with her in regards to it. She further stated R45 had recently called her crying and scared stating, She is afraid those bugs might come back. In an interview with State Registered Nurse Aide (SRNA) #1 on 06/25/2024 at 1:00 PM, she stated that she was doing rounds with another SRNA. She stated when she turned R45 over, she saw something white fall onto her gloved hand. She stated she started wiping the resident and observed small, white, rice-like objects falling from the resident and noted they were moving. She stated they were generally all over the bed and crawling out from Resident 45's skin. She stated she told the other SRNA that she was going to go get the nurse, and she left and came back with the nurse who assessed the resident and stated they looked like maggots. During further interview, she stated that they cleaned R45 up and called the DON who advised them against documenting the incident, and to wait and get direction from her because she needed to find out what to do about it. SRNA #1 stated she recalled seeing flies in R45's room. She stated approximately two weeks after the incident she was called into the Administrator's office and blamed by the Administrator for R45 getting the maggots. She stated the administrator stated to her that she was not doing her job because R45 did not get a bath. SRNA1 stated that was the first time she had worked with R45 in over three weeks because she was working the Memory Care Unit and not on the hall where R45 resided so it was not possible for her to have provided care to this resident. She stated she resigned from the facility after her meeting with Administrator. In an interview SRNA6 on 06/26/2024 at 2:45 PM, she stated she assisted staff with care and provided a bed bath for R45 on 07/14/2023. She stated there were always flies present in R45's room. She stated she had seen maggots on the resident's bed but not on her. In an interview with Licensed Practical Nurse (LPN) #1 on 06/25/2024 at 11:35 AM, she stated that she observed the maggots on R45 on 07/15/2023. She stated it was her first time working at the facility as she was a new employee. She stated SRNA #1 came and requested her to come to R45's room. She stated she assessed resident and noted maggots were falling out of R45's folds and creases in her legs, and abdomen. She stated she called the Director of Nursing (DON) and the DON advised her to just treat the resident with some Dankins solution (a type of hypochlorite solution used to clean wounds). She stated the DON told her that this had happened to the resident before. She stated the DON informed her not to chart the incident, but LPN #1 stated she knew that was wrong and documented her findings. She notified the Physician on call who gave orders to send R45 to the hospital. In an interview with Registered Nurse (RN) #4 on 06/27/2024 at 2:10 PM, she stated on 06/01/2024 she was summoned to R45's room by the SRNAs regarding possible maggot sightings on the resident. She stated she observed white particles noted coming out of the outer thigh area of the resident's Bilateral Lower Extremities (BLE), in the resident's abdominal folds, and the resident's inner creases. She stated the white particles appeared to be maggots to her but she was told by her DON that since she was not pest control that she cannot say what she though it was and was advised by the DON to document her findings as white particles instead of maggots. She stated she tried to keep R45 clean and dry and apply treatments as ordered to reduce the skin issues. She further stated that it would be a great idea for R45 to get more baths per week, but the facility just did not have the man power to do so. In an interview with the Director of Nursing on 06/27/2024 at 1:20 PM, she stated if a resident has skin breakdown and wound care recommended they increase the number of baths a resident received they would do so. The DON stated that in her opinion R45 was on a great bathing schedule as it was. During further interview the DON stated the nursing staff were very well trained to care for this resident and provide them with a complete bed bath. She further stated R45 has a history of refusing care because she has a preference of which staff members provided her care. In a second interview with the Director of Nursing on 06/28/2024 at 12:48 PM, she stated she received a call from the nurse around 9-10 at night, the nurse informed her that she saw white things on R45' legs. The DON stated she told the nurse to call the on call physician who gave orders to send Resident #45 to the hospital. She further stated within this month RN # 4 called her and informed her that she saw them again and she advised her to call the medical director and he ordered treatments for resident. She stated she just told staff to document the facts, and state what they saw. In an interview with the Medical Director (MD) on 06/27/2024 at 3:33 PM, he stated the On Call Doctor gave the order for R45 to go out the ER. He stated that R45 had had them at least twice that he was aware of. The MD stated the Root Cause of the problem was the flies in the facility. In an interview with the Administrator on 06/28/2024 at 1:23 PM, She stated the DON contacted her and she instructed them to call the on call physician services who ordered R45 to go out to the hospital. She stated she followed up with the family in regards to the situation. During the interview, she stated she maintained an open line of communication for them to talk with her about any concerns. She stated that they have pest control come monthly, placed fly lights in residents' rooms, fly swatters, air blowers, and tried to keep the windows shut. She stated she had to educate R45 on keeping the windows shut. She stated the resident was her own person and would tell you what she wanted and could be very non-compliant and resistant to care.