**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff, Wound Nurse Practitioner (WNP), Nurse Practitioner (NP), and Physician interviews, the facility failed to prevent resident's gangrenous right foot ulcer from contracting a maggot infestation. The maggots were discovered on 7/10/23 by Nursing Aide #1 (NA#1) during the early morning rounds. The Nurse Practitioner was notified and saw a whitish worm-like movement in resident's right foot ulcer that resulted in Resident #1 being transported to the emergency room (ER) for evaluation and treatment. The surgeon removed the visible maggots crawling in and out on his right foot ulcer in the ER and ordered an antibiotic as prophylaxis for possible necrotizing fasciitis (an aggressive skin and soft tissue infection that causes dying of the muscle and tissues). On 7/11/23 the Physician and the Treatment Nurse removed 63 additional maggots. A reasonable person could have feelings of anger, distress, fear and/or anxiety knowing maggots were in their wound. This was for 1 of 3 residents (Resident #1) reviewed for ulcers (skin conditions). Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of critical limb ischemia (inadequate blood supply to body part) of both lower extremities, and Peripheral Vascular Disease (PVD). The Minimum Data Set (MDS) on 7/13/23 coded Resident #1 with severely impaired cognition. Resident #1 could communicate his needs to staff. He was coded to require extensive assistance with bed mobility, transfer, dressing, personal hygiene, and toilet use. Impaired Range of Motion (ROM) of the right lower extremity. Review of the vascular consult record on 4/28/23 revealed the resident developed a 2nd toe ulcer on the right foot and was diagnosed with critical right lower extremity ischemia with dry gangrene (a condition where a loss of body supply causes body tissues to die). The Vascular Surgeon suggested amputation and was discussed with the resident and family. The resident and his family member refused the amputation and wanted to treat it conservatively. The Vascular Surgeon ordered to clean the wound daily and paint with half strength povidone-iodine (an antiseptic). Record review of the physician treatment order dated 6/20/23 revealed to apply povidone-iodine generously and leave open to air every day to the right 2nd toe/foot. The Treatment Administration Record (TAR) for 7/1/23 through 7/20/23 reflected the physician order and was signed daily as completed by a nurse. Interview with Nurse #1 on 7/20/23 at 1:49 PM revealed that she did the treatment of the right foot ulcer on 7/9/23 and no maggots were observed. An SBAR (Situation Background Assessment Recommendation) note dated 7/10/23 at 8:21 AM completed by the Nurse Unit Manager revealed the ulcer on the top of Resident #1's right foot was noted with maggots and larvae. Nursing Aide #1 (NA#1) was interviewed on 7/20/23 at 10:27 AM and stated on 7/10/23 at 6:00 AM she saw some whitish movement in the resident's right foot during early morning care rounds. She immediately called Nurse#1 in the hall and reported the observation of the maggots. The NA also stated that the resident was bed bound and didn't get out to the chair or bed. She stated she had never seen flies in the room and the resident was always covered with a blanket. Interview with Nurse #1 on 7/20/23 at 10:40 AM revealed she was called by NA #1 to the Resident #1's room the morning of 7/10/23. She stated she saw a white worm-like substance in the resident's right foot ulcer indicative of maggots. She called the Nurse Unit Manager into the room. She stated she had never seen fly activity in Resident #1's room. Interview with the Nurse Unit Manager on 7/20/23 at 10:30 AM revealed Nurse #1 called her into Resident #1's room on morning of 7/10/23 and showed the resident's right foot wound and she saw whitish maggots in the residents' foot. She notified the Wound NP and Treatment Nurse right after she saw the maggots. Nurse Unit Manager stated she didn't see any fly activity in Resident #1's room. Interview with the Wound NP on 7/20/23 at 8:01 AM revealed she was called into the Resident #1's room early in the morning of 7/10/23 to check his right foot ulcer and she noticed maggots in the wound. She said the Treatment Nurse was in with her, and she let the Treatment Nurse notify Hospice. She recommended sending Resident #1 to hospital ER for evaluation. She said there were lots of maggots in the wound and needed immediate attention. She stated the ulcer had a small wet opening that probably attracted flies to lay eggs and became maggots. The Wound NP stated there were no visible flies when she was in the resident's room. Interview with the Treatment Nurse on 7/20/23 at 8:12 AM revealed during the early morning rounds with the Wound NP on 7/10/23, they were called in the Resident #1's room. She stated they saw several moving maggots in the right foot ulcer, and she called the Hospice Nurse about the maggots and expressed the recommendation of Wound NP to send the resident to hospital ER. The Treatment Nurse stated that they informed the family member about the ulcer with maggots and the immediate transport of resident to the hospital ER. Emergency Management Services (EMS) was contacted and transported the resident to the hospital. Review of the hospital records dated 7/10/23 revealed that Resident #1 arrived at 9:05 AM and was evaluated in the hospital ER. During the ER visit, they consulted general surgery to evaluate the right foot ulcer. The report from the surgeon revealed the visible maggots crawling in and out the right foot ulcer were removed, and an antibiotic treatment was ordered as prophylaxis for possible necrotizing fasciitis (an aggressive skin and soft tissue infection that causes dying of the muscle and tissues). A wound treatment instruction was ordered to irrigate with Sodium Hypochlorite Solution and pack with povidone-iodine-soaked gauze twice daily and resident was sent back to the facility on 7/10/23. Record review of the treatment orders transcribed on 7/10/23 revealed to irrigate the right foot ulcer with Sodium Hypochlorite Solution (skin disinfectant) and pack with povidone-iodine-soaked gauze twice daily. The Physician was interviewed by phone on 7/20/23 at 11:59 AM and stated that Resident #1 had PVD and there was no blood flow in his right foot. The resident developed gangrene on the right foot that started from the 2nd right toe. The foot lost blood supply and turned all toes on the right foot to black and wet gangrene was observed. He stated the wet gangrene had a foul odor like decaying meat and would attract flies. The Physician stated that the resident refused to amputate his foot and wanted to keep his body parts. He stated that the treatment with povidone-iodine-soaked gauze was implemented to maintain the ulcer. He said they consulted the vascular specialist and the Vascular Surgeon recommended amputation, but the resident refused the amputation. The Physician stated that when he visited the resident on 7/11/23, he ordered to soak the right foot ulcer with hydrogen peroxide, and they got a lot of maggots out. Interview with the Treatment Nurse on 7/20/23 at 8:12 AM revealed she was with the Physician on 7/11/23 when they soaked the resident's right foot ulcer with hydrogen-peroxide. She said there were 63 maggots removed and then she dressed the wound with gauze. She stated that she did the same treatment on 7/12/23 and she removed 2 more maggots. And on 7/13/23, she said there were no more maggots from the ulcer. Observation of Resident #1's right foot ulcer with the Treatment Nurse was done on 7/20/23 at 8:17 AM. The Treatment Nurse pulled back the sheet and a disposable bed pad was observed covering the right foot. The Treatment Nurse uncovered the right foot and revealed all toes were black and had necrotic (dead tissue). Some areas showed crusty black skin and there was some wetness on top of his right foot with no signs of infection. Several observations of Resident #1's room on 7/20/23 at 8:17 AM and 1:51 PM were made the day of the investigation and there was no fly activity observed in his room. Observations on 7/20/23 at 2:24 PM different halls, common areas of the facility, and other residents' rooms showed no fly activity. Several observations on 7/20/23 revealed the front door of the facility continuously had visitors and residents who were coming in and out to the patio in the front of the building. All residents sitting on a wheelchair going out the front door took longer to close while wheeling out. The door in the front entrance did not have a fly fan (a fan above the door to supply high velocity of air stream to keep insects from entering the building). There was no fly activity observed in the lobby. Interview with the Nurse Practitioner on 7/20/23 at 12:14 PM revealed at the beginning Resident #1's right foot ulcer was dry and then it became moist. She stated she smelled a rotten odor during her visit to Resident #1 from the previous weeks since June 2023. She said that one fly can lay 150 eggs and she was not surprised with the wound the resident could attract flies because of the rotten odor. She stated that it was an acute onset, and she believed the maggots were present no more than 24 hours. Interview with Nurse #2 on 7/20/23 at 11:35 AM revealed she had seen some flies on her hall (100), but they were not so much of an issue. Interview with the Maintenance Director on 7/20/23 revealed there were two main doors used to enter the facility. One in the hallway close to the kitchen in the back and one in the front. He stated the back door had a fly fan and the front door didn't have a fly fan. The Maintenance Director indicated he had not observed any fly activity in the facility and there was not a problem with flies. Review of the monthly pest control visit logs from March 2023 to July 2023 showed there were ants identified in April and May 2023. The ants were treated and no further reports of ants after. Fly activity was not identified as a problem during any of the visits. Interview with the Director of Nursing (DON) on 7/20/23 at 12:36 PM revealed the nurses and unit manager made her aware of the maggots on resident's right foot ulcer in the morning of 7/10/23 before the resident was sent out. She stated the room that Resident #1 resided in was warm all the time as the resident wanted it that way. She said they moved the resident into another room to make it cooler because a warm room could make the odor worse. The DON indicated the facility did not have a problem with flies. The DON stated that there was sporadic fly in the building. An interview with the Administrator and the Regional Nurse Consultant on 7/20/23 at 10:59 AM revealed that they don't know what happened with Resident #1 because they don't have any problems with flies. The Administrator stated that they acted quickly to send the resident to the hospital ER for treatment. She stated that the front door was the only entry for flies to get into the building when the visitors and residents were going in and out to the front patio. The Administrator was notified of the immediate jeopardy on 7/20/23 at 5:01 PM. The Administrator provided the following corrective action plan with a compliance date of 7/13/23. Corrective Action for Resident that was identified with wounds on 7/10/23. Nursing identified maggots and immediately reported to Wound Nurse who notified Wound Nurse Practitioner. Resident sent to ER for treatment and removal of maggots on 7/10/23. Resident returned with new treatment orders of Dakins/Sodium Hypochlorite to right foot topically and to apply betadine wrap for protective covering, every day and evening shift. On 7/11/23 the Medical Director removed numerous maggots. On 7/12/23 Wound Nurse removed 2 more and continued daily monitoring for any maggots and Wound Nurse Practitioner continued weekly monitoring of appropriate treatments. Facility worked with resident on his preference for a room change which promoted an improved temperature and a private room, residents room was changed 7/12/23. Any resident with open wound, gangrenous wound, tube feeding, stoma's and ostomies are at risk of being affected. An audit performed of these residents showed there were no other affected residents. Audit completed by Director of Nursing and nursing supervisors 7/11/23. On 7/11/23 The Administrator provided fly swatters to front receptionist, nurses stations and department managers. The Administrator provided the Activities Director with fly swatters to hand out to alert and oriented residents. The side door closer to dumpster has a blow back system to prevent flies/pests entering. Residents that enjoy going outside in the front area are being provided with increased assistance getting in/out of the door to avoid the door being open too long and adjusting timing of door as needed. On 7/11/23 the Wound Nurse informed the receptionist to assist residents going in and out of the front door to minimize the time the door is open and prevent flies from entering. The administrator, HR Coordinator and receptionist check on residents daily that are outside for hydration and discuss reminders regarding doors being opened for long periods can result in flies in the facility. The facility provides a full-time day and evening receptionist and a weekend receptionist from 8am-8pm. Wound Nurse and charge nurse monitor dressings daily for wounds, tube feedings, stoma's/ostomies to assure no issues with maggots and if there is an open wound or drainage that may attract flies, review/revise treatment to prevent/protect from flies. There have been no concerns noted with wounds and maggots since 7/12/23. Pest control is in the building monthly and for the past six months have not identified flies as being an issue nor any recommendations. Director of Nursing educated Wound Nurse on 7/11/23 to increase monitoring of any resident with wounds that are open to air or gangrenous and treatment changes as needed to prevent any maggot infestation. Wound Nurse will continue to work closely with charge nurses for monitoring wounds and any concerns with maggots. Wound Nurse and Charge Nurses dispose of dirty wound dressings in a double bag immediately after the dressing change to prevent flies and/or maggots. The double bag is then taken to the soiled utility room. This has been an ongoing practice at the facility. The Director of Nursing and Nursing Supervisors held a nursing staff meeting on 7/12/23 to update on importance of fly prevention and nurses' observation of wounds for any signs of maggots. Nurses and Nursing Assistants attended the meeting. The Director of Nursing and Nursing Supervisors verbally called any nursing staff not on the schedule to communicate highlights of the meeting which included awareness of flies and maggots. In addition, there is an education/communication binder at the nurse's station to promote continuous communication and education. The Director of Nursing and nursing supervisors document and update binder with in-services and communication for the nurses and nursing assistants to read. On 7/12/23- The Administrator and HR Coordinator placed visual reminders regarding being aware and mindful of flies in the facility. The visual reminders are located on the Bee Kind Board, by the time clock, in the breakroom and in the Administrator's office located by the refreshment area provided by the Administrator for all staff and families who visit almost daily. For ongoing prevention, on 7/11/23 Administrator and Director of Nursing reviewed deep clean schedule with Environmental Director and discussed any high-risk rooms. High Risk would include residents that are tube fed with a potential for leakage on the poles. Discussed that the leakage could attract flies. Environmental Director to ensure poles are cleaned daily. The facility has an ongoing program called (Caring Angels). The Department Heads and Managers are assigned a group of rooms with the goal of visiting them weekly on a regular basis. The Residents Caring Angel is posted on the resident's bulletin board in their room so that they know who the Angel is and their contact information. On 7/11/23 the Administrator advised the department managers/Angels to communicate to their residents the importance of prevention of flies. Communication included the following tips: Report spills to staff immediately, request for tray pickup timely, maintain personal food items in closed containers, encourage good hygiene, visual reminders were posted in resident's rooms. Facility reviewed concerns regarding residents with maggots during morning meeting on 7/11/23 as an AD HOC QAPI to monitor any resident with open wounds and potential for maggots. The Director of Nursing, Nurse Supervisors and Wound Nurse are monitoring Residents with wounds, that are tube fed, stomas and ostomies for any signs of drainage and maggots. Monitoring is 5 days a week for four weeks and then three days a week for four weeks. Findings will be reviewed at QAPI on 7/25/23 for any revisions or updates. On 7/25/23, the facility's credible allegation for immediate jeopardy was validated. Resident #1 was observed to be in a private room and wound was free of any maggots. During the tour of the facility residents were observed to be assisted in and out of the front door, and fly swatters were present through- out the facility. The in-services included information on managing an unexpected case of maggots, notification of administration for any changes to wound areas that are left open to air, increased monitoring of open wound areas, as well as fly prevention. Staff interviews confirmed education was received for fly prevention and daily monitoring of wounds, ostomies, and tube feed sites for the presence of maggots. The facility provided evidence of daily Quality Assurance auditing of all residents with wounds, ostomies, and tube feed for the presence of maggots beginning 7/10/23 and ongoing. The facility's corrective action plan was validated as 7/13/23.