**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews with staff, Medical Director, Nurse Practitioner (NP) and emergency room Physician, the facility failed to provide treatment and services to replace an old, discolored, and leaking gastric feeding tube after 5/04/25 when approximately 5 inches of the tube broke off during routine feeding tube care. In addition, the facility failed to schedule an appointment with a gastroenterologist to assess for a feeding tube replacement. On 6/18/25, the feeding tube site was found with approximately 25 maggots in the skin surrounding her feeding tube during care. Resident #1 was sent to the Emergency Department (ED), where approximately 5 more maggots were removed, and it was noted there was some induration (thickening and hardening of the skin) and erythema (abnormal redness of the skin or mucous membranes) concerning for cellulitis (bacterial infection of the skin and the tissue beneath the skin). The ED provider documented the feeding tube appeared aged and soiled and a new feeding tube was inserted. Resident #1 was admitted to the hospital for treatment of sepsis (a life-threatening response to infection) with acute hypoxia (low levels of oxygen in the tissue) due to abdominal wall cellulitis, a catheter-associated urinary tract infection (UTI), and bacteremia (presence of bacteria in the blood). She was treated with intravenous (IV) antibiotics and was discharged on 6/23/25 with orders to continue IV antibiotics for 2 additional weeks. A reasonable person has an expectation of receiving treatment and care to prevent an infestation of maggots and would have experienced feelings such as embarrassment, anger, and disgust. The deficient practice occurred for 1 of 3 residents reviewed for feeding tubes (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including vascular dementia, cognitive communication deficit, neuromuscular dysfunction of the bladder, a gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) tube and dysphagia (difficulty swallowing). Resident #1's current comprehensive care plan noted she had a feeding tube to maintain adequate nutrition and hydration. Interventions included for staff to monitor for abdominal pain, distension, tenderness, and nausea or vomiting. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] documented she had short- and long-term memory problems and severely impaired cognition for decision-making, inattention, disorganized thinking, and altered level of consciousness constantly present. The MDS noted she had limited range of motion in both upper extremities and was dependent on staff for completion of her activities of daily living (ADLs). The MDS indicated she had an indwelling catheter and a feeding tube, received 51% or more of her calories and 501 cc of fluid daily by the feeding tube. Resident #1's May 2025 and June 2025 Medication Administration Record (MAR) noted Resident #1 received Isosource (tube-feeding formula) 1.5 Cal formula at 55 milliliters an hour through her gastric tube starting at 5:00 AM and continuing until 3:00 AM the next morning. An additional entry noted for the nurse to provide 200 cubic centimeters (cc) of water every 4 hours and to flush the tube with 60 cc of water before administering medications and 30 cc of water between each medication administered. Resident #1's May 2025 through June 2025 nursing progress notes, MAR, and the Treatment Administration Record (TAR) did not document any abnormalities with Resident #1's feeding tube. The TAR noted for the nurse to cleanse Resident #1's skin surrounding the feeding tube site daily with normal saline, apply T-drain sponge, and secure with tape. The daily site care was signed as being completed daily on the MAR until 6/18/25 when she went to the hospital. Nurse #3 documented on 5/4/25 and 5/5/25 during the night shift for providing feeding tube care and flushes. Resident #1's nursing progress notes dated 5/04/25 at 9:46 PM written by Nurse #3 documented that when she was de-clogging and flushing the feeding tube, several inches of the tube broke off, but noted the feeding tube was still patent and functioning. In a phone interview on 6/27/25 at 10:09 AM, Nurse #3 said in May, while providing medications and flushes, approximately 5 inches of the end of Resident #1's feeding tube broke off into her hand. Nurse #3 stated at that time, the feeding tube tubing was thicker silicone, and it appeared old and was no longer transparent. Nurse #3 indicated the tubing was very long, and there was still more than an inch of tubing available to provide flushes and formula. She stated she wrote the incident to the provider in the communication log and reported the incident to the oncoming nurse (Nurse #2) for a referral to a gastroenterologist. Nurse #3 explained when she documented she was de-clogging the tubing, it was not due to an obstruction, it was due to a small amount of residual formula left in the tube that she needed emptied into the stomach. Nurse #3 said she had not observed any leaks or abnormalities, such as a sweet smell from the formula, prior to the tubing breaking or in the following days before she was hospitalized . The Provider Communication Book entry dated 5/4/25 written by Nurse #3 noted for Resident #1 that part of the tube feed broke off. Resident #1's nursing progress note on 5/05/25 at 3:42 PM written by Nurse #2 documented the feeding tube was still running fine even after tube was shortened. In a phone interview on 6/27/25 at 10:00 AM, Nurse #2 said she provided feeding tube site care for Resident #1. She stated it was reported to her that the end of the feeding tube had broken off in May 2025, but the tubing was still intact and Nurse #2 was able to provide the flushes and formula ordered. Nurse #2 indicated she did not notify the provider for a referral because she remembered hearing Nurse #3 say she had written the information in the provider communication book. She said she had observed the feeding tube was stained and appeared old at that time. Nurse #2 recalled a sweet smell from the formula around Resident #1 when caring for the resident at times but had not seen any cracks or leaking from the tubing, so she did not think it was a concern. In her interview on 6/25/25 at 4:12 PM, Nurse #1 said she had learned from Nurse #3 (date not recalled) that the end of Resident #1's feeding tube broke off. Nurse #1 said the tubing was old and brittle (not easily flexible) at the time. Nurse #1 recalled there were a few times (dates not recalled) when she would observe drops of formula on the bedding and stated it was due to the feeding tubing leaking. She stated she would also at times smell a sweet smell in the room and on the resident that smelled like the formula. In a phone interview on 7/15/25 at 3:31 PM, Nurse #4 stated she spoke with the NP about Resident #1's feeding tubing breaking off on 5/05/25 after Nurse #3 reported the incident to her and also about needing the feeding tube assessed for replacement on 5/12/25. She stated she remembered hearing about a referral for a gastroenterologist (GI) appointment, but stated the NP wrote her own orders and Nurse #4 did not remember seeing an order. She stated the normal process was for the NP or Physician to write their own orders into the medical record, and the nurse will print the order for a referral and give it to the Director of Nursing (DON). A Nurse Practitioner (NP) progress note dated 5/12/25 at 7:47 PM documented the nurses reported that there was crusting around Resident #1's feeding tube. The NP noted when she assessed the site, there was hypergranulation (granulation tissue naturally forms when a wound is healing, but too much of this tissue results in a condition known as hypergranulation. Hypergranulated tissue is usually swollen or bumpy, red, and painful) with evidence of a fungal infection. The NP also noted that nursing staff inquired about a routine change of the feeding tube. The NP noted that per her Electronic Medical Record review, Resident #1 had the feeding tube placed 10/18/23 under anesthesia performed by a general surgeon. The NP noted the (feeding tube replacement) procedure [would be] moderately difficult due to Resident #1's anatomy and previous feeding tube placement. The NP included in the note that per guideline review, these feeding tubes may not require routine changing if they are functioning well. Some guidelines recommend to change the tubing every 1-2 years. Nursing staff denied any issues with function or patency of the tube. The Nurse Practitioner placed a nonurgent GI (gastroenterologist) consult to further assess the tube and make evaluations for any future routine changes if needed. In an interview on 7/15/25 at 11:00 AM, the Nurse Practitioner stated she did not recall being notified that approximately 5 inches of Resident #1's feeding tube had broken off. She stated the nurse asked her on 5/12/25 about when to get the feeding tube replaced and reported there was crustiness around the feeding tube site. The NP said she assessed the feeding tube site and noted a mild fungal infection and hypergranulation around the feeding tube site. She said there was nothing abnormal that she observed about the feeding tube. The NP indicated there was no leaking, no sweet smell of the formula (but she stated she usually wore a mask when assessing the residents and so may not have smelled anything due to the mask), and the feeding tube was functioning normally. The NP stated she remembered writing the orders for a gastroenterology consultation and for the antifungal treatment. The NP explained if she had been told the feeding tube had broken off, she would have noted it in her progress note on 5/12/25. The NP stated she was at the facility two to three times a week and did rounds and spoke with charge nurses at each nurses' station. She stated she notified Resident #1's responsible party and spoke with the Unit Manager about the referral and antifungal order and sent a message through the medical practice's portal to the Medical Director, who replied he agreed with her plan for a GI consult. The NP stated she also emailed the Director of Nurses (DON) about the referral and the antifungal order. She stated the facility would write in the communication book or tell her verbally when she was making rounds if there were any concerns with a resident's condition. The NP said because changing the feeding tube wasn't an emergency, she would expect there would be about a month or two wait for an opening at the GI doctor. Resident #1's physician's orders dated 5/13/25 documented an order for nystatin-triamcinoloneOintment (an antifungal) 100,000-0.1 unit/gram-% topically around the feeding tube twice a day. The order instructed that prior to application, to cleanse around the feeding tube with antibacterial soap and water, gently pat dry, apply the ointment and cover site with split gauze. There was no order found documented in the clinical record for a referral to the gastroenterologist from 5/04/25 to 6/17/25. There was no documentation Resident #1 saw a gastroenterologist from 5/04/25 through 6/17/25.In a phone interview on 7/15/25 at 2:54 PM, the facility Transportation and Appointment Scheduler stated she did not receive an order for a referral to a gastroenterologist in May 2025. She stated she did not have access to the medical record, so the nurses would print an order for a referral and put it in her mailbox. She stated she did not receive an order from the nurse to schedule an appointment for Resident #1. She stated specialist appointments would be scheduled quickly when she received the order.In an interview on 7/15/25 at 2:42 PM, the Unit Manager stated she remembered speaking with the NP about Resident #1's fungal infection and about a referral to the gastroenterologist. She stated she did not handle referrals to outside physicians, so she was not aware of what happened with the referral. In a phone interview on 7/15/25 at 3:40 PM, the DON stated when the provider wrote an order for a referral, the nurse would print the order and give the order to her. The DON would then review the referral information in the facility Morning Meeting and the order was given to the Transportation and Appointment Scheduler. She stated she did not remember having an order for a gastroenterology referral for Resident #1. She stated the NP would enter her own orders into the medical record, but would verbally communicate with the charge nurse, the Unit Manager, and the DON about any new orders or concerns. The DON further stated the usual facility practice was for the NP notes to be uploaded to the chart and they were not reviewed for any additional information or missed orders and that the facility nurses and management relied on the verbal information from the NP. She stated she remembered the NP told her about the order for the antifungal treatment and discussed the referral to the gastroenterologist, but because there was not an order for the referral, the appointment was not made, and she did not remember having an order for a gastroenterology referral for Resident #1. In a phone interview on 6/27/25 at 10:00 AM, Nurse #2 said she provided feeding tube site care for Resident #1 on 6/16/25 and 6/17/25. Nurse #2 stated on both days, she lifted the disk to clean the site, and she did not see any maggots in the site. She stated Resident #1 did not appear to be in any pain or to have any acute concerns. Nurse #2 indicated she had not noted any flies in the room and stated the window in the room was closed. She stated when she performed the care, the feeding tube was not leaking and was not cracked. In a phone interview on 6/27/25 at 10:09 AM, Nurse #3 said she worked the night shift (7:00 PM to 7:00 AM) on 6/16/25 and 6/17/25. Nurse #3 indicated there was not an order to clean and care for the feeding tube site on the night shift, but she provided flushes and assessed the area when giving medications. Nurse #3 stated she did not lift the disk to look under it and she did not see any maggots. She stated Resident #1 did not show any signs of a change in condition on her shifts and Resident #1's vital signs were normal, and she didn't appear to be in any distress. She stated the window to the room was closed and she did not see any flies in the room during those shifts. Resident #1's Subjective, Objective, Assessment, and Plan (SOAP) assessment dated [DATE] and written by Nurse #1 documented that Resident #1 was found with maggots surrounding her feeding tube site. Her vital signs were within normal limits. Her blood pressure was 124/67, her pulse was 71, and her temperature was 97.6 degrees Fahrenheit. Nurse #1 documented she notified the Nurse Practitioner, who ordered Resident 1 to be sent to the hospital. An interview with Nurse #1 on 6/25/25 at 4:12 PM revealed she had been off on 6/16/25 and 6/17/25. When she returned to work on 6/18/25, she began to do the daily feeding tube site treatment for Resident #1 and as she removed the protective disk around the tubing, she found approximately 25 maggots surrounding Resident #1's feeding tube site. She said the tubing was old, brittle, leaked drops of formula at times, and that she could smell a sweet smell from the formula when entering Resident #1's side of the room. Nurse #1 indicated the maggots could not be seen until the protective disk was lifted up away from the tubing. She said she immediately notified the Unit Manager, the Assistant Director of Nursing (ADON), the provider, and Resident #1's responsible party. Nurse #1 stated the ADON cleaned the wound with normal saline and removed approximately 25 maggots from the site. In a phone interview on 6/27/25 at 4:26 PM, the Unit Manager said she and the ADON were in their afternoon meeting when Nurse #1 came into the room and reported Resident #1 had maggots in her feeding tube site. The Unit Manager stated she and the ADON went to Resident #1's room and when they arrived, there were no flies in the room, Resident #1's window was not open, and the room was clean. The Unit Manager further stated she was not able to see the maggots initially. She stated the surrounding skin was not red and the area was not swollen. The Unit Manager recalled there was no dressing covering the feeding tube site at that time, and the nurses would not have been able to see the maggots when flushing the tube or when giving Resident #1 her feeding tube formula. She stated when she lifted the disk protecting the feeding tube site, she saw approximately 20 maggots in the site. The Unit Manager indicated the ADON washed the area with normal saline and removed the maggots from the site. She said Resident #1's vital signs were within normal limits, and Resident #1 did not appear to be in any distress. In a phone interview on 6/27/25 at 4:42 PM, the ADON stated she and the Unit Manager were in their afternoon meeting when Nurse #1 came in and reported seeing maggots in Resident #1's feeding tube site. She stated when they arrived in the room, she did not see any flies in the room, the room had been cleaned. The ADON recalled she was not able to see the maggots until she moved the disk covering the site and the maggots were not visible unless the edge of the disk was folded to provide site care. She stated she flushed and cleaned the site with normal saline and removed approximately 20 maggots. The ADON did not remember seeing any more maggots in the site when Resident #1 left for the hospital. She indicated Resident #1's feeding tube was not leaking, was not cracked, and she was able to flush the tubing without difficulty. The ADON Resident #1 did not appear to be in any distress and her vital signs were normal. She stated when the managers spoke with other staff members who had worked, no one remembered seeing any signs of maggots. Resident #1's hospital records included an Emergency Department (ED) Physician Note dated 6/18/25 and written by the ED Physician noted Resident #1 was sent to the hospital due to a feeding tube malfunction. When she was examined in the ED Triage department, her blood pressure was 84/50 (normal blood pressure was approximately 120/80) and she was noted to be grimacing. The physician noted Resident #1 was sent from the facility when they found maggots in and around her feeding tube. The Physician noted her feeding tube was in place, had multiple visible maggots around the wound, and had surrounding skin excoriation (raw, irritated, and sometimes bleeding patches on the skin) or erythema (any abnormal redness of the skin caused by dilation and irritation of the superficial capillaries). The ED Physician also noted the feeding tube itself appeared old and soiled. Laboratory tests completed on 6/18/25 in the ED and reported to the provider on 6/20/25 noted two blood cultures were drawn and both were positive for the bacteria Staphylococcus aureus and proteus mirabillis. The hospital History and Physical dated 6/18/25 noted Resident #1's feeding tube was found to be derelict with maggots surrounding the stoma site in the ED. A computed tomography (CT) scan done 6/18/25 in the hospital noted there was soft tissue thickening along the cutaneous (skin) surface and the soft tissues on the left upper area of her abdominal wall immediately adjacent to the tubing indicated cellulitis of the surrounding tissue needed to be considered. Resident #1's hospital Discharge summary dated [DATE] noted she was diagnosed with sepsis, acute hypoxia due to abdominal wall cellulitis, a catheter-associated urinary tract infection (UTI), cellulitis of the abdominal wall, and bacteremia. She was treated with the antibiotics Vancomycin, Zosyn, and intravenous (IV) Ancef while in the hospital with orders to continue the Ancef upon return to the facility until 7/04/25. In a phone interview on 6/27/25 at 5:18 PM, the ED Physician stated she remembered Resident #1's skin surrounding the feeding tube was indurated (hardened) and excoriated. She said when she examined Resident #1, nurses had already removed 2 maggots from the site and there were approximately 3 more in the site remaining on the skin in the site. The ED Physician recalled the feeding tubing itself was discolored and non-transparent, which was an indicator that the tubing had not been replaced for a long time. In an interview on 6/27/25 at 5:15 PM, the Director of Nursing (DON) stated the facility immediately responded to Nurse #1 reporting the maggots in Resident #1's feeding tubing site. She stated all other residents with feeding tubes and/or with any wounds were examined and no other resident was found to have maggots. The DON further stated maggots can appear quickly, within 8-12 hours, and the nurses on the previous shifts had not observed any. She stated Resident #1's vital signs, pain assessments, and nursing observations did not indicate she had any acute concerns. The DON indicated the feeding tube breaking in May was not an emergency since the nurses could flush, infuse the formula, and care for the feeding tube site. In a phone interview on 6/27/25 at 1:01 PM, the Medical Director stated the NP told him about a gastroenterologist appointment to replace the feeding tube but because she was at the facility, she responded to the situation appropriately while she was there. The Medical Director stated he was made aware (date not recalled) that Resident #1 was found with maggots in her feeding tube site. He stated he had examined Resident #1 the week preceding 6/18/25 and her feeding tube appeared old but there were no signs of maggots or of any dying tissue in the feeding tube site, which was what maggots would feed on. He further stated he could not find a cause for the maggots. The Medical Director explained that the maggots could have infested the area quickly, within 8-12 hours, so the day shift the previous day would not have observed any maggots. He stated the normal life expectancy for the tubing was approximately 6 to 12 months depending on how long a resident had the feeding tube in place. The Medical Director stated he believed the tubing had been changed in October 2023, so approximately 18 months was longer than the normal life expectancy of the tubing, but if the tubing was functioning, it was not cracked, and was not leaking, not having the tubing replaced since 2023 was not a concern. He further stated the NP told him about a gastroenterology consultation and he agreed with her that it was appropriate for Resident #1. The Administrator was notified of Immediate Jeopardy on 7/11/25 at 2:53 PM. The facility provided the following corrective action plan with a compliance date of 6/20/25. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 5/12/2025 Provider was notified by nurse that feeding tube site was noted to have crusting, missing several inches and may need to be changed. Per Providers note on 5/12/2025 feeding tube site was noted to have hyper granulation with some evidence of fungal infection and no erythema or purulent drainage. The provider ordered antifungal cream 2 times a day for 10 days and placed a non-emergent GI consultation to further assess the tube and make evaluations for any future routine changes if needed. The feeding tube was still patent and infusing well. On June 18, 2025, a resident was noted to have maggots in her g-tube during wound care and medication administration. Upon observations of the feeding site on 6/18/2025, it was noted to have leaking around the site; the feeding tube was noted to have broken off several inches and the feeding tube was discolored and brittle. The area was cleaned thoroughly using normal saline and a new peg tube split sponge was applied and secured. The resident also was being treated for a sacral wound, and the facility staff nurse turned her over and visualized and cleaned the sacral wound. No evidence of maggots was found in the sacral wound at that time. The nurse practitioner was notified of the findings, and an order was received to send the resident to the hospital for further evaluation. Facility maintenance assistant performed deep cleaning of the room and pest control service. The facility observed no flies in the facility and no flies were noted in this resident's room. The facility purchased fly swatters and Professional Pest Control Company performed pest control in facility on 6-19-2025. The kitchen door has a blower, which is functioning, and all other doors were observed to be closed securely. The resident was admitted to the hospital with sepsis, gastrostomy tube dysfunction, cellulitis of the abdominal wall, and bacteremia but has since returned to the facility. The hospital replaced the feeding tube and started resident on antibiotics for cellulitis of the abdominal wall and bacteremia. On 6-25-2025 after the resident readmitted from the hospital to the facility, an order was obtained to clean the feeding tube site and change the dressing two times per day. Nurses will inform the Provider of any signs and symptoms of infection, leaking, malfunctioning, or brittleness of the feeding tube. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.All residents have the potential to be affected by deficient practice. On 6/18/25, Assistant Director of nursing and Unit manager audited all residents that have peg tubes and wounds were evaluated to ensure no other residents had evidence of maggots in their wounds. No other residents had maggots or pests in their wounds or peg tubes. On 6/18/2025 the ADON/Designee audited all residents with feeding tubes to assess the integrity of the tube, any leaking, draining, or signs and symptoms of infection around the feeding tube site. No areas of concern were identified. The Assistant Director of Nursing audited all residents' rooms who have feeding tubes and Central Supply to ensure the formula is stored appropriately and no formula was on the floor. No areas of concern were identified. The ADON audited resident rooms who have feeding tubes to ensure the pole was clean and syringes were cleaned and stored appropriately. In addition, pest control services were notified to treat and evaluate any concerns with flies in the facility. They performed pest control services on 6/19/25. No pest issues were noted by the pest control contractor when services were performed. The maintenance assistant inspected 100% of the entire building to ensure there were no issues with pests. No negative findings. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Director of nursing/designee performed competencies on G-Tube management and educated on skin care of feeding tube site to include assessing for erythema, edema, drainage, quantity, odor, patency and integrity of tube and or appearance and to inform Provider of any concerns for f/u related to with 100% licensed nursing staff to include changing assessing site and that tube is patent, dressing changes, monitoring for s/s of infection. Completed 06/18/25. The DON/Designee educated all current certified nursing assistants to notify the nurse of any drainage, odor or abnormality of the feeding tube or site observed during care and to keep open wounds and feeding tube sites covered during care. Completed 6/18/2025 The DON/Designee educated all nursing staff on ensuring any open wounds, surgical sites and feeding tube sites need to be always covered to prevent attracting flies. Completed 6/18/2025.The Administrator educated all staff on ensuring doors are securely closed and not to leave doors open for any reason. Completed 6/18/2025. The administrator educated the Maintenance Director on monitoring the blower over the kitchen door functioning properly weekly. This education was completed on 6/18/2025. Administrator/designee educated 100% of all other departments on how to report pest control concerns/issues. Training included how to report pest sightings and timeliness of reporting. Completed on 06/18/25. Administrator/designee educated all housekeeping employees to ensure feeding tube poles were clean and floors in resident's rooms with feedings were free from formula on the floor and to clean up any area identified immediately. Completed 6/18/2025. The facility purchased fly swatters for each unit in the facility on 6/18/2025. Administrator/designee educated all staff that fly swatters are available on each unit and they are expected to eliminate flies when they are observed and promptly notify maintenance for pest control follow up. Completed 6/18/2025. Director of nursing/designee educated all employees that were not scheduled to work via phone. Completed on 06/18/25. Director of nursing/designee educated 100% staff to keep entrance doors securely shut, to empty soiled linen and trash barrels promptly. Completed 06/18/25. Director of nursing/designee will complete education to employees that are on vacation prior to returning to work. Director of nursing/designee will educate all new hire employees during on boarding/orientation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Include dates when corrective action will be completed. The Administrator and Director of Nursing discussed the Resident #1 incident regarding feeding tube on 6/18/2025 and determined to have ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 6/19/2025 with the Interdisciplinary team to discuss the incident with Resident #1 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director Designee was notified by the Administrator via phone on 6/18/2025 regarding Resident #1's feeding tube incident and what interventions that were put in place for Resident #1 and the plan of correction to prevent abuse. The Director of Nursing implemented the plan of correction to prevent abuse on 6/19/2025. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. If noncompliance is identified during these three months, immediate correction, reeducation of staff members and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. Director of Nursing/designee will complete audits of 5 resident rooms 5 times a week x12 weeks to ensure no pest sightings. This audit will include observations of wounds, surgical sites, lacerations and peg tubes to include ensuring the integrity of the tube is not compromised and the site has no signs/symptoms of infection, leakage, discoloration or brittleness and to ensure free of maggots. The Director of Nursing/Designee will audit rooms formula is stored and resident's rooms with feeding tubes to ensure formula is stored appropriately, poles and floor are clean, and syringes are cleaned and stored appropriately 5 times per week X 12 weeks. Director of nursing/designee will audit nursing units daily to ensure trash/linen barrels are emptied promptly 5 times a week x12 weeks. Administrator/designee will audit two common areas 3 times a week for 12 weeks to ensure doors are closed securely and no pest sightings. The results of the audit will be reported monthly in QAPI x 3 months by the Director of Nursing. Alleged date of IJ removal: 6/20/25 On 7/16/25, the facility's corrective action plan was validated. Resident #1 was observed to be in a semi-private room and 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 throughout the facility. Staff interviews confirmed education was received and included information on G-tube care; including proper care and maintenance, verifying tube feedings are running as ordered, tubes are flushed and patent, and G-tube sites are cleaned with appropriate dressing applied per order. NAs should notify nurses of any abnormalities such as leakage, discoloration, and/or odor. Ensure proper skin care and assessment of feeding tube sites, including monitoring for redness, edema, drainage (quantity & odor),[TRUNCATED]