**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff, Emergency Department Physician's Assistant, Outpatient Clinic Nurse, Dialysis Nurse Manager, and Medical Director interviews, the facility failed to control the presence of flies in the facility resulting in a maggot infestation of a resident's wound for 1 of 6 residents (Resident #263) reviewed for wound care. On 7/30/22 Resident #263's left lower leg wound was infested with maggots. She presented to the emergency department with approximately 60-65 maggots in her left lower extremity wound. The findings include: Resident #263 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (receiving dialysis 3 times weekly), cellulitis (skin infection) of the left lower extremity, diabetes, and peripheral vascular disease (reduced blow flow to limbs). A progress note dated 7/11/22 at 12:35 pm written by Nurse #3 revealed Resident #263 was transported to the emergency department for evaluation of altered mental status. A review of the Pest Control Logs indicated the Pest Control Company visited the facility on 7/18/22. All fly traps in resident hallways were checked. No abnormal findings were noted during the service call. A progress note dated 7/20/22 at 5:40 pm written by the facility's Corporate Nurse Consultant revealed Resident #263 was admitted back to the facility with an order for a cardiology appointment on 7/29/22. A Physician's order dated for 7/20/22 revealed an order to cleanse left lower extremity with an antiseptic cleaner, pat dry, apply a petroleum-based dressing to wound bed, and wrap with rolled dressing daily. The 5-day Minimum Data Set (MDS) assessment dated for 7/27/22 indicated Resident #263 was moderately impaired for cognition and required extensive assistance from 1-2 facility staff members to complete activities of daily living. The Resident was coded as receiving dialysis during the MDS assessment period. She was also coded as being diagnosed with venous ulcers (open areas on skin due to abnormal vein function). Resident #263's July 2022 Medication Administration Record revealed the wound dressing treatment for the left lower extremity was signed off by the Resident's assigned nurse once daily as ordered by the Physician from 7/20/22-7/30/22. An interview was completed on 8/24/22 at 3:00 pm with Nurse #4. She indicated she was assigned to Resident #263 on dayshift on 7/28/22. The Nurse stated she provided wound care as prescribed to the Resident's left lower extremity. She revealed she did not observe maggots in the wound during the dressing change. Nurse #4 revealed she did observe 2 flies in Resident #263's room. The Nurse stated she did not observe them in the room during the dressing change. She stated she made the Assistance Maintenance Director aware of the discovery after observing the flies. The Nurse stated he visited the room and used a fly swatter to get rid of them. An interview was completed on 8/24/22 at 3:06 pm with the Assistant Maintenance Director. He indicated he recalled a Nurse (Nurse #4) notifying him of flies in a resident's room around the week of 7/28/22. The Assistant Maintenance Director stated he went to the resident's room and used a fly swatter to rid the room of flies. He was unable to recall what room it was in. He further stated if there had been an abundance of flies, the facility would have had contacted pest control immediately to come into spray. An interview was completed on 8/22/22 at 11:05 am with Nurse #1. She revealed the nurses assigned to Resident #263 completed the Resident's daily wound dressing treatments because the facility did not have a Wound Treatment Nurse. Nurse #1 stated she completed the Resident's scheduled wound dressing treatment on 7/29/22 during the day shift. The Nurse revealed she did not observe maggots in the Resident's wound during the dressing change. She indicated the previous wound dressing was always intact and never loose prior to removing it to apply a new dressing. She further stated the wound bed contained dark colored tissue with minimal amount of drainage. She indicated she did not observe any flies in the room during the Resident's dressing change. Nurse #1 stated it took her approximately 10 minutes to complete the dressing change to Resident #263's left lower extremity. Nurse #1 stated when she provided wound care to the Resident, she had all supplies needed in the Resident's room, and closed the door during the dressing change. She indicated she observed the Resident's room prior to starting wound dressing changes for flies. The Nurse further stated Resident #263 only left her room to attend appointments or go to dialysis. Nurse #1 revealed the facility provided fly swatters at the nurse's station if needed. An interview was completed on 8/22/22 at 2:28 pm with Nurse #6. The Nurse indicated she was assigned to provide care to Resident #263 during nightshift beginning on 7/29/22 and ending in the morning on 7/30/22. She revealed when she prepared the Resident for transport to dialysis on the morning of 7/30/22 Resident #263's left lower extremity dressing was dry, intact, and secure prior to her leaving the facility. Nurse #6 indicated she did not observe flies in the Resident's room during her shift. She revealed the facility has fly swatters available throughout the facility to use if 1-2 flies are observed. Nurse #6 stated if an increase in flies were observed she notified the Administrator and placed the location in the Pest Control Company's logbook (binder located at each Nurse's station the Pest Control Technician checks each visit for any insect/pest activity). A progress note dated 7/29/22 at 4:04 pm written by Nurse #1 indicated the Resident was out of the facility at a Vascular appointment. An interview was completed on 8/23/22 at 9:30 am with a Nurse from a Heart and Vascular Care outpatient clinic. She indicated Resident #263 had an appointment on 7/29/22. The Nurse further revealed the Resident was being seen for a cardiology appointment. She stated Resident #263's wound was not visualized by the Physician. A progress note on 7/30/22 at 1:07 pm written by Nurse #3 revealed while prescribed wound dressing treatment was being provided larva (immature form of insect) was observed. The Physician was notified and advised the Nurse to call emergency medical services and send Resident #263 to the emergency department for evaluation and treatment. An interview was completed on 8/23/22 at 11:11 am with Nurse #3. She indicated she was assigned to provide care to Resident #263 during dayshift on 7/30/22. She stated after Resident #263 returned from dialysis; she went in to change her dressing. Nurse #3 indicated the previous wound dressing to the left lower extremity was dry, intact, and secure and stated when she removed the dressing, she observed 2-3 maggots in the wound bed. The Nurse revealed she cleaned the wound, provided the prescribed wound treatment, and contacted the Physician to make him aware of the Resident's change in condition. The Nurse stated the Physician gave her an order to send the Resident to the emergency department for evaluation and treatment. Nurse #3 indicated she had not observed flies in the Resident's room during her shift. A review of Resident #263's emergency room record revealed a progress note dated 7/30/22 indicating maggot infestation present to her left lower extremity wound. Resident #263 was treated at the hospital for an infection of the left lower extremity wound with intravenous fluids and antibiotics. An interview was completed on 8/22/22 at 7:30 pm with the admitting Physician Assistant (PA) at the emergency department. The PA indicated Resident #263 arrived at the emergency department with her bilateral wounds covered with dry, intact dressings. He stated when the dressings were removed 60-65 maggots were observed in the left lower extremity wound. The PA stated the maggots were removed, the wound was cleaned, and a wound dressing was applied. He indicated maggots invading a wound had the potential to cause an infection. A review of the Pest Control Logs indicated the Pest Control Company visited the facility on 8/1/22. The log indicated a fly spray was applied to all entrance/exit doorways and facility hallways. No sanitation issues or pest control concerns were noted during the visit. An interview was completed on 8/23/22 at 2:16 pm with the Administrator. She indicated the pest control company was contacted the next business day to visit to spray for flies. She stated the company visited on 8/1/22 and sprayed all entrance/exit doorways and facility hallways. The Administrator revealed the Pest Control company last visited on 7/18/22. The technician checked all fly traps in resident hallways. No abnormal findings were noted during the service call. She further indicated the pest control company was contracted to visit the facility monthly to spray for pests. The Administrator stated the facility hallways have fly lights located on all the hallways that attract and trap flies and fly swatters for immediate use. She indicated the facility management staff were assigned resident rooms and complete daily morning room rounds. The Administrator stated staff had been educated to immediately notify maintenance and herself of any increase in fly activity. She revealed these rounds consist of checking for insects and any items that would attract insects. The Administrator stated the findings from the room rounds were discussed during the facility's morning meeting and any concerns were handled immediately. An interview was completed on 8/23/22 at 4:47 pm with the Medical Director. He indicated Resident #263 was admitted to the facility with cellulitis (skin infection) in her left lower extremity and bilateral lower extremity venous ulcers. The Medical Director stated the left lower extremity wound had an odor and he felt this and the multiple trips the Resident made to dialysis, a fly may have been attracted to the dressing and flown under it. He further stated the Resident was diagnosed with venous and arterial insufficiency that had impeded the healing of the wound. The Medical Director indicated he felt the facility had provided proper wound care and had notified him of all changes in the wound and in the Resident's health. An interview was completed on 8/24/22 at 9:20 am with Nurse #5. She indicated she had observed Resident #263's dressing to her left lower extremity appeared loose once after receiving a dialysis treatment, but she stated it was not recently and was unable to recall the dates. Nurse #5 stated she had never observed the wound being exposed when she returned from dialysis. The Nurse continued to state she reinforced the dressing if she was able or removed the loose dressing and applied a new one. The Nurse indicated the Resident did not touch or attempt to remove her dressing. Nurse #5 stated she had never observed flies in Resident #263's room. An interview was completed on 8/22/22 at 4:28 pm with the Dialysis Nurse Manager. The Nurse indicated she had been able to observe the dressings to Resident #263's bilateral lower extremities during her dialysis treatments. She indicated the dressings were always dry, intact, and secure. The Nurse further stated due to the dialysis process, the Resident's swelling in her lower extremities lessens and may cause the dressings to loosen. She continued to state the wounds were never exposed during her dialysis treatments and she never observed the dressing to be loose. A review of Resident #263's electronic medical record revealed she resided on the 300 hall during her stay at the facility. An observation was completed on 8/25/22 at 12:05 pm and revealed it was located across from an entrance/exit door. An observation was completed on 8/25/22 at 12:10 pm of the fly fan above the entrance/exit door located across from the room Resident #263 resided. The fan was blowing out. An interview was completed on 8/22/22 at 3:30 pm with Resident #53. He indicated there were 2-3 days in the last month that 1-2 flies were in his room. He stated he did not notify staff because he felt it was not a problem. An interview was completed on 8/23/22 at 8:39 am with Resident #44. She stated she had 1-2 flies in her room in the last 1-2 months. The Resident indicated facility staff had a fly swatter to get rid of the fly. An observation was completed on 8/24/22 at 9:30 am of a fly flying out of room [ROOM NUMBER]. A second fly was also observed flying in the Resident hallway. A facility staff member was observed going to get a fly swatter to attend to the fly. An observation was completed on 8/25/22 at 1:40 pm of a fly swatter located at the 200 hall nurse's station and 300 hall nurse's station. During an interview on 8/24/22 at 3:06 pm with the Assistant Maintenance Director. The Assistant Maintenance Director stated the flies entered the facility through the entrance/exit doors. He indicated fly lights were located on all facility hallways and fly fans were placed above entrance/exit doors. The Assistant Maintenance Director revealed the Pest Control company visited monthly to inspect the fans and lights. He stated fly swatters were located throughout the facility for staff to use when needed. An interview was completed on 8/24/22 at 4:25 pm with the Regional Plant Operations Manager. He indicated fly lights were located on each resident hallway. He further stated pest control checks the traps when they visit monthly to determine if any additional spaying for insects needed to be performed during that visit. The Administrator was notified of Immediate Jeopardy on 8/24/22 at 8:44 am. The facility provided the following corrective action plan with a completion date of 8/3/22. On 7/30/22, Resident noted with foreign matter to the left leg wound bed that appeared to possibly be maggots. Resident had a cardiology appointment on 7/29/22 that she was transported to and from. Resident returned to the facility after the appointment with a progress note related to the visit with no documentation of any maggots being found during the examination. The Resident also goes out for dialysis treatments three days per week. Element 1 - (Resident(s) Affected) - On 07/30/22 this Resident had left lower extremity wound cleansed per Licensed Nurse, MD notified of findings and ordered resident to be examined at hospital. Resident was sent to the hospital as ordered on 07/30/22. The resident did not return to this facility. Element 2 - (Other Residents who could have been affected) a) On 07/30/22 current facility residents received a skin check and residents with skin integrity issues were assessed by licensed staff to visibly observe for any presence of foreign matter present to the impaired skin integrity areas. No concerns were identified. On 07/31/22 and again on 08/01/22 current facility residents received an additional skin check and residents with skin integrity issues were assessed by licensed staff to visibly observe for any presence of foreign matter present to the impaired skin integrity areas. No concerns were identified. b) On 07/30/22 the provision of treatments was validated through direct observation, by licensed staff for the current resident population who had skin integrity issues had treatment completed and ordered dressings intact. No concerns were identified. This was observations validated by the Director of Nursing, Assistant Director of Nursing, and the Unit Manager. Element 3 - (Action the entity will take to alter the process or system) a) Pest Control arrived at the facility per request of the facility Administrator for additional prophylactic treatment on 8/1/22. Pest Control did not find any pest activity during the onsite visit on 8/1/22. They also documented there were no sanitation issues that could cause pest control issues. Pest Control comes to the facility monthly for pest control inspection and treatment that is for flies and other insects and or pests. b) Education was provided to full-time, part time, agency, and as needed staff on 07/30/22 regarding the following: If anyone notices an abundance / increase (such as droppings, infestations, swarms) of insects, flies, gnats will notify maintenance and place in the pest control book and make the Administrator aware. Also, education was provided to full-time, part time, agency, and as needed staff regarding ensuring all foods are closed in containers or in plastic bags and education was provide on the origin of where maggots come from (flies laying eggs) and that it only takes one fly to cause maggots in a wound. This education was provided by the Director of Nursing, the Assistant Director of Nursing, and the Unit Manager. The pest control book is a book located on nursing station one that staff are to log information on any increased pest activity. The staff will log the pest, location, time, and person reporting. The pest control service looks at this book at each visit. Air curtains were already in place at the facility along with fly lights and fly traps. Element 4 - (Quality Assurance and Performance Improvement) a) Ad Hoc QAPI completed with Medical Director and the facility Administrator, Director of Nursing, and the Unit Manager on 08/01/22. b) Administrator reviewed audits of skin checks that were done on 07/30/22, 07/31/22, and 08/01/22. No concerns identified. c) The QAPI team, during monthly QAPI meetings, will discuss any concerns that arise related to (r/t) any maggots being observed or found in the facility and any pest control issues observed or voiced. d) All staff are alert for monitoring fly presence and will utilize the pest control book and notify the Administrator if any concerns are noted with fly presence. e) Pest Control comes to the facility monthly. During the monthly pest control visits the pest control service provides the following services r/t flies: observes and changes out the fly lights, observes and changes out glue boards, monitors for any increased sign of flies. The facility Administrator is responsible for implementing this plan. Alleged Date of compliance: 08/03/22 Onsite validation was completed on 8/25/22 through staff interviews, observations, and record reviews. Inservice was confirmed to be provided on identification of flies and areas of concern that would attract flies and notification process. Staff were interviewed to validate the in-service was completed on insect control. Review of education conducted with Nurse #7 regarding steps to take if an increase in flies were observed and what were areas in the facility that may attract flies was completed. Skin checks of residents on 7/30/22, 7/31/22, 8/1/22 were reviewed with no concerns noted. A review of the wound treatment audit completed on 7/30/22 revealed no concerns. An interview was completed on 8/25/22 at 10: 30 am with Nurse #8. She indicated if she observed a fly in a resident's room, she would use attempt to use a fly swatter to get rid of the fly, notify the maintenance department, and the Administrator. An interview was completed on 8/25/22 at 2:10 pm with Nursing Assistant #1. She stated the facility had fly swatters available for use. NA #1 indicated if she observed flies in the facility, she would immediately let the Administrator and the maintenance department know and write the location of the flies in the pest control logbook. An observation was completed on 8/25/22 at 3:00 pm of hallway 300. Fly lights were located on hallway and in working order. An observation was completed on 8/25/22 at 3:10 pm of hall 100's entrance/exit door. A fly fan was observed attached above the door and blowing out. An observation was completed on 8/25/22 at 3:15 pm of the Pest Control Logbook located at the 100 hall nurse's station. An interview was completed on 8/25/22 at 4:08 pm with Nurse #7. She indicated if she observed flies in a resident's room, she would immediately contact the maintenance department. Nurse #7 stated she would then attempt to locate the source that was attracting the flies (open food, drink) and attempt to remove it. The Nurse stated fly swatters were available for use to immediately get rid of the flies. Nurse #7 stated prior to completing a wound dressing change she would observe the room for flies and get rid of them if some were observed. The Nurse also stated she always closed the door during wound dressing changes. The facility's corrective action plan was validated to be completed as of 8/3/22.