**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of the facility water management plan and maintenance logs, review of legionella water test results, review of the Centers for Disease Control and Prevention (CDC) guidance related to legionella, review of infection control tracking, and interviews with staff and representative from the Local Health Department (LHD), the facility failed to develop, implement and follow a comprehensive and effective infection control program/water management plan to prevent the continued presence of legionella bacteria in their water supply. Upon identification of elevated legionella levels, the facility failed to re-evaluate or update their water management risk assessment and water management plan or provide effective intervention to mitigate the risk of legionella growth. The facility also failed to ensure residents did not have access to or use water from areas where legionella could be present. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death beginning on 01/30/25 when second water sample testing results from testing conducted on 01/23/25 by the facility showed an increase in legionella bacteria growth in the facility water system and the facility failed to implement water maintenance interventions to mitigate the risk of legionella and/or as recommended by the local health department (LHD). On 02/05/25 additional water sampling testing was completed with results obtained 02/12/25 which revealed the presence of legionella was considerably increased from the testing done on 01/23/25. The facility's failure to implement and/or revise appropriate water management measures to mitigate the growth of legionella placed all 40 current residents in the facility at risk of developing serious life-threatening illness and/or death from Legionnaire's disease. In addition, concerns that did not rise to the level of Immediate Jeopardy were identified when the facility failed to establish and implement an effective infection surveillance system to track infections and monitor infection trends. Lastly, the facility failed to ensure appropriate infection control techniques were followed when performing wound care for Resident #37 to prevent the spread of infection. This affected 42 of 42 residents, which included one resident, Resident #37 observed for wound care and two residents, Resident #18 and #95 who no longer resided in the facility at the time of the survey. On 03/19/25 at 3:37 P.M., the Administrator, Director of Nursing (DON), Infection Preventionist (IP) #302, and Maintenance Manager #322 were notified that Immediate Jeopardy began on 01/30/25 when the facility received water testing results positive for legionella and failed to take immediate action and implement effective corrective including actions recommended by the LHD to address water testing samples that were positive for legionella growth. Between 01/23/25 and 02/12/25 additional water testing conducted by the facility showed the legionella levels continued to rise with no evidence of effective measures to mitigate the risk for Legionnaire's disease. The lack of comprehensive and effective water management plan and the identification of legionella in the facility water supply placed all residents at risk for developing serious illness and complications, including the potential for death, related to legionella infection/Legionnaire's disease. The Immediate Jeopardy was removed on 03/28/25 when the facility implemented the following corrective actions: o On 03/06/25 an all-staff in-service was completed on risks, signs and symptoms and interventions for legionella by the DON and IP Nurse #302. o On 03/19/25 by 6:30 P.M. water to each sink in all facility rooms was shut off to prevent accidental use by residents and staff. Gallon jugs of purified water were put in place to wash hands with dates and names on each. o Beginning 03/20/25 the DON/designee would audit employee call-offs weekly for the next two weeks, monitoring for any symptoms related to legionella illness. Any concerns would be immediately reported to the Administrator and addressed by the Quality Assessment Performance Improvement (QAPI) committee as necessary. o On 03/21/25 the facility contracted with PT enterprises to assist with the water management plan. PT enterprises came to the facility and took twelve water samples (four swabs and eight additional 250 ml potable water samples). o On 03/21/25 point of use filters for all water sources in the facility were ordered. o On 03/23/25 the DON brought in hot and cold-water dispensers for use on the second and third floors. This water was provided for residents' use for any residents who did not want to drink bottled water and staff were responsible for bringing the water to residents. Additional bottled water was supplied to the fourth floor. o On 03/23/25 the DON educated the weekend staff and agency staff working on-site on not using the room sinks or shower on the second floor, as well as signs and symptoms of legionella. o On 03/24/25 a Legionella assessment data collection form was created in point click care (PCC), which included a set of vital signs, a review of potential symptoms of legionella, a place for a narrative, and a yes or no question as to whether or not the resident experienced more than three symptoms beyond their baseline. All nurses would be educated on this form by 04/09/25. Any nurse not educated by this date would not be allowed to work the floor until the education was completed. Nurses would complete this assessment on resident admission and with resident change of respiratory condition. o On 03/24/25 new legionella filters were received and placed on the main floor bathroom sink, therapy room sink, room [ROOM NUMBER] sink faucet, shower heads on the second, third and forth floors, at the nursing station sinks on the second, third and forth floors and on the dialysis center sinks by Maintenance Manager #322. o On 03/24/25 Legionella tests for six residents who were transferred from the facility for signs and symptoms of respiratory distress were completed. o On 03/25/25 a contracted plumbing company ([NAME] Plumbing) came to the facility to evaluate appropriate adapters to fit on the sink filters. They also evaluated sanitation. The water remained off to the room sinks at this time. *On 03/26/25 the DON/designee completed resident assessments (legionella assessment data collection form) for all facility residents. The resident assessments would continue to be conducted weekly by the DON/designee and/or Infection Preventionist for three weeks beginning 03/31/25. Any concerns would be immediately reported to the Administrator and Medical Director for follow-up o On 03/27/25 the facility Water Management Committee, including the Administrator, DON, IP #302, Maintenance Manager #322, Housekeeping/Laundry Supervisor, RT Director and Dietary Manager met to further discuss the facility's Water management -Legionella plan. o On 03/27/25 the facility QAPI committee met to review any updates to the water management plan and complete audits. The facility new water management protocols initiated on 03/27/25 included: a.) Each faucet and shower head aerator would be cleaned with an approved scale and lime build-up cleaner semi-annually to ensure proper water flow quarterly beginning in June 2025. b.) Beginning 03/28/25 the hot water boilers would be set at 140° or greater, differing from previous plans where they were set at 135 degrees. Facility staff would record the temperature of each hot water device weekly and adjust immediately if less than 140°. To ensure compliance to policy, staff would retest the following day to confirm appropriate temperature. c.) Hot water holding tanks would be set at a minimum of 140° versus previous 135°F to inhibit the growth of Legionella and other opportunistic pathogens. Facility staff would record the temperature weekly and adjust immediately if less than 140° to ensure compliance. d.) Beginning 03/27/25 regular cleaning and changing of filters would be done per manufacturers' recommendations. The facility would remove scale and clean using approved cleaning agents semi- annually and changing the filters every six months or per manufacturer recommendations. Maintenance Manager #322 would audit monthly to ensure compliance and audits will be reviewed in QAPI meetings. e.) Beginning 03/28/25 weekly flushing of water would be added to housekeepers assignments to be completed Monday or Tuesday each week which would consist of flushing for three minutes each faucet and showers also flush all toilets at least once every week. The supervisor would review documentation weekly to ensure compliance. Audits would be reviewed, and the facility would determine where the failure occurs during QAPI meetings. f.) If the facility experiences one or more positive cases of legionellosis, the facility would conduct semi-annual testing to determine if the water management plan (WMP) was effective in controlling legionella and the Maintenance Manager #322 will follow up with the vendor to determine failure to conduct and correct this. g.) Beginning on 03/27/25 for any positive legionella in the water, the facility would contact PT enterprises, to conduct testing on water samples, provide alternate water sources for bathing and patient care, inspect all faucets for built-up scaling and cleaning with appropriate cleaner and replace all filters on incoming water sources. h.) Legionella filters would be changed per manufacturers' recommendations beginning on 06/01/25. On 03/30/25 the facility received ordered parts which were being installed with a plan to have all installation of parts/filters completed by 04/01/25. Interviews on 04/01/25 between 11:46 A.M. and 12:15 P.M. with Licensed Practical Nurse (LPN) #353, Respiratory Therapist (RT) #330, Certified Nurse Aide (CNA) #368, CNA #335, LPN #352, and LPN #301 confirmed they had received instruction not to use any sinks or other running water unless the faucet had a new filter in place (which was visible to the observer) and that water remained turned off to sinks on the fourth floor and some unoccupied rooms on the second floor where filters were not yet applied. During these staff interviews, each confirmed they had received education on risks of legionella in the water and signs and symptoms of legionella related infection. Although the Immediate Jeopardy was removed on 03/28/25, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the facility LEGIONELLA ENVIRONMENTAL ASSESSMENT FORM revealed the facility water risk assessment was last completed on 05/16/23. The risk assessment revealed the facility had encountered a prolonged period of reduced occupancy on the second floor and toilets were flushed and faucets were run during that unspecified timeframe. Review of the assessment revealed the facility tested for legionella but did not include summaries, acceptable control levels, or legionella response policy or procedures. The risk assessment revealed the facility did not use water filters or thermostatic mixing valves. The risk assessment further revealed the facility used Salem City Municipal Water and did not ever measure disinfectant levels at the point of use. The facility maintenance activities were to include routine running water and flushing toilets in unused areas of the building and checking hot water temperatures on all floors. Review of the facility Water Management Template revealed the water management team (WMT) consisted of the Administrator, the DON, Maintenance Manager #322, IP #320, Dietary Manager #312, Housekeeping Manager #320, and Director of Respiratory #311. The WMT was responsible for overseeing implementation of the water risk management. Review of a facility Microbiology Analysis Report from Cardinal Environmental Laboratories, LLC dated 01/15/25 revealed the water sampled from the facility on 01/08/25 identified legionella test results were 7.97 most probable number (MPN) per milliliter (ml). There was only one testing location, one test sample from the dialysis den. Review of a facility Microbiology Analysis Report from Cardinal Environmental Laboratories, LLC dated 01/30/25 revealed the water sampled from the facility on 01/23/25 identified legionella tests results were 13.4 MPN/ml. There was only one testing location, one test sample from the dialysis den. This result was noted to be higher than the result of the water sampled on 01/08/25. The facility failed to provide evidence of additional investigation as to why the levels were this high or evidence of interventions to mitigate the presence of legionella at this time. Review of a facility Microbiology Analysis Report from Cardinal Environmental Laboratories, LLC dated 02/12/25 revealed the water sampled from the facility on 02/05/25 identified legionella tests results were 121 MPN/ml, a considerable increase from the test results received on 01/30/25. There was only one testing location, one test sample from dialysis den. The facility failed to provide evidence of additional investigation as to why the levels were this high or evidence of interventions to mitigate the presence of legionella at this time. Review of the Circle of Care Water Management Program policy (last updated 01/08/24) revealed the facility was to revise and update their legionella risk assessment annually and as needed. The policy further revealed their water management practices were to include documentation of the following: - Weekly hot water temperatures and as needed - Weekly temperatures of the hot water tanks - Weekly cold-water temperatures - Running water and flushing toilets in resident areas where low water use has occurred (frequency unspecified) - Routine maintenance of the ice machine, unoccupied resident rooms, whirlpool hot tubs, shower head, and shower hoses (frequency unspecified) - Plumbing and fixtures throughout the facility due to the age of the building The policy itself was not updated to reflect changes in the facility's floor plan. Review of the weekly Water Maintenance Monitoring logs revealed documentation of weekly room hot and cold-water temperature monitoring and hot water tank temperature monitoring. There were no logs indicating routine maintenance or cleaning of showers, whirlpools, tubs, shower hoses, or flushing and running water in unoccupied resident rooms. Interview on 03/17/25 from 3:55 P.M. to 4:15 P.M. with Maintenance Manager #322 revealed the facility's routine water maintenance included checking the hot water tank temperatures and the hot and cold-water temperatures weekly on each floor, with the Weekly Resident Room Temperature Monitoring Log only containing four slots per week to document water temperatures. A follow-up interview on 03/18/25 at 8:25 A.M. with Maintenance Manager #322 confirmed the facility water management did not include use of any disinfectant, sanitizer, or regular descaling or cleaning of the whirlpool tubs or shower heads on the second, third, and fourth floors, and the facility did not keep a log noting all unoccupied rooms were maintained according to their water management plan. No evidence was provided that any residents were assessed for symptoms of Legionnaires' Disease between 01/30/25 and 03/18/25. This included assessment and/or testing for two residents, Resident #95 and #18 who had respiratory symptoms/hospitalization during this time period. In addition to all facility residents being at risk for complications associated with legionella, the facility identified 11 residents with tracheostomies and/or ventilators, Resident #3, #7, #26, #27, #34, #36, #37, #42, #94, #95, #96 and five residents who received on-site hemodialysis, Resident #26, #31, #34, #95 and #145. On 03/18/25 at 1:21 P.M. interview with the LHD Environmental Health Director (EHD #356) revealed he was made aware of legionella growth in the facility water supply on 01/22/25 during a visit to the facility for another reason. EHD #356 revealed he provided verbal direction to facility management when on-site on 01/22/25 and 02/06/25 in response to the legionella which included super-heating the water, which he described as turning the water up to a minimum of 175 degrees Fahrenheit (°F ) over night, draining the water system, flushing, and sanitizing the water. EHD #356 further revealed it was his belief the facility had sanitized their water and installed point of use filters before residents began using the water for bathing. During this interview, EHD #356 confirmed there was a risk at the sink if residents were using their room sinks to brush their teeth and the filters were not placed at the point of use. EDH #356 further stated the facility wanted to run their own legionella water tests and attempt to work on the issue on their own for the first few weeks, but the levels kept climbing, reaching 121 MPN/ml. On 03/07/25, EDH #356 contacted Maintenance Manager #322 and arranged to come to the facility to perform their own water sampling for legionella testing (taken from two sites on 03/10/25, one near the holding tanks and one from the fourth-floor dialysis den). Interview on 03/18/25 from 2:30 P.M to 2:36 P.M. with Resident #28 revealed he used the sink in his bedroom for washing his hands and brushing his teeth. During the interview, he pointed out the toothbrush and tube of toothpaste sitting on the sink, next to the hot water knob. Further interview with Resident #28 revealed he was told he could not shower for a week or two about a month ago, then started using the shower room thereafter (he was uncertain of exact dates). The resident was then instructed on 03/17/25 that residents were no longer able to use the second-floor shower but could use the shower on the third floor and then on 03/18/25 he stated he was told he could start using the second-floor shower room again. Resident #28 confirmed he showered in the second-floor shower room on Friday, 03/14/25, before being informed residents were not supposed to shower on the second floor. Interview on 03/18/25 at 2:40 P.M with Resident #17 revealed he had been using the sink in his room to wash his hands, brush his teeth, and shave. Interview on 03/18/25 at 3:10 P.M. with IP #302 and the DON confirmed residents were not to be using the sinks in their rooms to brush their teeth and were not to shower in the second-floor shower room. Both the DON and IP #302 confirmed the second-floor shower door was not locked and there were no signs or other visual cues reminding residents not to use their sinks or the second-floor shower room. During the interview, IP #302 stated she spoke with a nurse at the health department and the local health department nurse did not recommend testing residents for legionella if they were asymptomatic, stating they were told the residents would present as unstable if they did have an infection caused by legionella. On 03/18/25 at 3:35 P.M., interview with Maintenance Manager #322 confirmed the facility flushing process did not involve completely emptying the entire system and filters were not applied to the faucets in any sinks, including those in resident rooms, or the second-floor shower room. Maintenance Manager #322 also confirmed the increase of legionella growth from 7.97 MPN/ml from the water sample taken on 01/08/25 to 13.4 MPN/ml from the water sample taken on 01/23/25 to 121 MPN/ml from the water sample taken on 02/05/25. He was unable to provide any additional steps the facility took to mitigate the risk of legionella after the last test result came back, except for placing a shower head filter on the third and the fourth-floor showers. However, it was identified the facility water supply was on an open loop and water moved throughout the whole building and not just to designated areas. Interview on 03/19/25 3:45 P.M. with the Administrator, the DON, and IP #302 revealed they were unaware the legionella test results from water sampled on 02/05/25 rose to 121 MPN/ml. Interview on 03/19/25 at 4:28 P.M. with Medical Director #369 revealed his understanding of the facility's legionella issue was that their water tested positive for legionella and the facility shut off the water, had the local health department (LHD) come to the facility, and the numbers were trending down to a more appropriate level. Medical Director #369 denied knowledge the LHD ruled out that legionella came from outside the facility or that the legionella growth counts in the facility water had increased to 121 MPN/ml by 02/05/25 with no further available test results since. During the interview, the Medical Director expressed concern that the facility resident population was high risk for legionella related disease and complication due to their acuity level and comorbidities. On 03/19/25 at 4:40 P.M., interview with the DON revealed the facility just discontinued use of the ice machine because the filter in the ice machine did not specify it was approved for legionella. On 03/20/25 at 4:10 P.M., interview with the Maintenance Manager #322 confirmed the water was turned off to all sinks in the building on 03/19/25 by 6:03 P.M. and the ice machine was not in use because it did not have a filter appropriate for water with legionella. On 03/24/25 at 9:00 A.M. a telephone interview with Lab Manager #370 from Cardinal Environmental Laboratories revealed the laboratory runs water screening tests for legionella using 200 test tubes to find the most probable number (MPN) versus colony-forming units (CFU). He further confirmed 121 MPN/ml far exceeds the allowable from the CDC and that corrective action should be taken by any facility with a positive number, especially if results were greater than 10 MPN/ml and if they housed the elderly or residents who may be immunocompromised. He stated the difference in the tests is the CFUs measured the number of colonies and the MPN could mean there was one colony or numerous colonies for each measured number. Interview on 03/24/25 at 10:20 A.M. with the Administrator and Maintenance Manager #322 revealed a shower filter from the third floor was placed on the second-floor showerhead on the evening of 03/18/25. Both stated the facility had ordered two shower heads with filters in them and two additional filters, allowing a filter from one of two shower heads on the third floor to be taken to the second floor. Neither was able to provide proof that more than two shower heads and/or filters were ever ordered. Interview on 03/25/25 at 3:05 P.M. with the DON confirmed the facility had not begun screening residents for signs and symptoms of legionella when the legionella count initially started to increase and did not complete legionella screening on all residents on 03/24/25. Review of the assessments titled Legionella Signs and Symptoms for Potential Exposure - V 2 revealed the legionella screening assessments were completed on all residents who were in the facility on 03/24/25, except Residents #11, #20, #31, and #144. Additionally, no assessment was found for Resident #29 who was in the hospital on [DATE] but returned to the facility on [DATE]. Interview on 03/24/25 at 8:58 A.M. with the LHD DON #371 revealed the facility reached out to her on 02/04/25 to inquire about testing residents who were ventilator dependent for legionella since they had some legionella growth in their water. LHD DON #371 stated she reached out to the Ohio Department of Health (ODH) Infectious Disease (ID) nurse, who returned her call on 02/05/25. Further interview with LHD DON #371 confirmed she spoke with the facility on 02/05/25 and let them know that the ODH ID nurse stated that residents with legionella would present with symptoms beyond baseline. During the interview, LHD DON #371 confirmed she instructed the facility to contact her of any residents that had symptoms that were outside of their baseline, and they would discuss testing at that time. During the interview, LHD DON #371 confirmed the facility had not informed her of any residents with any respiratory symptoms or any ventilator residents with assessments outside of their norm. A follow-up phone interview with LHD EHD #367 on 03/26/25 at 9:15 A.M revealed it was his understanding the facility had already contracted Eco Labs to assist with disinfecting the water and that they were placing appropriate filters made specifically for legionella on all the faucets and showers when he met with the DON, IP #302, and Maintenance Manager #322 in early February 2025. During the interview, EHD #367 reiterated he was unaware the facility had not installed point of use filters or proceeded with the water disinfection evaluation process at that time. Interview on 03/26/25 at 4:35 P.M. with the DON confirmed the Legionella Signs and Symptoms for Potential Exposure - V 2 form had a prompt to indicate whether the resident had three symptoms that varied from their baseline. The DON stated she utilized the CMS website guidance to determine that three symptoms listed on the legionella screening questionnaire would indicate a need to test for legionella. Review of the CDC guidance titled What Clinicians Need to Know about Legionnaires' Disease revealed no direction related to the requirement of three symptoms before testing for Legionnaires' Disease but did indicate people at risk for healthcare associated pneumonia and who may have other risk factors should be considered for testing when there is a potential concern related to legionella. Interview on 03/26/25 at 5:41P.M. with the DON verified the legionella assessments for five residents who were currently in the facility (Resident #11, #20, #29, #31, and #144) were not completed. The DON added Resident #29 had just returned from the hospital on [DATE] so she wasn't in the facility when these assessments were completed Monday 03/24/25. Interview on 03/31/25 at 11:27 A.M. with Maintenance Manager #322 confirmed the facility had not yet received all the point of use filters but had installed all the filters on the second and third floor room sinks but were waiting for adapters to install the last eight or nine filters on room sinks on the fourth floor. He further revealed the water to those sinks were turned on, but staff and residents were not yet informed they were allowed to use their sinks because he was waiting for all the filters to be installed before notification was made. Regarding the main water breaks that had occurred, Maintenance Manager #322 revealed there was one on the street where the facility was located about a month ago around 02/12/25, after the facility's water initially tested positive for legionella, but was not positive about the date. Interview on 03/31/25 at 3:04 P.M with a representative from the City of Salem Water Department confirmed there was a waterline break near the facility was on 02/05/25. No other water line breaks were reported near the facility. Note- the water line break on 02/05/25 corresponds to the high level of legionella (121 MPN) noted in the facility's water samples taken on that same date. Review of Maintenance Manager #322's notes from 01/08/25 to 03/11/25 revealed he super-heated the water in the facility on 01/22/25 from 1:00 P.M. to 4:30 P.M. by turning the water heater up to 160 °F before flushing the water throughout the building. The notes also revealed the water was super-heated to 150 °F on 02/03/25 for three hours before flushing. On 01/23/25, 01/24/25, 01/27/25, 01/28/25, 01/29/25, 01/30/25, and 02/04/24, the water heaters were turned up to 135 °F and all faucets were run for 10 minutes. On 02/06/25, 02/07/25, 02/10/25, 02/11/25, 02/12/25, 02/14/25, 02/17/25, 02/18/25, 02/19/25, 02/21/25, 02/24/25, 02/26/25, 02/28/25, and 03/04/25 the water heaters were turned up to 130 °F and all faucets were run for 10 minutes. Further review of these notes revealed the filters were changed and clean. There was no reference as to what filters were changed or how they were cleaned. Review of the facility New Water Management Plan (WMP) dated March 2025 revealed the facility had 62 certified beds and three shower heads. In addition, on 03/27/25 review of the WMP dated as revised March 2025 revealed the plan failed to contain a component that specifically addressed what immediate action steps the facility would implement with a water test sample that was positive for legionella. An interview on 03/27/25 at 9:15 A.M. with the Administrator revealed the new water management plan had not yet been reviewed or implemented by the facility and the water management team would be meeting at a yet to be determined time to discuss the new plan. She also confirmed the new WMP contained some misinformation, including the facility certified bed capacity was 55, not 62 and that aside from three stationary shower heads, the facility also used two additional hand-held shower wands for bathing purposes. Review of an addendum to the facility's March 2025 WMP revealed additional direction in an addendum dated 04/01/25 that if the facility should test positive for legionella in their water in the future, the facility would contact PT Enterprises, a company the facility contracted with for water management support, to conduct additional water sampling and testing, provide alternate water sources for bathing and resident care, inspect all water outlets for built-up scaling, cleaning with appropriate cleaners, and replacement of all filters on incoming water sources. Review of the Centers for Disease Control (CDC) website (https://wwwn.cdc.gov/elite/Public/EliteHome.aspx ) revealed laboratories can test their Legionella isolation techniques against standardized samples through the Environmental Legionella Isolation Techniques Evaluation Program. Participating labs receive a panel of lyophilized test samples each year from the Wisconsin Sate Laboratory of Hygiene. Some of the test samples are Legionella positive and some are Legionella negative. The test samples may also include other organisms commonly found in water. Participating labs process the test samples and report their results. The labs that correctly identify Legionella in two consecutive panels receive documentation for passing the proficiency test. Review of the Centers for Disease Control (CDC) Environmental Legionella Isolation Techniques Evaluation (ELITE) Program revealed Cardinal Environmental Laboratories, LLC was not a member of CDC's ELITE program. Review of the Centers for Disease Control and Prevention (CDC) website direction on legionella control measures at https://www.cdc.gov/investigate-legionella/php/healthcare-resources/control-measures.html revealed healthcare facilities should avoid use of water from sinks or tub faucets in resident rooms, restrict showers, and limit use of non-sterile ice from ice machines for anyone at risk for aspiration or who have swallowing difficulties. 2. Review of the closed medical record for Resident #95 revealed an admission date of 11/29/24 and a discharge date of 03/17/25. Resident #95 had diagnoses including respiratory failure, pleural effusion, osteomyelitis, stage four pressure ulcer[TRUNCATED]