**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure a resident environment that was safe, clean and sanitary to prevent the spread of disease-causing organisms and infections when Resident #5 who had wounds infected with maggots, was observed handling linens and propelling throughout the facility with the drainage/maggots leaking onto the floor from his wheelchair and when 3 of 70 sample residents (Resident #12, #13 and #14) reviewed for infection control. The facility had a census of 70. A partial extended survey was conducted 11/1/2023 through 11/2/2023. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to Resident #5, whose wounds were infected with maggots and had drainage, was observed propelling in his wheel chair and draining fluids and maggots onto the facility floor, when Resident #5 was observed to be scratching and touching his wounds with his hands, and then touching towels/linens on the clean linen cart, and when 3 of 70 sampled residents (Resident #12, #13 and #14) complained of rolling there wheelchair in the drainage and getting it on their hands. The facility's failures resulted in Immediate Jeopardy. All residents had the potential to be affected by the deficient practice. The Administrator, Regional Nurse Consultant (RNC) and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-584 on 11/1/2023 at 9:15 AM, in the Interview Room. The facility was cited Immediate Jeopardy at F-584 at a scope/severity of J which is substandard quality of care. The Immediate Jeopardy began on 10/25/2023 through 11/1/2023 with the last day of IJ being 11/1/2023. The facility submitted an acceptable IJ Removal Plan on 11/3/2023 at 2:01 PM. The corrective actions of the Removal Plan was validated by the surveyor on 11/6/2023 through review of medical record review, observations, and interviews. Noncompliance of F-584 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility is required to submit a plan of correction. The findings include: 1. Review of the facility's undated policy titled, Isolation Precautions, revealed .Contact precautions .intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment .Facility staff will apply Standard Precautions to all residents under the assumption that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services . Review of the facility's policy titled, RESIDENT RIGHTS, dated 10/18/2022, revealed .All residents will be treated equally .Safe environment. The resident has the right to a safe, clean, comfortable, and homelike environment . 2. Review of medical record revealed Resident #5 was admitted to the facility on [DATE], with a readmission on [DATE], with a diagnosis of Paraplegia, Obstructive and Reflux Uropathy, Antisocial Personality, Pressure Ulcer to the Buttock Stage 3, right heel, and Sacral, Opioid Dependence, and Enterostomy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact, rejected care 4 to 6 days a week, and was totally dependent on the staff for Activities of Daily Living (ADLs). Review of the Behavior Note, dated 9/11/2023, revealed .Res [resident] declined personal hygiene and wound care during hospice visit today .Res continues with very foul odor with fluids dripping from wheelchair. Linens in wheelchair are visibly soiled . Review of the Social Service Notes, dated 10/23/2023, revealed .refused condom catheter placement .Pt aware he was leaving bodily fluids all over the hallway floor and in his room . Review of medical record revealed Resident #12 was admitted to the facility on [DATE] with a diagnoses of Heart Failure, Diabetes, Chronic Respiratory Failure, and Chronic Kidney Disease. Review of the quarterly MDS dated [DATE] revealed Resident #12 had a BIMS score of 15, which indicated he was cognitively intact. Review of medical record revealed Resident #13 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia, Epilepsy, and Chronic Obstructive Pulmonary Disease Review of the quarterly MDS dated [DATE] revealed Resident #13 had a BIMS score of 15, which indicated he was cognitively intact. Review of medical record revealed Resident #14 was admitted to the facility on [DATE] with a diagnoses of Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Muscular Dystrophy. Review of the quarterly MDS dated [DATE] revealed Resident #14 had a BIMS score of 15, which indicated she was cognitively intact. 3. Observation and interview on 10/25/2023 at 6:54 AM, Licensed Practical Nurse (LPN) #3 was asked what the large brown dried puddle was on the floor near the 500-hall nursing station. LPN #3 stated . [Named Resident #5] .he let his wounds drip all over the facility and maggots are falling from the back of his wheelchair . Observation on the 300 Hall on 10/30/2023 at 10:11 AM, revealed Resident #5 was at the clean linen cart pulling linen off the cart and pilling it onto his wheelchair. Resident #5 was observed to reach down the right side of his back with multiple up and downward scratching motion, and continued to pull the clean linen off the linen cart placing the linen onto his wheelchair. Resident #5 moved away from the linen cart to the other side of the hallway and a half dollar size puddle of clear drainage was observed next to the linen cart. Observation on the 300-Hall on 10/30/2023 at 11:10 AM, with LPN #5 revealed a puddle of clear liquid on the floor across from the linen cart where Resident #5 was sitting in his wheelchair. Observation on the 600-Hall on 10/31/20023 at 10:34 AM, revealed two small puddles of fluid on the floor in the hallway near the double fire doors on the left side of the hall. 4. During an interview on 10/30/2023 at 8:57 AM, Licensed Practical Nurse (LPN) #1 was asked if she was aware Resident #5 was leaking drainage from his wheelchair. LPN #1 stated, .Yes .we have reported he [Resident #5] has drainage coming from his wounds .told [Named Assistant Director of Nursing [ADON] he is leaking again .we were told he has a right to refuse care . LPN #1 was asked if she knew if any of the residents complained about the drainage and maggots. LPN #1 stated, .Yes .they are getting this [drainage/maggots] on their wheelchairs .getting it on their hands when they roll over it in their wheelchairs . During an interview on 10/30/2023 at 1:09 PM, Certified Nursing Assistant (CNA) #2 was asked if she had seen any drainage or maggots coming from Resident #5's wheelchair. CNA #2 stated, .I have .just in his room .a hand full [maggots] in the floor .never seen in the hallway .they crawl to the edge of the door .just maggots .he does have liquid that drips down the hallway .he come out from his hall and go to the door to smoke break and down the 600 hall to the dining room .it like drops .sometime it's big drops .sometimes it's grape size drops .if he is sitting in one spot it will wind up being a puddle . CNA #2 was asked if any of the residents complained of the drainage and maggots. CNA #2 stated, .Yes . [Named Resident #12, #13, and #14] .when he sat [sit] and smoke it's a puddle under him .smells and he is leaking . CNA # 2 was asked if he was allowed to pull linen off the linen cart. CNA #2 stated, .I don't think so .he will help himself . During an interview on 10/30/2023 at 1:10 PM, the Hospice RN was asked if she seen the maggots drop off his wheelchair. The Hospice RN stated, .Yes ma'am .they will be in the hallway .on the 300 Hall .where he wanders there will be droplets everywhere he goes .it's a possibility there are some residents who wander down the hall bare footed and could step in it [maggots or drainage] . The Hospice RN was asked what all the drainage from Resident #5 is. The Hospice RN stated, .the catheter could not get it [place] .I could not advance the condom catheter .the [condom catheter] would not stay on .he is constantly dribbling with urine and saturated in urine all day .the drainage is all the above .ostomy .urine .his wounds also drain . During an interview on 10/30/2023 at 2:09 PM, the Wound Care Nurse was asked if she felt it was a health hazard for the other residents when Resident #5 is observed leaking drainage and maggots throughout the facility. The Wound Care Nurse stated, .I would not like it .I would not be happy if I rolled through [wheelchair] and got it on my hands . During an interview on 10/30/2023 at 3:45 PM, the Director of Nursing (DON) was asked what you have done to protect the other residents in the facility about the drainage. The DON stated, .We can't make him stay in his room .we have attempted to get guidance[cooperate] .have not gotten it .guidance on how to handle the situation .no ma'am . The DON was asked if she was made aware when Resident #5 was outside smoking over the summer and maggots fell out from under his wheelchair and the staff had to wash down the smoking area. The DON stated, .No, not aware of that . During an interview on 10/31/2023 at 11:19 AM, the Social Worker was asked if it is safe for the other residents in the facility when Resident #5 is dripping drainage and maggots in the facility. The Social Worker stated, .I don't know what the fluid is .I don't think I would want a resident walking or wheeling through it [drainage] . During an interview on 11/2/2023 at 7:19 AM, the Floor Technician was asked if he remembered going outside on the smoking area and hosing down maggots Resident #5 had dropped on the concrete. The Floor Technician stated, .Yes .I was called outside they [staff] came and got me to go to the smoking area near the 500-nursing station .in the smoking area .it was over the summer .I did have to hose off the concrete cement .there was maggots .I had to hose it off for safety . During a telephone interview on 11/2/2023 at 8:15 AM, the Hospice Medical Director was asked if he was aware Resident #5 had maggots in his wound. The Hospice Medical Director stated, .Yes .I have been made aware of that .we have tried to stress doing the wound care on a regular basis .he is not interested in the treatments on regular basis . The Hospice Medical Director was asked what is Resident #5's prognosis. The Hospice Medical Director stated, .he is on hospice care .it's a pretty poor life expectancy less than 6 month .he has osteomyelitis, wound problems, and he has an infection in his wounds . The Hospice Medical Director was asked if he was aware Resident #5 was leaking fluids and maggots throughout the facility. The Hospice Medical Director stated, .I believe they have told me his wounds were oozing from the chronic inflammation and from his infection .we have addressed the need for wound care and ostomy care . The Hospice Medical Director was asked should Resident #5 be in contact isolation with the chronic infection in his wound drainage. The Hospice Medical Director stated, .that I'm not sure of .he was getting treated for chronic osteomyelitis at the hospital, and his infection that is bone deep you can see the bones and hardware . The Hospice Medical Director was asked if a resident has chronic osteomyelitis is that a type of wound infection. The Hospice Medical Director stated, .Yes .that's correct . The Hospice Medical Director was asked if it was safe environment for the other residents in the facility when Resident #5 is going throughout the facility leaking drainage and maggots on the floors. The Hospice Medical Director stated, .No .it doesn't sound like it is .if you don't know what in the fluids are .it would be a risk for the other residents .he would need to be keep in some type of isolation .he would need to be in contact isolation .that would be appropriate . The Hospice Medical Director was asked, what was the reason for Resident #5's admission to hospice care. The Hospice Medical Director stated, .part of his diagnosis is for pain management .he stops all treatment in the facility .they contacted us .he was placed on hospice care . During an interview on 11/2/2023 at 11:30 AM, the Infection Preventionist was asked what type of resident would be placed in contact isolation. The Infection Preventionist stated, .a resident with .any kind of infection .the resident may or may not have .infected wounds . The Infection Preventionist was asked should the resident have signage on their door to identify the isolation. The Infection Preventionist stated, .Yes . The Infection Preventionist was asked if have a resident who is dripping drainage from their wounds should they be isolated. The Infection Preventionist stated, .I always been taught if it is cover .they can leave the room .if it is dripping and the dressings are saturated the nurse should be notified to change it dressing .they [the resident] would not be allowed to come out of the room if the wound is dripping in the floor .it [dressing] should be changed . During an interview on 11/2/2023 at 2:35 PM, the Nurse Practitioner (NP) was asked looking at the drainage and maggot dripping on the floor do you believe the resident have the right to a is safe and clean environment. The NP stated, .Yes .sure . During an interview on 10/25/2023 at 3:00 PM, Resident #12 was asked if he had any concerns with Resident #5 leaking drainage and maggots in the facility. Resident #12 stated, .Oh .yea .definitely we were outside smoking during break and there was a big puddle of them [maggots] out there .they had to get someone to come and wash them [maggots] down . Resident #12 was asked when was the last time he saw the drainage and maggots in the facility. Resident #12 stated, .it was last week .we have to roll over it in our wheelchair . During an interview on 10/30/2023 at 5:48 PM, Resident #13 was asked if he had any concerns about Resident #5 drainage and dropping maggots in the facility. Resident #13 stated, .if we don't see it, we roll right through it .it gets on our hands sometime .we see piles of maggots on the floor fall out the back of his wheelchair . Resident #13 was asked how often you see the drainage and maggots. Resident #13 stated, .if he is out of his room, its everyday .you can look under his chair it looks like brown water .his blanket is soiled with brown stains .he has this strong odor about him like a dead animal . Resident #13 was asked if he felt it was a health hazard for the drainage and maggot on the floor in the facility. Resident #13 stated, .Yes .to us it is .he has known he has maggots .when he sat [sits] in one spot .you can see a little puddle under him .the other night he was sitting by the tv [television] eating .he had 10 inch puddle under the chair .he drops little drips down the hall when he roll down the hallway .I saw the maggots .outside and in front of [Named Social Workers] office one day .we have to roll our wheelchair with our hand and eat dinner with the same hands . During an interview on 10/30/2023 at 8:02 AM, Resident #14 was asked if she had any concerns or had she seen any drainage or maggots on the floor from Resident #5. Resident #14 stated, .Yes .liquid all over the floor .every day .it's not safe for everyone in this building .us that know try to roll around it [drainage] .we have some that don't know .it gets on the wheelchair .on their [residents who wander] feet's walking through it .it's not safe .maggots on the floor .yes ma'am . Resident #14 was asked when the last time was she seen the maggots on the floor. Resident #14 stated, .a month ago .I was coming down the hall .it was in a brown pile .still alive and the pile was kind of moving .he [Named Resident #5] spreading it around the rest of the building .I seen it outside too .the maggots in a puddle underneath his wheelchair .they [staff member] got one of the housekeeping with a water hose and sprayed it down .we don't understand why he [Resident #5] don't realize this .[dropping drainage and maggots] . Resident #14 was asked if she felt it was a health hazard with the drainage and maggots being dropped in the facility. Resident #14 stated, .Yes .when it brown and stinky and looks like [feces] .yes, it is a health hazard . The surveyors verified the Removal Plan by: 1. On 8/1/2023 FNP spoke with the resident regarding his refusal of most all care to include wound care, incontinence care and hygiene and importance in complying with care. On 10/31/2023 Resident #5 was seen by FNP (Family Nurse Practitioner) regarding reports of resident ongoing refusals for wounds to be seen or dressing changes, incontinence care and resident awareness of wound status. FNP notes per wound notes from 10/27/2023 Resident has declined for facility staff to or complete wound care. All measurement and assessment finding are through hospice findings due to resident refusing for facility staff to complete wound care. There is less odor and less drainage from wounds this week. The surveyor verified by medical record review, observation, and staff interviews. 2. On 10/31/2023 a waterproof drainage barrier was placed. The barrier attaches to the underside, external portion of the wheelchair extending the length of the wheelchair to the front underside of the chair to ensure no direct contact made with resident. as the barrier is not touching the patient or impeding movement, the resident was acceptable of the barrier placement. DON (Director of Nursing) discussed with patient and patient verbalized agreement. Nursing staff education begun 10/31/2023 to change drainage barrier daily and as needed for soilage & laundering. In order to monitor, the licensed nurses have been assigned a task on the EMAR (Electronic Medication Administrating Record) to change the barrier daily and as needed through their designated shift. Nurses will visualize the barrier is in place and functioning properly underneath the external portion of resident's wheelchair throughout their shift. The surveyor verified by medical record review, observation, and staff interviews. 3. On 11/1/2023 DON visualized Resident #5 in wheelchair with no drainage noted to floor in room or common area outside of room, floor clean with waterproof drainage barrier in place functioning properly. The surveyor verified by observation and staff interviews. 4. Education began on 11/1/2023 with Housekeeping/Environmental services staff on proper cleaning techniques which included a deep clean procedure form & the 5-step cleaning method. The 5-step cleaning method includes: 1. Pulling trash out of all assigned rooms (per housekeeper); 2. Sweep; 3. Mop; 4. Bathroom; and 5. Dusting. Education also included a monthly deep cleaning schedule. The surveyor verified by medical record review, observation, and staff interviews. 5. On 11/1/2023 the Linen cart on 300-hall removed from the Hallway, cleaned, and linen laundered & replaced. All linen from hallway was placed in a locked storage area. The surveyor verified by observation and staff interviews. 6. Education began on 11/1/2023 with laundry personnel and nursing staff regarding linen cart removal & placed behind locked doors. The surveyor verified by medical record review, observation, and staff interviews. 7. Resident #5 personal linen placed in room. Nursing home administrator spoke with resident on 11/1/2023 regarding personal linen placement in room. Visual reminder placed on personal linen cart in Resident #5's room for resident & staff. Resident agreeable currently. The surveyor verified by observation and staff interviews. 8. Education provided to Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN) to clean floor with disinfectant after housekeeping off duty or when unavailable. They will clean the floors with disinfectant when any substance is visualized on the floor. The surveyor verified by observation and staff interviews. 9. Education began 11/1/2023 to all staff members by Director of Nursing regarding F584 Resident Rights: Safe/Clean/Comfortable/Homelike Environment. The surveyor verified by observation and staff interviews. 10. Education will continue each shift until 100% (percent) of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The surveyor verified by observation and staff interviews. 11. Newly hired nursing & (and) housekeeping employees will receive education of above prior to working the floor. The surveyor verified by observation and staff interviews. 12. The Housekeeping staff will monitor resident #5 room cleanliness per the cleaning assignment protocol which included a deep clean procedure form and deep cleaning schedule. Resident #5's room will receive a weekly deep clean, which is enhanced from the standard deep cleaning schedule which is monthly. Housekeeping Supervisor will monitor by utilizing the deep clean list form (audit tool) for the enhanced cleaning schedule assignment and completion. This process will include the Housekeeping Supervisor taking the deep clean list form that has been checked off by the housekeeper and visualizing the room for herself. She will check the room by completing the deep clean list form. This action will be completed weekly. The surveyor verified by observation, and staff interviews. 13. The Environmental Supervisor will report any deficiencies noted from the deep cleaning list form to the Administrator. The surveyor verified by observation and staff interviews. 14. The Administrator will report any trends identified in the monthly QAPI (Quality Assurance and Performance Improvement) Committee meeting. The surveyor verified by staff interviews. 15. Removal plan discussed and approved by Medical Director (MD) on 11/1/2023, 11/2/2023, and 11/3/2023. The surveyor verified by staff interviews. 16. Reviewed and approved removal plan by QAPI Committee on 11/1/2023, 11/2/2023, and 11/3/2023. The surveyor verified by observation and staff interviews. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, timeanddate.com, medical record review, fall investigation review, observation and interview, the facility failed to provide adequate supervision for a cognitively impaired resident at risk of elopement, and ensure a safe environment for 2 of 7 (Resident #16 and #11) sampled residents reviewed for accidents, and supervision. On 10/31/2023 Resident # 16 exited the facility through the front exit door, by a visitor who entered the door code, opened the door, and let Resident #16 outside into the courtyard, an unsafe environment. Resident #16 was observed knocking on the 300/400 Hall exit door approximately 174.1 feet from the front door. The temperature outside was 46 degrees. The facility failed to conduct appropriate elopement assessments and elopement drills on all shifts with the elopement on 10/31/2023. The facility's failure to prevent a resident with known exit seeking behaviors from eloping to an unsafe environment resulted in Immediate Jeopardy for Resident #16. The facility failure to prevent and monitor falls resulted in actual harm when Resident #11 who was severely cognitively impaired and was at high risk for falls sustained a left hip fracture that required surgery to repair. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Regional Nurse Consultant (RNC) #2 and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 on 11/29/2023 at 10:35 AM, in the Interview Room. The facility was cited Immediate Jeopardy at F-689 at a scope/severity of J which is Substandard Quality of Care. The Immediate Jeopardy for F689 began on 10/31/2023 through 11/30/2023 with the last day of IJ being 11/30/2023. An acceptable IJ Removal Plan, which removed the immediacy of the Immediate Jeopardy, was received on 12/1/2023 at 1:02 PM. The corrective actions of the Removal Plan was validated by the surveyor on 12/4/2023 through review of medical record review, education review, observations, and interviews. Noncompliance of F-689 continues at a scope and severity of G related to Resident #11's falls and injury. The facility is required to submit a plan of correction. The findings include: 1. Review of the undated policy titled Elopement Risk, revealed .This facility ensures that residents who exhibit unsafe wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to unsafe wandering or elopement risk .Elopement occurs when a resident leaves .a safe area without authorization .and /or any necessary supervision to do so .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, Implement interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .Resident will be assessed for risk of elopement upon admission/readmission and quarterly throughout their stay by interdisciplinary care plan team (IDT) using the Elopement Risk .Supervision will be provided to help prevent accidents or elopements .Active exit seeking residents will be placed under staff supervision .Reporting requirement to the State agency shall be conducted .Procedure Post-Elopement .A nurse will perform a physical assessment, document, and report finding to physician .A social service designee will re-assess the resident and make any referrals . Review of the Facility's undated policy titled Incident and Accidents, revealed .It is the policy of this facility for staff to utilize Risk management, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident .Incident is defined as occurrence or situation that is not consistent with the routine care of a resident .The purpose of incident reporting can include .Assuring that appropriate and immediate interventions are implemented and corrective action are taken to prevent recurrences and improve the management of resident care .Licensed staff will utilize Risk Management to report incidents/accidents and assist with completion of any investigation information to identify root cause .The following incidents/accidents require an incident/accident report but are not limited to .Elopement .Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions . Review of the Facility's undated policy titled Accidents and Supervision, revealed .The resident environment remains as free of accident hazards as it possible, and each resident receives supervision .to prevent accidents .Risk refers to any external factor, facility characteristic or characteristic of an individual resident that influences the likelihood of and accident .Supervision refers to intervention and means of mitigating risk of an accident . Review of the Facility's undated Policy titled, Fall Risk Assessment, revealed .It is the policy of this facility to ensure the facility provides an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents . 2. Review of medical record revealed Resident #16 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease, Atrial Fibrillation, Chronic Kidney Disease, and Dementia. Review of the Care Plan dated 6/20/2021, revealed .Potential for wandering/elopement r/t dx of dementia, confusion and disoriented to place .12/20/2022 noted wandering .8/1/2023 with confusion noted and looking for her red car .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . initiated .3/26/2023 .Identify pattern for wandering .initiated 3/26/2023 .Observe for triggers for wandering/eloping, Document .initiated 8/7/2023 . Review of the SLUMS Examination dated 12/5/2022, revealed Resident #16 had a score of 8/30 which indicated Dementia (group of symptoms affecting memory, thinking and social abilities). The SLUMS score interpretation provides different thresholds based on the education level of the patient. Scores of 27 to 30 are considered normal in a person with a high school education, scores between 21 and 26 suggest a mild neurocognitive disorder, and scores between 0 and 20 indicate dementia. Review of Care Plan dated 4/18/2023, revealed .Resident educated on asking for staff assistance with outdoor activity . Review of the Physician's Progress Note dated 6/2/2023, revealed .Don [Director of Nursing] requests resident be seen, reports she is currently on 1:1 observation r/t [related to] wandering and exit seeking .Severe late onset Alzheimer's dementia with agitation . Review of the SBAR (Situation, Background, Assessment, Recommendation) dated 6/2/2023, revealed .Situation: Resident noted with increased anxiety and restless behaviors. Background: Resident has Dx [diagnosis] of Alzheimer's .Assessment (RN) [Registered Nurse]/Appearance (LPN) [Licensed Practical Nurse] .Resident is walking up to exit doors looking for her red car in the parking lot. Resident states that she is going outside the door. Staff are unable to reorient or redirect resident. Attempts to provide activity are unsuccessful. Her anxiety has progressed this afternoon. Behaviors appear to occur more often and more severely in the afternoon hours . Review of the Elopement Risk dated 6/2/2023, revealed Resident #16 had a score of 16 indicating she was at high risk for elopement. Review of the Behavior Note dated 6/4/2023, revealed .Res [resident] noted packing up belongings in her room. Res asking where her husband is and how long will it be before he comes back. Redirection provided by staff with no success . Review of the Care Plan dated 6/7/2023, revealed .The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] dx Dementia . Review of the Mental Health and Wellness note dated 6/7/2023, revealed .History of Present Illness .Review of facility documentation does not reveal any new behavioral issues with exception of increased exit seeking behaviors . Review of the Behavior Note dated 6/8/2023, revealed .Resident noted with exit seeking behavior .pulling on exit door . Review of the General Nursing Note dated 6/8/2023, .This nurse observed resident pulling on door attempting to go to parking lot stating, 'I'm looking for my car so I can go home. I don't live here .' Increased agitation noted .Attempted to redirect and reassure resident w/o [without] success . Review of the Physician's Progress Note dated 6/9/2023, revealed .Severe late onset Alzheimer's dementia with agitation . Review of the IDT [Interdisciplinary Team] General Note dated 6/12/2023, revealed .Resident was placed on 1:1 observation 6/8/23-6/9/23 r/t [related to] exit seeking behaviors . Review of the Social Progress Note dated 6/18/2023, revealed .Pt [patient] has dx of dementia .Pt is confused and forgetful .Pt has trouble concentrating at times .Pt recently had exit seeking behaviors . Review of the Care Plan dated 6/20/2023, revealed .Resident requires assist with ADLS [activity of daily living] R/T dx of dementia, deconditioning, unsteady gait .Resident needs supervision with 1 person assist for locomotion on unit . Review of the annual MDS assessment dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 10, indicating she was moderately impaired, trouble concentrating on thing, such as reading the newspaper or watching television, required supervision and physical help for her activities of daily living (ADLs) and coded for cognitive loss/dementia. Resident #16's assessment was coded not exhibited for wandering behaviors. Review of the Social Progress Note dated 7/16/2023, revealed .Pt [patient] annual assessment is completed. Pt has dx [diagnosis] of dementia .Pt has Alzheimer's [a degenerative brain disease that causes memory loss, impaired thinking, disorientation, and changes in personality and mood] .Pt is confused and forgetful . Review of the General Nurse Note dated 7/23/2023, revealed . [Named Family Member #2] states that she has noted resident to be confused this afternoon. Resident has been calm and cooperative past few days, Confusion is baseline for resident, yet [Family Member #2] thinks it is worse today. [Family Member #2] states that resident was having trouble remembering who her [Family Member #2] was . Review of the Interdisciplinary Team General Note dated 8/2/2023, revealed .Pt noted on 8-1-23 [8/1/2023] with confusion looking for her red car and her daughter . Review of SBAR dated 8/3/2023, revealed .Resident noted recently with confusion, looking for cars in parking lots, smearing feces in bathroom and placing blame elsewhere . Review of the Physician's Orders date 8/5/2021, revealed monitor exit seeking behaviors this shift, and every day and night shift. Review of the Morse Fall Scale dated 8/27/2023, revealed Resident #16 scored a 55.0 indicating she was High Risk for falls. The Fall scale range revealed a 15-50 is high risk for falls. Review of the Medicare Meet IDT Note dated 9/1/2023, revealed .Pt referred to PT [Physical Therapy] due to noted unsteadiness during standing and ambulation and balance difficulties during ADLs [Activity of Daily Living] . Review of the Elopement Risk dated 9/1/2023, revealed Resident #16 scored a 6 indicating she was at low risk for elopement. There was no documentation on the Medication Administration Records (MAR) dated September and October 2023, for monitoring Resident #16's exit seeking behaviors. Review of the quarterly MDS assessment dated [DATE], revealed Resident #16 had a BIMS score of 13, indicating she was cognitively intact, trouble concentrating on things, such as reading the newspaper or watching television, and required supervision and physical help for her activities of daily living (ADLs) . Resident #16 was not coded for wandering behaviors. Review of the General Nurse Note dated 9/24/2023, revealed .Resident noted with confusion .Resident states 'We all came to this church together, if I would've known it would be like this, I would've never came. I'm very unhappy with the ones who came here with me & just left me here like this by myself. Something has got to be done about all of this' . Review of the General Nurse Note dated 9/24/2023, revealed .Resident noted with confusion this afternoon. Resident noted pacing looking for car . Review of the Care Plan dated 9/27/2023, revealed .Resident at risk for pain r/t [related to] dx [diagnosis] of depression .dementia may not be able to articulate needs . Review of the Medicare Meet IDT Note dated 10/6/2023, revealed .Pt referred to PT [Physical Therapy] due to noted unsteadiness during standing and ambulation and balance difficulties during ADLs [Activity of Daily Living] . Review of the Care Plan dated 10/15/2021, revealed .Resident needs supervision with 1 person assist for transfers .Resident needs supervision with set-up assist for locomotion off of unit .Resident needs supervision with set-up for ambulation in corridor . Review of the Physician's Progress Note dated 10/27/2023, revealed . Severe late onset Alzheimer's dementia with agitation [In the late stage of the disease Alzheimer's, called severe dementia due to Alzheimer's disease, mental function continues to decline. The disease also has a growing impact on movement and physical capabilities] . Review of TimeandDate.com dated 10/31/2023, revealed the weather at 5:55 PM was 46 degrees with a low of 34 degrees. Review of the COMMUNICATION-with Family, 10/31/2023 at 10:34 PM, revealed .Alerted RP to incident involving resident going outdoors to pick a rose, spoke to RP regarding stable vital signs, no injuries present, 1:1 initiated per agency protocol, continuing to monitor resident, no concerns voiced regarding incident. Review of the Investigation Summary dated 10/31/2023, revealed .Interviews held with per IDT with staff present noted that visitor had opened door coming in to visit family member and resident was standing at the door, visitor allowed resident to go through the door & he walked to his family member's room. Visitor stated there had only been no more than approximately 3-5 minutes since time he entered facility & time staff member came & asked him if he had seen a resident go out the front door . Review of the medical record revealed the facility failed to reassess Resident #16 for elopement risk when she exited the facility on 10/31/2023. Review of the Physician's Progress Note dated 11/3/2023, revealed .Routine follow up nursing home visit. No change in diagnosis or medicines since last visit. There was no documentation the Medical Director assessed the Resident #16 related to the elopement. Review of the Elopement Risk dated 11/9/2023, revealed Resident #16 scored a 16 indicating she was at high risk for elopement. Review of the ELOPEMENT DRILL DOCUMENTATION FORM dated and performed on 11/10/2023, revealed an elopement drill that was only completed for the first shift. There were no drills performed for the other 2 shifts related to the 10/31/2023 elopement. The facility failed to conduct an appropriate elopement assessments and elopement drills on all shifts with the elopement on 10/31/2023. Observation on 11/21/2023 at 10:54 AM, with the Maintenance Director and Assistant revealed the Maintenance Director used a measuring wheel with digital display to measure the distance from the front door to the pathway Resident #16 traveled to the 300/400 Hall exit door was 174.1 feet. The measurement from the resident room to the front door was 198.1 feet. Observation of the courtyard on 11/21/2023 at 10:57 AM, revealed the following: a. To the left of the front door was a huge rock in the flower bed on the side of the metal railing and a concrete child statue, a large black metal Shepards hook, concrete pathway with open groves leading to the 300/400 Hall exit door, a concrete area with a concrete table with 2 concrete benches, a tree with 3 large trunks with one of the trunks cut and exposing the sharp wooden edges, at the base of the tree was exposed large tree roots, on the far back wall of the facility was a black hose pipe curled up on the wall hooked up to a faucet, a metal gate with a latch that was easily opened that opened to the facility parking lot and street, behind the rose bushes was a large black box, a black long water hose attached to a water faucet lying on the ground, a gravel path leading to the large black box, several stepping stones in the flower bed and around the black box, 2 black plastic pipes with ridges [single wall perforated drain pipe] coming from under the ground on each side of the rose bushes and a metal bench on the pathway across from the rose bushes. b. Exiting the front door was a paved concrete walkway with black metal railing on each side leading to the black metal front gate with a latch that easily opens. A gate latch is a locking mechanism that is used to secure gates on fences using a metal bar and lever that is raised to open the latch and lowered to close it. c. To the right of the front door in the courtyard was a large 3 tier concrete water fountain with dirt in each tier, a flagpole with a concrete base with uneven ground, 2 large ant hills, a large covered patio with a gallon of hand sanitizer sitting on the wooden rail, a fire extinguisher in a glass case, a fire blanket, a large gray trash can, a small red metal container for cigarette butts, several metal tables and chairs, to the right outer side of the covered patio was a concrete flower bed filled with dirt, a black device with a water faucet on top with a black hose attached, and black mesh netting. d. The right side of the covered patio contained 2 small ponds with multiple sized medium to large rocks, the ponds were filled with gravel, a large blue handled shovel and a small wooden bridge was between the 2 ponds, and a single wall perforated black plastic drain pipe emerged from the ground over one of the ponds, which contained a large steppingstone. During an interview on 11/21/2023 at 9:11 AM, the Infection Preventionist was asked about the day Resident #16 exited from the facility on 10/31/2023. The Infection Preventionist stated, .I was working as an aide that day on the 300/400 Hall .I have a text when it occurred .I was leaving the floor going to my office to get something .I was behind the desk charting .I was coming from the nursing station in route to my office .as I was passing the east wing doors [300/400 Hall] .she [Resident #16] was approaching the door trying to get in . The Infection Preventionist was asked if she knew how long Resident #16 was outside. The Infection Preventionist stated, .No I don't . it was 5:56 PM when I saw her .she was reaching for the door .I saw her through the glass door . The Infection Preventionist was asked if she witnessed Resident #16 exit the facility. The Infection Preventionist stated, .No . During an interview on 11/21/2023 at 10:43 AM, the Regional Nurse Consultant #1 was asked if the elopement incident on 10/31/2023 was reported to the state. The Regional Nurse Consultant #1 stated, .No . she [Resident #16] did not meet the definition of elopement .nothing to report . The Regional Nurse Consultant #1 was asked if any staff members saw Resident #16 exit the facility. The Regional Nurse Consultant #1 stated, .No . a visitor saw her go out the door . The Regional Nurse Consultant #1 was asked if the visitor screened in the facility to verify the time the resident exited the facility. The Regional Nurse Consultant #1 stated, .No . I do not have a punched time . The Regional Nurse Consultant #1 was asked if the Ombudsman was notified. The Regional Nurse Consultant #1 stated, We did not . The Regional Nurse Consultant #1 was asked who is responsible to ensure the resident safety in the facility. The Regional Nurse Consultant #1 stated, .Anyone . The Regional Nurse Consultant #1 was asked if the facility completed an elopement assessment post elopement. The Regional Nurse Consultant #1 stated, .No . we did not complete another one .we did not deem she tried to elope .on 9/1/2023 she was a low risk . The Regional Nurse Consultant #1 was asked if the care plan was revised to reflect the resident exiting the facility. The Regional Nurse Consultant #1 stated, .If they are exit seeking and can't redirect .yes .that is not anything necessary to care plan [when resident gets out the building] . The Regional Nurse Consultant #1 was asked what she considered and elopement. The Regional Nurse Consultant #1 stated, .In our policy we have the definition of elopement when a resident leaves the premise or a safe area . Observation and interview on 11/21/2023 at 11:28 AM, out on the courtyard, the Administrator was asked if he felt it was safe for the Resident#16 to be outside, alone, and unsupervised in the courtyard. The Administrator stated, .After investigation we felt it was safe .after what she [Resident #16] told us she was safe .she walked down the sidewalk from the front door to pick the [NAME] .it had gotten cooler 2 nights before .there had been [NAME] on the bushes .there was no blooms when she was outside .there was just buds . The Administrator was asked if he felt a resident who was outside alone, without staff knowledge, and unsupervised was safe. The Administrator stated, .Yes . The Administrator was asked if it was dark outside. The Administrator stated, .It was darker .yes . The Administrator was asked who's responsible for the resident's safety in the facility. The Administrator stated, .The Administrator . The Administrator was asked if he was familiar with the federal regulation related to elopement. The Administrator stated, .Yes .the residents have to be in a safe environment at all times . The outside courtyard was noted with several rose bushes with long sharp [NAME], uneven ground and groves and cracks in the concrete pavement. During an interview on 11/21/2023 at 3:35 PM, LPN #7 was asked about the nurse's note written on 10/31/2023 at 7:03 PM, that documented Resident #16 had an incident involving elopement. LPN #7 stated, .after the investigation it was determined it was not an elopement .I was told that it was incorrect documentation and not a true elopement .by [Named Regional Nurse Consultant #1] . During a telephone interview on 11/21/2023 at 12:47 PM, the Registered Nurse (RN) Supervisor #1 was asked about the incident when Resident #16 got out the facility on 10/31/2023. The RN Supervisor #1 stated, .what I know about that [Resident #16 elopement] .we were at 300/400 nursing desk .[Named Infection Preventionist and Licensed Practical Nurse [LPN #5] and me .[Named Infection Preventionist] said [Named Resident #16] is outside .by this time she was knocking on the door [300/400 Hall door] wanting to come in .we had seen her walk by the window .there is a big window there at the nursing station .[Named Infection Preventionist] went around and open the door [300/400 Hall door] and she came in . The RN Supervisor was asked if she know how Resident #16 got outside. The RN Supervisor stated, .No . not at that time . [Named LPN #1] she is the one who figured out how she got out .it was by a family member . [Named LPN #1] asked [Named Family Member #1] if he had seen anybody go out .he said yes .there was a lady there [at the front door] he thought she was a visitor .when he opened the door to come in, he allowed her out . The RN supervisor was asked how the family member got into the building and if he had the code to the door. The RN Supervisor stated, .at the time he did have the code .yes . The RN Supervisor was asked if it was dark and cold outside. The RN Supervisor stated, .It was .it had start to get dark .it was cool . The RN Supervisor was asked how Resident #16 was dressed and if she appeared to be cold. The RN Supervisor stated, .she was fully dressed in a shirt, pants, and shoes .I asked her what she was doing outside .I told her it's cool out there .she said just a little . The RN Supervisor was asked if any of the staff members witnessed Resident #16 exit the facility. The RN Supervisor stated, .No . not that I'm aware of .as far as I know no one saw her leave the facility .we saw her at the window .she was knocking on the door to come back in . The RN Supervisor was asked if she had any [NAME] in her hand when she was knocking on the 300/400 Hall door. The RN Supervisor stated, .No .she did not have anything in her hands .not that I recall . During a telephone interview on 11/21/2023 at 1:06 PM, Licensed Practical Nurse (LPN) #1 was asked to tell me about the incident when Resident #16 exited the facility. LPN #1 stated, .I know that I was sitting on 600- Hall completing my alert charting for the evening .I noticed a few of the staff members coming from the 300/400 Hall with [Named Resident #16] they looked panic in the face .I asked, what's wrong .[Named RN Supervisor #1] said she [Resident #16] was outside .me and [Named LPN #5] said someone had to let her out .let's go outside to see if there are any family members we can ask .I went outside and searched the area .there was no family in sight .I had seen 2 family members who just came in [Named family member #2] he has seen a resident up there [front] roaming on the 100/200 Hall at nursing station .I left him and went to next family member [Named family member #1] .asked if he let anyone out .he said yes, he let a lady out she [Resident #16] had on shoes and everything .I told him you just let one of our residents out the building .from there [Named RN Supervisor #1] called [Named DON [Director of Nursing] . LPN #1 was asked if the family member told her a time frame when he let Resident #16 out the facility. LPN #1 stated, .No . I don't know the time .I can't say for sure .I thought he was in the building for 3-5 minutes .but he did not screen in the building like he was supposed to .I can't give a time frame .no ma'am . LPN #1 was asked if the family member had the code to the door. LPN #1 stated, .Yes . During a telephone interview on 11/21/2023 at 1:18 PM Certified Nursing Assistant (CNA) #10 was asked when Resident #16 exited the facility on 10/31/2023. CNA #10 stated, .I was walking towards the front and me and [Named Infection Preventionist] seen her at the side door at the 300/400 Hall exit door .she [Resident #16] needed to be let in . I knew she was not to be out there [in the courtyard] in the first place .she was standing close to the door .she was on the concrete in front of the door . CNA #10 was asked if she saw Resident #16 knocking on the 300/400 Hall exit door. CNA #10 stated .No I don't believe so .we [Named Infection Preventionist] open the door and let her in . CNA #10 was asked if Resident #16 said anything about how she got outside. CNA #10 stated .No . she said it was cold outside and glad to be back in . CNA #10 was asked how Resident #16 was dressed. CNA #10 stated, .She had on long sleeves, jeans, shoes . CNA #10 was asked if Resident #16 had any [NAME] or anything in her hands. CNA #10 stated .No . not that I remember . CNA #10 was asked if Resident #16 stated she was outside picking [NAME]. CNA #10 stated .No ma'am . CNA #10 was asked if she saw Resident #16 exit the facility. CNA #10 stated, .No . During an interview on 11/21/2023 at 3:35 PM, LPN #7 was asked about the night of 10/31/2023 Resident #16 exited the facility. LPN #7 stated, .I got involved when the RN Supervisor [was] walking [Named Resident #16] down the hallway .I [was] at the end of the hallway doing a medication pass .I took her [Resident #16] to her room for vital signs and head to toe assessment .I asked her what happen .she said she wanted to go outside to pick flowers .notified [Named DON] of the situation .got investigation statements .complete incident report .she had no injuries .no reported pain .I started neuro [Neurological] checks and put her on 1:1 till the end of the investigation . LPN #7 was asked what Resident #16 was wearing. LPN #7 stated, .No jacket .she had on house shoes, 3/4 length sleeved shirt and pants .LPN #7 asked if she saw Resident #16 exit the facility. LPN #7 stated, .I did not see her exit the building . LPN #7 was asked when the last time she saw Resident #16 on 10/31/2023. LPN #7 stated, .It was around 5:35 PM [The Infection Preventionist revealed it was 5:56 PM when she let Resident #16 back in the facility] . During an interview on 11/27/2023 at 9:04 AM, the Occupational Therapist was asked if it was a safe area outside in the courtyard walking alone unattended. The Occupational Therapist stated, .she doesn't need to be by herself .different area such as in the flower beds she not safety or uneven ground it would not be safe it could cause some loss of balance . The Occupational Therapist was asked if it was a safe idea situation for Resident #16 to be outside alone with her history of high risk for fall. The Occupational Therapist stated, .No . During an interview on 11/27/2023 at 10:06 AM, the Speech Therapist was asked if he assessed Resident #16 cognition. The Speech Therapist stated, .Yes .I completed a standardize cognitive assessment to get an idea of how safe and oriented the resident was .she was well into the dementia with a score of 8/30 .1-19 less than high school graduate and fall into the dementia range and she scored an 8/30 .I talk to her daily .her cognition if I tested her again it would be the same or worse .she has severe memory issues, short term and long term .that how it's been since the day I met her .she is not cognitively intact . The Speech Therapist was asked if he thought it was safe for Resident #16 to be in the courtyard alone. The Speech Therapist stated, .[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Job Description, record review, observation, and interview, the facility failed to maintain an infection prevention program to prevent the development and transmission of infection when Resident #5, whose wounds were infected, with maggots, and draining, was observed propelling in his wheel chair and draining onto the facility floor and when Resident #5 was observed to be scratching and touching his wounds with his hands, and then touching towels/linens on the clean linen cart. The facility failed to ensure staff used appropriate infection control practice for 3 of 3 (Certified Nursing Assistant (CNA) #1, #2 and #3) CNAs observed to perform personal hygiene care. The facility had a census of 70. The facility's failure to prevent the development and transmission of potential infection when Resident #5, who had wounds infected with maggots, was observed propelling himself throughout the facility, and large amount of drainage/maggots was noted to leak on the floor placed residents at risk, which resulted in Immediate Jeopardy. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Regional Nurse Consultant (RNC) and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-880 on 11/1/2023 at 9:15 AM, in the Interview Room. The facility was cited Immediate Jeopardy at F-880 at a scope/severity of J. The Immediate Jeopardy began on 10/25/2023 through 11/1/2023 with the last day of IJ being 11/1/2023. An acceptable IJ Removal Plan, which removed the immediacy of the Immediate Jeopardy, was received on 11/3/2023 at 2:01 PM. The corrective actions of the Removal Plan was validated by the surveyor on 11/6/2023 through review of medical record review, education review, observations, and interviews. Noncompliance of F-880 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility is required to submit a plan of correction. The findings include: 1. Review of the facility's undated policy titled, Isolation Precautions, revealed .Contact precautions .are measure that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment .Facility staff will apply Standard Precautions to all residents under the assumption that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services . Review of the facility's undated policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub .Before applying and after removing personal protective equipment (PPE), including gloves . Review of the facility's undated policy titled, Catheter Care, revealed .It is the policy of this facility to ensure that residents with indwelling catheter received appropriate catheter [helps drain urine from your body] care .Using a circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner soap) .with a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis .with a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter .Dry area with towel . Review of the facility's undated policy titled, Perineal Care, revealed .Perineal care .refers to the care of the external genitalia and the anal area .Basin .filled .with warm water .Washcloths, towels, toilet paper .Perineal Cleanser .If perineum is grossly soiled, turn resident onside, remove any fecal material with toilet paper, the remove and discard .Cleanse buttocks and anus, front to back .Thoroughly dry . Review of the Infection Preventionist Job Description signed 10/11/2021, revealed .Develop and implements and ongoing infection prevention and control program to prevent recognize and control the onset and spread of infection in order to provide a safe, sanitary, and comfortable environment .Oversee resident care activities that increase risk of infection ( .use and care of urinary catheters, wound care, incontinence care .Treats all residents with dignity and respect. Promotes and protects all resident's rights .) 2. Review of medical record, revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Paraplegia, Contracture Right and Left Knee, Peripheral Vascular Disease, Major Depression, Obstructive and Reflux Uropathy, Pain, Antisocial Personality, Pressure Ulcer to the Buttock Stage 3, right heel, and Sacral, Opioid Dependence, Enterostomy, and Anxiety. Medical record review revealed Resident #5 was admitted to the hospital from [DATE] - 2/27/2023 and was admitted for Hospice Services on 2/28/2023. Review of the Hospital Records dated 2/15/2023, revealed, .2/16/2023 . Consultation .IMPRESSION AND PLAN .status post ileostomy [a stoma that is surgically constructed to create an opening for intestinal waste to exit the body], chronic Foley [catheter is inserted into the urethra, the tube that carries urine out of the body], chronic nonhealing wound, decubitus [injuries to skin and underlying tissue resulting from prolonged pressure on the skin] sacrum, bilateral hip, buttock and thigh, also lower extremity left leg, chronic osteomyelitis [an infection in the bone caused by bacteria or fungi] with exposed joint cavity and severe contracture .He has plethora [large or excessive amount] of pathogens growing from his wounds, MRSA [Methicillin-resistant Staphylococcus aureus (MRSA) is an infection of Staphylococcus (staph) bacteria staph bacteria that's become resistant to many of the antibiotics], Enterococcus faecalis [Enterococcus faecalis is a species of bacteria that is naturally found in the intestines which cause difficult to treat infection in the nosocomial setting. The are a common cause of urinary tract infection, bacteremia], ESBL Providencia [Extended spectrum beta-lactamases (or ESBLs for short) are a type of enzyme or chemical produced by some bacteria that are responsible for a wide range of human infections] .History and Physical Exam .Assessment/Plan .Infected wounds .Chronic wounds .Sepsis [a serious condition in which the body responds improperly to an infection] .Anemia [is defined as a low number of red blood cells] . Review of the Mental Health and Wellness Notes, dated 3/15/2023, revealed .No reported concerns of increased or worsening behavior . The Mental Health Note failed to address Resident #5's continued noncompliance and refusal of care in the facility. Review of the Behavior Progress Note dated 5/22/2023 at 11:03 AM, revealed .Resident [Resident #5] noted with foul odor and fluids leaking from wheelchair .at 20:42 [8:42 PM] .Pt [patient]noted with extremely foul smelling and dripping brownish liquid from underneath him . Review of the Interdisciplinary Team (IDT) note dated 5/22/2023 Note at 20:42 [8:42 PM] .Pt [patient] noted with extremely foul smelling and dripping brownish liquid from underneath him . Review of the Mental Health and Wellness Notes, dated 6/7/2023, revealed .No reported concerns of increased or worsening behavior . Record review revealed Resident #5 was admitted to the hospital on [DATE] - 7/12/2023. Review of Named Hospital Records dated 6/29/2023, revealed .Chronic extensive lower extremity wounds .Evidently upon arrival to the ER [emergency room] these wounds were covered and maggots .Bacteremia [bloodstream infection] due to Salmonella [common bacterial disease .fecal matter is one of the most common transport mechanisms for this infection] species .Recurrent pressure wounds infections .Chronic bilateral lower extremity osteomyelitis [infection in a bone] .admitted with recurrent infection of pressure wounds .he has maggots [the larva of a fly] coming out of his sacral wound. His ostomy [opening in the abdomen for waste .to exit the body] is not attached and he has feces pouring onto his abdomen .He has bad decubitus [Ulcers which occur on the skin surface due to prolonged pressure] wound with drainage chronic osteomyelitis .polymicrobial [diseases, caused by combinations of viruses, bacteria, fungi, and parasites, are being recognized with increasing frequency] MRSA and ESBL .His wounds are deep down to joint cavity with exposed joint tissue . Review of the Hospice Visit Noted Report, dated 7/14/2023, revealed .PT [Patient- Resident #5] HAD TO GO TO THE HOSPITAL AND HE HAD SOME INFECIONS FROM HIS WOUNDS . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Metal Status (BIMS) score of 14, which indicated he was cognitively intact, rejected care 4 to 6 days a week, and was totally dependent on the staff for Activities of Daily Living (ADLs). Review of the Hospice Visit Note Report, dated 7/18/2023, revealed .PT [Resident #5] IS LAYING IN WC [wheelchair] IN ROOM RN [Registered Nurse] ASSESSMENT COMPLETED .RN NOTES MAGGOTS IN FLOOR UNDERNEATH PT . Review of the Hospice Visit Note Report dated 7/31/2023, revealed .PT IS LAYING IN WC IN ROOM .PT HAS COLOSTOMY, WHICH IS CURRENTLY UNCOVERED WITH STOOL NOTED IN FLOOR UNDER WHEELCHAIR .MAGGOTS ALSO NOTED IN FLOOR SCATTERED AROUND ROOM . Review of the Hospice Visit Note Report dated 8/2/2023, revealed .PT IS LAYIG IN WC IN ROOM, SWATTING FLIES .ASSISTANCE WITH TRANSFERRING TO BED .WHEN STAFF CAME IN TO CLEAN WHEELCHAIR HIS CHAIR WAS COVERED WITH CRAWLING MAGGKTS [maggots] FROM HIS WOUNDS . Review of the Hospice Visit Note Report dated 8/31/2023, revealed .PT RESTING IN WC UPON ARRIVAL PT HAS STRONG ODOR FOUL ON ROOM FROM WOUNDS .MAGGOTS IN WOUNDS . Review of the Behavior Note dated 9/11/2023, revealed .Res [resident] declined personal hygiene and wound care during hospice visit today .Res continues with very foul odor with fluids dripping from wheelchair. Linens in wheelchair are visibly soiled . Review of the Hospice Visit Note Report dated 9/11/2023, revealed .LARGE PRESENTS OF FLYS IN ROOM AND PT [patient] PILES LINENS ON TOP OF HIM IN EFFORT TO MASK THE ODOR, PT TRAILS DRAINAGE THROUGHOUT FACILITY FROM WOUNDS AS HE ROLLS DOWN THE HALL IN WC [wheelchair] .PT VERBALIZED UNDERSTANDING OF NOT DOING WOUND CARE AND THAT MAGGOTS ARE IN HIS WOUNDS . Review of the Hospice Visit Note Report dated 9/14/2023, revealed .PT RESTING IN W/C AT NURSING STATION .PT STACKS LINENS OVER SELF TO MASK ODOR STRING [strong] ODOR THROUOUT [throughout] HALLWAY, PT LEAKS DRAINAGE THROUGHOUT HALLWAY AS HE ROLLS ALONG WITH MAGGOT .REMOVED OLD DRESSING GREEN BLACK WET AND COATED WITH ROTTING FLESH, PT HAS MAGGOTS ALL THROUGHTOUT WOUNDS, ALL OVER SCROTUM, PENIS AND IN AND OUT OF ANUS [opening at the end of the intestines where waste leaves the body] . Review of the Mental Health and Wellness Notes dated 9/14/2023, revealed .No reported concerns of increased or worsening behavior . Review of the Hospice Visit Note Report dated 9/20/2023, revealed .FOUL ODOR AND LEAKING WOUND DRESSINGS, MAGGOTS CRAWLING DOWN WHEEL CHAIR [wheelchair] AND ON FLOOR IN PT ROOM . Review of the Hospice Visit Note Report dated 9/21/2023, revealed .Social Worker Hospice Notes .MULTIPLE FLIES NOTED FLYING AROUND PT WHEELCHAIR. PT WOUNDS APPEAR TO BE LEAKING ONTO FLOOR IN A TRAIL BEHIND HIM . Review of the Interdisciplinary Team (IDT) General Note dated 9/22/2023, revealed, .This nurse asked resident if he could please change colostomy bag as he is leaving behind a mess on the floor . Review of the Hospice Visit Note Report dated 10/2/2023, revealed .REPORTS PURULANT DRAINAGE IN THE FLOOR AROUND PT . Review of the Hospice Visit Note Report dated 10/16/2023, revealed .URINE AND WIUND [wound] DRAINAGE DRIPPINGBIN [dripping in] FLOOR AROUND PT . EDUCATION TO PT ON HAND HYGEINE FROM DIGGING IN WOUNDS PICKING OFF MAGGOTS AND NOT WASHING HANDS . Review of the Social Service Notes dated 10/23/2023, revealed .condom catheter noted in place and leaking urine on the floor . Review of the Social Service Notes dated 10/23/2023, revealed .refused condom catheter placement .Pt [patient] aware he was leaving bodily fluids all over the hallway floor and in his room . During observation and interview on 10/24/2023 at 12:15 PM, Resident #5 was asked if he had maggots in his wound. Resident #5 stated, .No . Resident #5 was asked how often his dressing is changed. Resident #5 stated, .every other day .on the day shift .by .hospice .and aide come in the same day, and they do my wounds .bed bath at the same time .on Monday and Thursday . During the interview there was a fly that landed on the resident right arm and gown, the linen under him was saturated with a brownish red stain, and there was a strong foul odor. Resident #5 was asked if the facility had a problem with flies. Resident #5 stated, .Yes, it is .it's all around the building .not as bad as it used to be . Observation in the resident's room on 10/24/2023 at 1:57 PM, revealed a fly that landed on his blanket. Observation and interview on 10/25/2023 at 6:54 AM, Licensed Practical Nurse (LPN) #3 was asked what the large brown dried puddle was on the floor near the 500-hall nursing station. LPN #3 stated . [Named Resident #5] .he let his wounds drip all over the facility and maggots are falling from the back of his wheelchair .when I see them [maggots] .I sweep them up and took them outside . LPN #3 was asked what the facility doing about Resident #5's drainage. LPN #4 stated, .I don't know .that is one of his puddles on the floor by the nursing station on the 500/600 hall .we try talking to him .he will say oh that is not mine .he will deny it .say it not his .he knows it his .we have told him . Observation on 10/25/2023 at 1:56 PM, revealed Resident #5 sitting at the 300-hall nursing station in his wheelchair watching a show on his tablet. Resident #5 had a strong foul odor and the linen under him was visibly soiled with a large amount of reddish-brown stain. Review of the Physician's Orders dated 10/30/2023, revealed .Cleanse wound to right hip .Apply Dakin's [used to prevent and treat skin and tissue infections that could result from pressure sores] soaked gauze and cover with dry dressing three times weekly and prn [as needed] .Cleanse wound to right great toe .Apply Dakins [Dakin's] soaked gauze and cover with dry dressing .Cleanse wound to right knee with wound cleanser, pat dry .Apply dakins [Dakin's] soaked gauze and cover with dry dressing three times weekly and prn . Resident #5 wounds were soaked with the Dakin's solution which is used to treat tissue infection and maggots in the wounds. Observation and interview on 10/30/2023 at 5:24 AM, LPN #4 was asked what's the pinkish brown dried puddle in the hallway is. LPN #4 stated, .its dried drainage [Named Resident #5] .at times you have to mop the 300 hall and the 200 .in front of the nursing station on the 500/600 hall around where it goes in towards the smoking area .it's not fair for the other residents to have to roll through that [drainage] . LPN #4 was asked if they had housekeeping on the night shift. LPN #4 stated, .No . LPN #4 was asked how often this occurs with Resident #5 leaving drainage on the floor. LPN #4 stated, .Daily . LPN #4 was asked what the facility is doing about the daily drainage. LPN #4 stated, .Nothing during the night .nothing is said . During an interview on 10/30/2023 at 5:51 AM, CNA #5 was asked if she has noticed any drainage coming from Resident #5's wheelchair. CNA #5 stated, .Yes ma'am .he did have a catheter he refused that .I'm not sure where its coming from .not sure he has wounds and urine .it drops from his chair .see drops here and a drop there . CNA #5 was asked if she was aware of any residents who have complained about Resident #5's drainage. CNA #5 stated, .Yes . [Named Resident #12 and #13] . CNA #5 was asked if she had seen any maggots coming from Resident #5's wheelchair. CNA #5 stated, .Yes ma'am .where ever he sit when he has them, they will fall right there .there has been people telling him he act like he doesn't care .I saw them myself it was sometime in late September early October .when I saw it in the common area on the 300 and 400 hall .it was like one here and one there .they was just crawling .just the maggots no liquid . During an interview on 10/30/2023 at 6:32 AM, CNA #6 was asked if she has ever seen maggots or drainage coming from Resident #5's wheelchair. CNA #6 stated .One day he was sitting on the 300/400 hall, one other aide brought to my attention .maggots was moving under his chair .we were killing them to keep from going in the other residents rooms .there was a puddle of fluid in the hallway I almost stepped in it .one day it was trails where ever he went .we got the mop and got it up .he was sitting up front at the desk .he rolled back to his room .there was trails going back to his room .about the size of a large grape . CNA #6 was ask if she had seen any flies in the facility. CNA #6 stated, .Yes ma'am .quite a bit, in the last 2 months . CNA # 6 was asked if she had any residents complain of the leaking of drainage in the hallways. CNA #6 stated, .Yes ma'am . [Named Resident #14] complained about Resident #5's drainage. Observation on the 300-hall nursing station on 10/30/2023 at 8:26 AM, revealed Resident #5 sitting at the nursing station in his wheelchair, a strong foul odor was noted. Observation on the 300-hall on 10/30/2023 at 10:11 AM, revealed Resident #5 was at the linen cart pulling linen off the cart and pilling it onto his wheelchair. Resident #5 was observed to reach down the right side of his back with multiple up and downward scratching motion, and continued to pull the clean linen off the linen cart placing the linen onto his wheelchair. Resident #5 moved away from the linen cart to the other side of the hallway and a half dollar size puddle of clear drainage was noted next to the linen cart. Observation in Resident #5's room on 10/30/2023 at 10:56 AM, revealed multiple flies landed on the over bed table, flies crawling on the walls and 4 flies lying on the resident's bed. Observation and interview on the 300-hall on 10/30/2023 at 11:10 AM, revealed a puddle of clear liquid on the floor across from the linen cart where Resident #5 was sitting in his wheelchair. LPN #5 went to the desk to get a bleach wipe to clean the puddle up and stated, it looked like urine .it [drainage] has a yellow tint to it. During an interview on 10/30/2023 at 1:10 PM, with the Hospice Registered Nurse (RN) and the Hospice Certified Nursing Assistant (CNA). The Hospice RN was asked when she provides wound care for Resident #5 how often is he getting a bath. The Hospice RN stated, .he gets his wound care on Mondays and Thursdays at 1:00 PM .the CNA comes with me and she gives him his bath . The Hospice RN was asked how long he has had the maggots in his wound. The Hospice RN stated, .he had the maggots since I started his care .it been for the past 3 to 4 months .he removes his dressing .I text [Named Wound Care Nurse] she tells him to get ready .he removes his dressing because of the maggots .all the wounds have maggots .buttock .down his left leg to the heel .right leg not as bad .he has 3 wounds on that leg .he take his hand and scrapes the maggots off with his hand . The Hospice RN was asked if she had seen the maggots drop from his wheelchair. The Hospice RN stated, .Yes ma'am .they will be in the hallway .on the 300-hall .where he wanders, there will be droplets everywhere he goes .a possibility that .some residents wander down the hall bare footed and could step in it [maggots or drainage] . The Hospice RN was asked if she had seen a lot of flies in the facility. The Hospice RN stated, .Yes, it like something out of a movie . The Hospice RN was asked where all the drainage is from. The Hospice RN stated, .the catheter could not get it [place] .I could not advance the condom catheter .the [condom catheter] want stay on .he is constantly dribbling with urine and saturated in urine all day .the drainage is all the above .ostomy .urine .his wounds also drain . The Hospice RN was asked what type of treatment in place for Resident #5's wounds. The Hospice RN stated, .clean with wound cleanser and Dakin's solution with a wet to dry dressing .the wound care nurse helps with wound care .[Named Wound Care Nurse] come in . During an interview on 10/30/2023 at 2:09 PM, the Wound Care Nurse was asked if she had seen maggots in Resident #5's wound. The Wound Care Nurse Stated, .Yes .all through the summer .in the summer there were a significant amount .we have a fly problem .he is not clean .they have a good food source . The Wound Care Nurse was asked if she had seen a lot of drainage coming from Resident #5. The Wound Care Nurse stated, .the sheets are soaked in drainage .it's either urine or from his ostomy .he roll around without his ostomy bag .sometime the drainage is worse than other times .right now it more urine .in the past it has been bad .sometimes it's dark and slimy .amber red . black, brown .don't know what it's going to be [the drainage] . use chuck pads .more absorbent .tried condom catheter .no go .ostomy bag .he wasn't keeping it [catheter or ostomy bag] on . Observation of the 600-hall on 10/31/20023 at 10:34 AM, near the double fire door on the left side of the hall near room [ROOM NUMBER] revealed two small puddles of fluid on the floor in the hallway. During an interview on 10/31/2023 at 12:15 PM, with the Regional Services Advisor and the Administrator, the Regional Services Advisor was asked if he was aware Resident #5 still had maggots in his wound. The Regional Services Advisor stated, .Yes off and on .it's been 2 weeks ago .they would clear up and come back . The Regional Services Advisor was asked who is ultimately responsible for the safety and welfare of the residents in this building. The Regional Services Advisor stated, .that is us, the Administrator . The Regional Services Advisor was asked with Resident #5's drainage and maggots from his wheelchair onto the floor, is it a safe and clean environment for the other residents. The Regional Services Advisor stated, .there are times when he is dripping .it's not the most sanitary thing .from that standpoint .it is not the most sanitary thing for them (the other residents) to wheel through the drainage and get it on their hands .no its not . During an interview on 10/31/2023 at 12:38 PM, the Director of Nursing (DON) was asked if the facility had addressed or completed a (PIP) Performance Improvement Project to address Resident #5's noncompliance and dripping the drainage and maggots through the facility. The DON stated, I don't have a PIP on [Named Resident #5] on his noncompliance .or have a plan in place .no I don't .we have a risk meeting weekly .clinical meeting daily .he has been discussed in QA [Quality Assurance] .I don't have any documentation of that with his name on it . During an interview on 11/1/2023 at 7:19 AM, the Infection Preventionist was asked if the Resident #5's wounds and maggots would considered an infection and is that something to track. The Infection Preventionist stated, .Yes .I would say yes . The Infection Preventionist was asked who is responsible for infection control in the facility. The Infection Preventionist stated, .It is everyone responsibility in the facility for infection control . The Infection Preventionist was asked should Resident #5 be allowed to handle and pull linen off the linen cart. The Infection Preventionist .No he should not be doing that . During a telephone interview on 11/1/2023 at 8:43 AM, the Psychiatric Family Nurse Practitioner (FNP) was asked if she had addressed Resident #5's behaviors. The FNP stated, .the last time I saw him was on 9/14/2023 .I have been seeing him for a while .I started in January 2022 .note say routine follow-up with him .he is sleeping fine nothing bothering him . his behaviors are chronic and ongoing .I been there for 6 month and there is nothing new . The FNP was asked if she has looked at the root cause of his refusal and behaviors. The FNP stated, When I talk to him, he doesn't want to engage in a conversation with me .he is busy watching videos .when I ask any question, he say .'I'm fine .I'm good' .not able to get meaningful conversation out of him .no he never shared with me the reasoning behind his refusal of care and treatments . The FNP was asked if she had addressed the maggots in his wound and the drainage. The FNP stated, .I have not been told that [about the maggots/drainage] but I do read their notes the facility documentation .I know his wound care has been an issue for a very long time .the fluids /drainage in the facility I have not address those issues with him specifically .my opinion of the situation and him as a person .he is a young guy who had this happen in his life and substance use disorder arrested development in his brain has developed .the way he thinks as a young guy living in a nursing home .he is ticked off about it .refusing care .he don't understand .he don't care .he want to control his life the best way he can .there is no medication to change the fact of how he feels .all that has happen to him .that don't change the fact the choice he is making is affecting everyone around him .he is affecting other resident in the facility .absolutely . During an interview on 11/1/2023 at 1:15 PM, the Wound Care Doctor was asked if Resident #5 had any type of infection. The Wound Care Doctor stated, .he has a strong body odor .he will not shower .yes .a 100 % [percent] infection .his wounds have colonized .it has created bacteria that has become a part of him . During an interview on 11/2/2023 at 7:19 AM, the Floor Technician was asked if he had seen any maggots coming from Resident #5. The Floor Technician stated, .Yes .occasional in the hallway .mainly on the 300-hall .maggots around his doorway . The Floor Technician was asked if he remembered going outside on the smoking area and hosing down maggots Resident #5 had dropped on the concrete. The Floor Technician stated, .Yes .I was called outside they [staff] came and got me to go to the smoking area near the 500-nursing station .in the smoking area .it was over the summer .I did have to hose of the concrete cement .there was maggots .I had to hose it off for safety . During a telephone interview on 11/2/2023 at 8:15 AM, the Hospice Medical Director was asked if he was aware Resident #5 had maggots in his wound. The Hospice Medical Director stated, .Yes .I have been made aware of that .we have tried to stress doing the wound care on a regular basis .he is not interested in the treatments on regular basis . The Hospice Medical Director was asked what is Resident #5's prognosis. The Hospice Medical Director stated, .he is on hospice care .it's a pretty poor life expectancy less than 6 month .he has osteomyelitis, wound problems, and he has an infection in his wounds . The Hospice Medical Director was asked if he was aware Resident #5 was leaking fluids and maggots throughout the facility. The Hospice Medical Director stated, .I believe they have told me his wounds were oozing from the chronic inflammation and from his infection .we have addressed the need for wound care and ostomy care . The Hospice Medical Director was asked should Resident #5 be in contact isolation with the chronic infection in his wound drainage. The Hospice Medical Director stated, .that I'm not sure of .he was getting treated for chronic osteomyelitis at the hospital, and his infection that is bone deep you can see the bones and hardware . The Hospice Medical Director was asked if a resident has chronic osteomyelitis is that a type of wound infection. The Hospice Medical Director stated, .Yes .that's correct . The Hospice Medical Director was asked if it was safe environment for the other residents in the facility when Resident #5 is going throughout the facility leaking drainage and maggots on the floors. The Hospice Medical Director stated, .No .it doesn't sound like it is .if you don't know what in the fluids are .it would be a risk for the other residents .he would need to be keep in some type of isolation .he would need to be in contact isolation .that would be appropriate . The Hospice Medical Director was asked, what was the reason for Resident #5's admission to hospice care. The Hospice Medical Director stated, .part of his diagnosis is for pain management .he stops all treatment in the facility .they contacted us .he was placed on hospice care . During a telephone interview on 11/2/2023 at 10:16 AM, the Director of Hospice Care was asked if she was aware Resident #5 had maggots in his wounds. The Director of Hospice Care stated, .I came out about a month ago .just to check in with [Name Resident #5] .he refuse wound care from my nurse .when I came that day he would not let me get close .I did not see any maggots .he would not keep the colostomy bag on .when my staff get there he will say I'm hurting .we have him on Methadone [is a long-acting opioid medication that is used to reduce withdrawal symptoms] .we told him we are here to help you .no nursing home in Memphis will accept him .tried a condom catheter he would not keep it on .sent to the hospital for a suprapubic catheter [is a medical device that helps drain urine from your bladder .enters your body through a small incision in your abdomen] he would not get the surgery .he is schedule on Mondays and Thursday at 1:00 PM for his wound care .it not for us to do all the wound care .the other times the facility is responsible for his wound care . The Director of Hospice Care was asked if she was aware of Resident #5 leaking drainage and maggots throughout the facility. The Director of Hospice Care stated, .Yes .sometimes he can be saturated with urine or be soiled . The Hospice Director was asked, what was the reason for Resident #5's admission to hospice. The Director of Hospice Care stated, .because of osteomyelitis .he is rotten from the inside out .the wounds are never going to heal .he is admitted for signs and symptom management which is his primary .pain management is a part of every service .his diagnosis of osteomyelitis and the w[TRUNCATED]