**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 eloped on 11/3/2024 out of facility and was across a 35 per mile street, at store near gas pumps, near a highway, that was 40 miles per hour. On 11/2/2024 Resident #1 attempted to elope, before a nurse stopped Resident #1 from going outside. An IJ was identified on 4/25/2025. The IJ template was provided to the facility on 4/25/2025 at 6:41 PM. While the IJ was removed on 4/26/2025 at 7:53 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not an immediate jeopardy due to facility's need to evaluate the plan of removal. This failure could place residents at risk of severe injury or even death. The Findings were: Record review of the provider investigation intake #543029 was documented the incident date was 11/3/2024 at 3:00 PM, with Resident #1 missing resident. Record review of the provider investigation intake #543029 was documented Resident #1 was a hospice respite resident, she was interviewed, independently ambulatory, not able to make informed decisions. Record review of Resident #1's admission Record, dated 4/23/2025, was documented she was admitted on [DATE] and was discharged on 11/6/2024. Further review revealed Resident #1 was at facility for respite care with a diagnosis of dementia (a broad term describing a decline in mental abilities, including memory, thinking, and reasoning, that significantly impacts daily life). Record review of Resident #1's discharge MDS, dated [DATE], was documented a planned discharge, admission was 11/1/2024, her BIMS score was 5/15 (severely cognitively impaired), and behavior was present, fluctuates of inattention and disorganized thinking, section for behaviors Resident #1 had delusions, wandering occurred 1 to 3 days. Resident #1 had dementia, Resident #1 was 59 inches and weighs 101 pounds and was on hospice care. Resident #1 was independent with walking 50 feet with two turns. Record review of Resident #1's baseline care plan, dated 11/1/2024, was documented discharge goals was for return to the community and receive respite care. The baseline care plan was documented Resident #1 was independent with walking 10 feet, chair/bed to chair transfer, sit to stand, lying to sitting on side of bed, sit to lying, roll left to right, eating, did not use mobility devices, resident was alert. cognitively impaired, always continent with bowel/bladder, skin was intact with no skin breakdown, and respite for 5 days by LVN A. Record review of Resident #1's care plan, dated 11/3/2025, was documented Resident #1 has had an episode of elopement and was a risk for wandering/elopement identified, initiated 11/3/2025. Interventions included identify triggers for wandering/elopement, identify if there is a certain time of day wandering /elopement, identify if there is a pattern and purpose of wandering, identify wandering/elopement de-escalation behaviors, provide care in a calm and reassuring manner, provide 1:1 supervision as elopement prevention and provide reorientation to surrounding environment. Record review of Resident #1's Elopement Risk Evaluation, dated 11/1/2024, had scored 0 by LVN A. Elopement risk assessment was marked as a yes for resident wanders, and resident wanders aimlessly or non-goal directed. Record review of Elopement Risk Evaluation score of 0 meant no risk. Record review of Resident #1's progress note, dated 11/1/2024 at 4:13 PM, was document Resident #1 arrived at 10 AM with family. Resident #1 was alert and oriented x1 and in good spirits. Resident #1 had dementia diagnoses and ambulated without assistance. Resident #1 wonders, needs supervision, easily re-directed and was very forgetful. Record review of Resident #1's 24-hour report, dated 11/1/2025, was documented Resident #1 was a new admission, hospice resident, respite for 5 days, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates without assistive devices, and required supervision. Record review of Resident #1's progress note, dated 11/02/24 at 6:31 AM, was documented Resident #1 was adjusting well to facility, was easily re-directed, wonders need continued monitor related to elopement risk/confusion. Record review of Resident #1's progress note, dated 11/02/24 at 4:12 PM, was documented Resident #1 was alert, forgetful and confused at times. Resident #1 was able to communicate well with staff and friendly. Record review of Resident #1's progress note, dated 11/02/24 at 10:56 PM, stated that resident was easily re-directed earlier in the day but became increasingly agitated and was placed on monitoring by LVN B related to an elopement attempt. LVN B stated she thought Resident #1 was still getting used to facility and she informed the oncoming nurse. Record review of Resident #1's 24-hour report, dated 11/2/2025, was documented Resident #1 was a hospice resident, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates without assistive devices, and required supervision. No changes Record review of Resident #1's progress note, dated 11/03/24, Resident #1 attended an activity with a church group. When the church group walked out, Resident #1 walked out with them. LVN A noticed Resident #1 was missing before dinner. LVN A notified staff to search for Resident #1. RN C found Resident #1 at grocery store gas pumps across the 2-lane road from the facility and near 4 lane highway. A head-to-toe assessment was done by LVN A upon Resident #1's return to the facility, and she was placed on 1:1 until her discharge on [DATE]. Record review of Resident #1's 24-hour report, dated 11/3/2025, was documented Resident #1 was a hospice resident, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates without assistive devices, and required supervision. Resident #1 was combative 3 episodes. Elopement- resident was brought back to facility safe/unharmed. no distress noted. in good spirits. 1:1 until further notice. ADM notified. Record review of Resident #1's 24-hour report, dated 11/4/2025, was documented Resident #1 was a hospice resident, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates with supervision due to elopement risk. Resident #1 had 1:1 care redirectable compliant. Record review of Resident #1's 24-hour report, dated 11/6/2025, was documented Resident #1 was a hospice resident, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates with supervision due to elopement risk. Resident #1 had 1:1 care redirectable compliant. Resident discharged today. Record review of the Elopement drill-in-service included 14 staff signatures. Record review of the staff list provided by facility included 51 staff that worked. full time at the facility. Interview on 4/24/2025 at 3:58 PM with LVN B stated she worked the night shift for the last 8 years. LVN B stated she was not working the day Resident #1 Eloped to store. LVN B stated the night before elopement, Resident #1 was close to the unlocked front door and attempted to elope that night, on 11/3/2025. LVN B stated she was monitoring and staff taking turns watching Resident #1 between monitoring and providing care to other residents. LVN B stated she notified LVN A on the on-coming shift about Resident #1's behaviors and wondering. LVN B stated Resident #1 was not attempting to go out the front door at the end of her shift, in the morning. LVN B stated she was not aware that Resident #1 wondered and had behaviors. LVN B stated the nurse before her shift only told her Resident #1 was on respite. Interview on 4/23/2025 at 1:05 PM with LVN A stated Resident #1 was forgetful, confused easily re-directed, disoriented to the facility, and would go into resident rooms. LVN A stated Resident #1 did not have a wander guard (no wander guard system in facility), was ambulatory, and spoke eloquent. LVN A stated Resident #1 was last seen at the church services, on Sunday. LVN A stated the church services was completed, and was not sure where Resident #1 was, she notified staff inside the facility, but no staff had seen her. LVN A stated she notified RN C that Resident #1 was missing, and she notified the ADM, DON, ADON, MD, hospice. LVN A stated RN C searched the perimeter of the facility with her and had found Resident #1 at the store, near the gas pumps. LVN A stated she stayed at the facility to provide care to residents and about 10 minutes later RN C drove up with Resident #1. LVN A stated she did conduct a head-to-toe assessment and Resident #1 did not have any injuries. LVN A stated Resident #1 had told her she was going shopping. LVN A stated she placed Resident #1 on 1:1 with staff for the rest of her shift and let the on-coming nurse know about the Elopement with Resident #1. Interview on 4/23/2025 at 1:39 PM with CNA V stated LVN A had notified her that Resident #1 was missing, and she took the facility van to search for Resident #1. CNA V stated RN C had found Resident #1 and brought her back to the facility from the store across from the facility. CNA V stated Resident #1 walked across the 2-lane street and across the store, that was near a 4-lane highway. CNA V stated there had been no elopements before or after Resident #1 eloped. Interview on 4/23/2025 at 2:27 PM with RN C stated she went to get Resident #1 for dinner and asked staff if they had seen the resident. LVN A searched the activity room and inside the facility. RN C searched the outside perimeter, and found Resident #1 at the grocery store, near the gas pumps. LVN A stated Resident #1 was missing for 15-20 minutes. LVN A placed Resident #1 on 1:1 monitoring with staff. Interview on 4/23/2025 at 3:36 PM with ADM stated Resident #1 was missing form facility for 10-15 minutes and was found by RN C. The ADM stated the Maintenance Supervisor stated he was working that day, Sunday in the front yard and saw an elderly women leave the church group. Interview on 4/23/20025 at 3:41 PM with the Maintenance Supervisor stated he was working, that Sunday. The Maintenance supervisor stated he was raking the leaves and saw the church group leave the facility but did not know a resident was with the church group. The Maintained Supervisor stated he went inside the facility, and LVN A had notified they had a missing resident that was with church group. The Maintenance supervisor stated, and he started searching for Resident #1. Interview on 4/24/25 at 9:56 AM with ADON stated she was not aware of Resident #1's attempt to elope on 11/02/24. ADON stated her expectations would be for nurse to call her. ADON stated they did not have a wander guard system and the front doors were not locked. ADON stated she would expect the nurse to re-evaluate Resident #1 for elopement risk. ADON stated if she had known about the attempt to elope, she would have initiated the 1:1 sooner. ADON stated if she was aware of Resident #1's wandering behavior, she would have told the nurses to monitor resident 30 minutes to every 1 hour daily. Interview on 4/24/2025 at 1:00 PM with the ADON stated in the morning staff meetings they review the 24-hour reports. The ADON stated they did have an elopement book and Resident #1's picture, admission record was placed in the elopement book. The ADON stated she was not sure when Resident #1 was placed in the Elopement book. The ADON stated the expectation for nurses was to do another Elopement Assessment after an Elopement, she was not sure why Resident #1 did not have one in her chart. Interview on ADON stated Resident #1 was missing for 5 minutes, and LVN A did notify her about the elopement. Interview on 4/24/2025 at 1:50 PM with the ADM stated they had conducted an elopement drill/in-service for staff on the Elopement policy. Interview on 4/26/2025 at 5:00 PM with the Administrator stated, as a result of the elopement, the facility no longer accepts respite care residents who are independently ambulatory and have advanced Alzheimer's. They also make it clear to families during early admission process that they do not have the physical barriers or staffing levels to manage a resident who wanders/exit seeks. An attempted interview on 4/25/2025 at 9:14 AM with family of Resident #1 did not answer, left a voicemail with no return call. Record review of Elopement Policy dated 2001 was documented The facility will identify residents who. are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan Will include strategies and interventions to maintain the resident's safety. o 2. If an employee observes a resident leaving the premises, he/she would: a. attempt to prevent the resident from leaving in a manner. b. get help from other staff members in the immediate vicinity, if necessary; and . c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: . a. Determine if the resident is out on an authorized leave or pass; b. If the resident as not authorized to leave, initiate a search of the building(s) and premises; and c.If the resident is not located, notify the administrator and the director of nursing services, ·the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility; the director of nursing services or charge nurse shall: a. examine the resident for injuries. b. contact the attending physician and report findings and conditions of the resident. c. notify the resident's legal representative (sponsor); d. notify search teams that the resident has been located. e. complete and file an incident report; and f. document relevant information in the resident's medical record. The Administrator was notified of an IJ on 4/25/2025 at 6:41 PM and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 4/26/2025 at 7:53 PM and included the following: Plan of Removal for Immediate Jeopardy Related to Resident Elopement (F689) Facility Name: [name] Facility ID Number: 004531 Date of Immediate Jeopardy Identification: 4-25-2025 Resident Involved: [name] Date of Elopement: 11-3-2025 Date of Return: 11-3-2025 1. On 4/25/2025 the Administrator and Director Nursing notified the Medical Director of Immediate Jeopardy. Medical Director reviewed the facility's Elopement Policy & Procedure and approved its continued use. At the time of this Plan of Removal, resident no longer resides in the facility. 2. On 4/25/2025, the facility conducted an Elopement Assessment on all current residents to identify elopement risks. 3. The facility implemented a change to its Elopement Assessment protocol to require nursing staff to perform elopement assessments on day 1, day 3, and day 5 for all new admissions, followed by quarterly assessments. A new elopement assessment will also be required for residents who are demonstrating new elopement or exit seeking behavior. Residents demonstrating changes of conditions in wandering or exit seeking behavior will be assessed through both clinical and physical methods to determine the cause in their change of condition. The facility will implement appropriate measures to mitigate the risk of elopement appropriate to the resident's needs and risk factors, to include but not limited to: Diagnostic testing Increased supervision Family Intervention Discharge to acute setting for further testing Medication Reviews and adjustments Discharge to appropriate setting Referral to psychological services Any changes of behavior or conditions that increase the resident's risk of elopement must be reported to the Director of Nursing or the Assistant Director of Nursing. 4. The facility DON or her/his designee will monitor compliance to its new elopement assessment protocol by reviewing new admission documentation during its daily clinical review for 4 weeks to ensure compliance. Any discrepancies or deviations from this protocol will be addressed by the DON and/or her designee for compliance. 5. Ad-Hoc QAPI meeting was held on 4-25-2025 with the Medical Director, Facility Administrator, Director of Nursing, and Assistant Director of Nursing to review the deficiency and the plan for removal of immediacy. The verification of the Plan of Removal is as follows: 1. Interview on 4/26/25 at 11:15 AM with the DON stated for the Ad-Hoc QUAPI meeting the ADM and ADON were present, and the Medical Director was in a conference call and reviewed the Elopement policy and discussed the IJ and plan of removal. Record review of Ad hoc meeting on 4/25/25 called MD on phone, conference call attendees were ADM, DON and ADON. Resident #1- At the time of elopement, staff located resident in seven minutes and returned her to the facility. Resident was assessed and found free of any injury and/or distress. Record review of Resident #1's face sheet dated 4/26/25 revealed she was admitted on respite on 11/1/24 and discharged on 11/6/24. Notification - The facility notified resident's responsible party and physician. At the time of the incident, the facility staff notified facility administrator and Director of Nursing. Record review of Resident #1's progress notes dated 11/3/25 at 19:46 was documented LVN A notified the ADM, family, RP, DON and ADON regarding Resident #1's Elopement and placed her on 1:1 care. On 11-4-2024, the facility staff conducted a head count to ensure all residents were accounted for and in the facility. Interview on 4/26/25 at 5:21 PM with ADM and DON stated they talked to 2 charge nurses, and they did a head count to confirm all residents were in the building. 2. Observation on 4/26/25 at 12pm revealed Elopement policy, Elopement binder and Elopement Assessment policy at each nurse's station. (2 nurse's stations). Record review of 51 residents had Elopement Assessment completed on 4/25/25. Record review of current resident list was document with a census of 51. On 4/25/2025, the facility provided education and a copy of the facility's Elopement Policy and Procedure. Facility management verified all staff members received and understood the Elopement Policy and Procedure. Upon confirming receipt, staff members were asked to verbalize their understanding of policy. Record review of the policy on Elopement were emailed to staff and were signed acknowledging they receive the policy. Record review of in-service for Elopement policy dated 4/25/25 had 64 staff signatures. All staff: Interviews on 4/26/25 between 11 AM- 4:45 PM: Training was on Wandering and Elopement, what to do if resident leaves the facility-try to re-direct and be kind, if combative will notify/call nurse/staff to help. If resident missing from facility, first find out if went out on pass with family at each nurse's station, search of the resident in building count resident, notify ADM, DON, and ask staff in the building. If not in building need to notify MD, family and police, staff check out the outside perimeter and beyond. To be the eyes and ears of the facility and be aware of resident coming and going. They have Policy and Elopement book at each nurse station and which resident is at risk. Nursing staff get reported from previous staff of new residents. DON emailed the staff policy and staff had to sign to confirm they received the email policy on Elopement/Wandering: D- Dietary Manager E- Dietary Cook F- Dietary aid G- CNA H- CNA I- Housekeeping J- OT K-CMA P- Laundry, before a CNA Q- Housekeeping/laundry supervisor R- HR S- Maintenance T- Housekeeping U- CNA V- [NAME], CAN Y- CNA (Night shift) Z- CNA (Night shift) AA-, prn, OT CC CNA EE-, OT, prn FF- PT, prn wknds, stated she did get training by DON. 3. Observation on 4/25/25 with nursing in-service on Elopement/Wandering and Assessments. The observation was led by the DON and 4 nurses were present. Record review of Elopement assessment dated [DATE] was documented 13, plus the DON that led the in-service, form nursing department. Interviews with staff on Elopements review policy and educate staff on how to proceed in case of Elopement and only Nursing staff: -Elopement Assessments in-services dated 4/25/2025. Record review of current staff list dated 4/25/25 revealed a total of 64 total staff, 51 current staff and included 14 nurses, that worked routinely and as needed. Interviewed staff the 2 shifts and staff stated they rotate weekend shifts. Interview on 4/26/25 at 11:03 AM with the DON nurses were educated on the Elopement Assessment -Educate on New changes related to when Elopement Assessment will be conducted. Interviews on 4/26/25 between 11 AM- 4:45 PM: Interviewees stated they were trained on Elopement and Assessments. Elopement assessments were to be done on admission, day 3, day 5, quarterly, prn. Nursing was to check for change of condition, notify the DON, MD, and family. If resident was missing check to see if they are out on pass, complete a head count, search inside the facility and outside. Notify RP, ADM, MD, DON and ADON and police. When the resident returned, document elopement assessment, progress notes incident report, and complete any treatment from MD if any injuries. Notify the RP, ADM, MD, DON and ADON and police once the resident is found. Staff stated they also, received an email from ADM/DON on elopement and signed that they received the policy. A- LVN B- LVN L- RN M- ADON N- LVN O- MDS, LVN W- LVN (Night shift) X- LVN (Night shift) BB- LVN DD- LVN prn, Record review of the Elopement in-services revealed All facility nurses were provided education of this new requirement on 4/25/2025. Record review of the staffing list dated 4/26/25 was documented the facility had 14 nurses. 4. Record review of Elopement Assessment Monitoring for New/re-admit Residents sheet was in POR binder, included 1 resident. The 1 re-admit resident elopement assessment was completed on 4/26/25. Resident was admitted on [DATE]. The Elopement Assessment Monitoring included a section for Day 1, Day 3, and Day 5, and included dates of completion section. Interview on 4/26/25 at 3:34 PM with ADON stated she will fill out the monitoring sheet for new/re-admit and change of condition regarding elopements. 5. Interview on 4/26/25 at 11:15 AM with the DON stated for the Ad-Hoc QUAPI meeting the ADM and ADON were present, and the Medical Director was in a conference call and reviewed the Elopement policy and discussed the IJ and plan of removal. Interview on 4/26/25 at 5:38 PM the MD stated he was told by the DON that they had an IJ for F689 on Elopement and participated in the Ad-hoc QUAPI mtg. Record review of Adhoc meeting on 4/25/25 revealed the MD was called on phone, conference call attendees were ADM, DON and ADON. The Administrator will be responsible for ensuring this plan is completed on 4-25-2025. Interview on 4/26/25 at 5:16 PM with ADM confirmed the POR binder was completed by each section and ensured the MD was in agreement with the Elopement policy and plan. Also, conducted elopement assessments for each resident and ensured all staff were educated on Elopement. On 4/26/2025 at 7:53 PM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not an immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for neglect, in that: The facility failed to prevent Resident #1 from having maggots in his tracheostomy site, who was hospitalized on [DATE] for maggot infestation around the tracheostomy and acute on chronic respiratory failure. Resident #1's stoma was suctioned around the trach until it was cleared of all maggots. A bronchoscopy was performed and cleared clots. Resident #1 was admitted to ICU for continued mechanical ventilation. An IJ was identified on 11/12/2023. The IJ template was provided to the facility on [DATE] at 3:59 p.m While the IJ was removed on 11/14/2023 at 3:18 p.m., the facility remained out of compliance at a scope of isolation and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice could place residents at risk of psychosocial harm, place them at risk of a decline in health and/or death. The findings were: Record review of Resident #1's undated facesheet revealed he was admitted to the facility on [DATE], readmitted on [DATE] and discharged on 11/08/2023. Resident #1's diagnoses included tracheostomy (an incision in the windpipe [trachea] for a direct airway to the lungs which results in a stoma for a tracheal tube to allow a person to breath or receive oxygen), chronic respiratory failure (inadequate oxygen and carbon dioxide exchange in the longs), heart disease and morbid obesity (complex chronic condition of excess body weight that can lead to serious health issues). Record review of Resident #1's Electronic Active Physician Orders revealed an order for Change Trach Collar Every Other Day on Shower Days M-W-F once a day on Mon, Wed, Fri. with a start date of 05/20/21. Record review of Resident #1's Electronic Active Physician Orders revealed an order for Trach: Shiley Cuffless 6 XLT with a start date of 05/25/2022. Record review of Resident #1's Electronic Active Physician Orders revealed an order for Monitor Trach stoma site daily for signs and symptoms of infection twice a day with a start date of 08/31/2022. Record review of Resident #1's TARs for October 2023 and November 2023 revealed tracheostomy care was performed three times a week as ordered with no indication the resident refused care. Record review of Resident #1's TARs for October 2023 and November 2023 revealed the trach stoma site was monitored twice a day with no indication of abnormalities noted. Record review of Resident #1's Wound Management report, dated 11/07/2023 revealed the resident had a non-pressure wound on his left thigh and no other skin issues were noted. Record review of Resident #1's most recent MDS, a Quarterly assessment dated [DATE], revealed his BIMS (Brief Interview of Mental Status) was 13 out of 15, indication his cognitive decision-making skills were intact; and required tracheostomy care. Record review of Resident #1's Care Plans for Problem area of Resident #1 is at risk for pneumonia, respiratory infection related to tracheotomy created on 07/20/2023. Under Approaches was Practice methods of infection control while doing trach care and teach Resident to practice methods of trach care. Record review of Resident #1's Care Plans for Problem area of Potential for infection related to tracheostomy, created on 07/20/2023, revealed under approaches was Assist with and provide oral care as needed. Monitor and report signs of hypoxia [low blood oxygen levels] .Monitor and report signs of respiratory distress . Record review of Resident #1's Care Plans for Problem area of Resident #1 has a tracheostomy: Shiley cuffless 6XLT-and is at risk for increased secretions, congestion, respiratory infections and infections to tracheostomy site, created on 12/24/2020. Under approaches was Change inner cannula Shiley size 6 on Monday, Wednesday, and Friday. Change trach [NAME] [sic] on Monday, Wednesday, and Friday (shower days) after shower .monitor for signs/symptoms of infection-report to MD. Record review of Resident #1's nurses note, dated 11/08/2023 by LVN C, revealed Patient reported during shower this afternoon, after coughing. He noted a bug that had fallen from his trach area. Upon assessment, at first no maggots were visible. Patient was then asked to extend his neck upwards where site was more visible and stretched. Maggots were then seen coming out of tracheostomy. Cleansed area with normal saline. Trach care administered. ADON aware. Orders given to send out to Hospital per NP. Administrator contacted RP. Record review of Resident #1's nurses note, dated 11/08/2023 by ADON, revealed This nurse and admin. [administrator] contacted RP in regard to maggots being found in trachea site. RP was informed that resident would be sent to Hospital. RP was understanding of the situation with no concerns stated at this time. Record review of Resident #1's SBAR note, dated 11/08/2023 by ADON, revealed the resident showed no signs of distress and it was noted small bugs appeared to be crawling in the trachea site and the resident was sent to the hospital. Record review of Resident #1's Hospital Emergency Provider Report, dated 11/08/2023 at 1712 (5:12 p.m.) revealed the chief complaint was maggots in trach. Record review of Resident #1's Hospital History & Physical, dated 11/08/2023 at 1942 (7:42 p.m.) revealed Patient is a [AGE] year-old male with past medical history of chronic hypoxic respiratory failure/obstructive sleep apnea/obesity hypoventilation syndrome status post chronic tracheostomy, morbid obesity ., . chronic diastolic heart failure ., who presented to the ER from nursing home for complaints of maggots over the tracheostomy area. Patient states that he noticed some maggots over the area and came to the ER for evaluation, patient denies any fevers, chills or any other complaints. Upon ER presentation, patient was found with adequate vital signs, afebrile [without fever] and with mild central vascular congestion. On examination, patient with multiple maggots over tracheostomy site . Record review of Resident #1's Hospital Critical Care Consult Note, dated 11/08/2023 at 2005 (10:05 p.m.), revealed the resident was admitted to the hospital for maggot infestation around tracheostomy .In ED [Emergency Department], patient was noted to have multiple maggots around his tracheostomy site. With RT [Respiratory Therapy] at bedside, patient was sedated/paralyzed then stoma was suctioned around trach until it was cleared of all maggots. Tracheostomy was then changed however during procedure, patient sustained superficial trauma causing bleeding. As such, bronchoscopy was subsequently performed and cleared of clots. Patient was then upgraded to the ICU for continued sedation/mechanical ventilation. Under Diagnosis was [AGE] year old male .was admitted to the hospital for maggot infestation around tracheostomy, and acute on chronic respiratory failure. Current medications administered in the hospital included Zosyn (an IV antibiotic). Record review of the Intake Investigation Worksheet, revealed the facility notified Texas HHSC on 11/08/2023 at 4:47 p.m. Resident #1 was found to have .maggots in the trach site. Although we could not confirm actual maggots at the time of this report, visual inspection of trach site shows movement underneath the hyper granulated skin of the trach sight [sic] and what appears to be several ends of very small maggots protruding from the hyper granulation of the skin. Based on the size of the possible maggots, this infestation is a current/acute incident. Record review of the facility's Provider Investigation Report revealed the following typed and signed statements: 1. Statement from LVN C - On Wednesday November 8th 2023, at approximately 3:15 [p.m.], I was approached by Resident #2 in the hallway. Resident #2 informed me that his roommate, Resident #1, had told him he had seen a maggot fly out from his neck/trach area and land on his lap. Resident #2 wanted me [LVN C] to go check on Resident #1. I asked Resident #1 if anything was wrong, he responded by saying everything was fine. I asked him if he had seen a maggot land on his lap, he said yes. I proceeded to inspect his Trach and witnessed a small maggot near the trach opening. I further spread the trachea opening and witnessed several more maggots inside the trachea opening. I then informed my Assistant Director of Nursing . 2. Statement from CNA H - On Wednesday November 8th 2023, at approximately 2:45 [p.m.], I showered Resident #1. Resident #1 is particular about his showers in the fact that he likes to clean himself and does not like being watched. I set him up, have [sic] the water running for him and will continually check on him. That day, I did not see any maggots on Resident #1 during the shower or prior to the shower. 3. Statement from ADON - At approximately 3 PM was called down to Resident #1's room by Charge Nurse LVN C. Upon entering the room Resident #1 was noted sitting on the edge of bed and Charge Nurse stated that resident appeared to have maggots in trachea site. Upon further assessment and resident leaning head back, you could see very small maggots inside the site located around the hyper granulation tissue within the trachea site. At this time call was placed to NP [Nurse Practitioner] who stated we [the facility] .need to send out to ER but she would reach out to the resident MD to verify. Resident #1 appeared to be in no distress and stated he felt fine. I spoke with resident and nurse and they both stated that scheduled trachea care had been performed on the last scheduled day. Shortly after received further direction from NP to send [Resident #1] to ER no preference in hospital was given. Administrator was .notified of the situation. 4. Statement from Administrator - On Wednesday 11-10-2023, at approximately 3:00 p.m., I was notified by facility Assistant Director of Nursing (ADON) that Resident #1 had small maggots in his trachea/trach area. The ADON contacted nurse practitioner and obtained an order to send resident to the hospital. The facility staff searched the resident's room for possible infestation, but none was present. At the time of this investigation, the resident remains in the hospital. Record review of a list of residents with trachs provided by the facility, dated 11/10/23, reflected only one resident with a trach. That resident was Resident #1. In an interview on 11/10/2023 at 11:09 a.m., LVN C stated Resident's #1's roommate (Resident #2) informed her Resident #1 told him Resident #1 had coughed up a maggot. LVN C stated she went to Resident #1's room, spoke to Resident #1 about what his roommate mentioned to her, and Resident #1 stated he had coughed in the shower and a maggot came out, but he had thrown it away. LVN C changed his trach collar, had the resident raise his chin up in a hyperextension position and she saw some small maggots trying to crawl out of his stoma (trach site) but did not see any on the resident's inner cannula. She immediately notified the ADON. LVN C stated she had performed trach care to Resident #1 on 11/06/2023, when she assessed the stoma site it was very clean with no odors or insects seen around the site. LVN C stated Resident #1 would not refuse trach care and very seldom would he go outside. In an interview on 11/10/2023 at 3:54 p.m., the ADON stated LVN C informed her Resident #1 had maggots around his trach site, so she came and examined Resident #1. The ADON said she first had Resident #1 lean his head back and she did not see any insects around his trach site until she used her hands to pull the skin on his neck that was around the trach site back and she saw what looked like maggots around the stoma site. The surveyor handed her a ruler with inches and centimeters on it and the ADON said the insects were thin, whitish/yellow, and about 1 cm in length. The ADON stated the insects were on the edge of hyper-granulated tissue that was around the resident's stoma site. The ADON asked Resident #1 if the nurses were doing tracheostomy care and he said they were. The ADON notified Resident #1's physician who gave orders to send the resident to the hospital, notified the resident's responsible party and the administrator. In an interview on 11/10/23 at 1:49 p.m., the Administrator stated Resident #1 would frequently touch his trach site but would not refuse trach care. The Administrator stated he contacted Resident #1's physician who stated the flies would naturally be attracted to any wound. In an interview on 11/11/2023 at 8:03 a.m. with Hospital RN D, she stated Resident #1 arrived on the night shift and maggots were suctioned from his trach site. Hospital RN D stated Resident #1 had been on a ventilator yesterday (11/10/2023) due to irritation to his trachea but today he was off the ventilator and received oxygen via the trach, and the nurse who was caring for Resident #1 was Hospital RN E. In an interview on 11/11/2023 at 8:32 a.m. with Resident #1 in the hospital revealed he could not vocalize but could mouth his responses. When asked if he did his trach site care or the nurses, he mouthed the nurses did it. When asked if he ever saw any insects in the facility, Resident #1 mouthed roaches and flies. When asked who he told about the flies, Resident #1 mouthed Administrator. When asked if he would ever go outside, Resident #1 mouthed no. In an interview on 11/11/2023 at 8:37 a.m., Hospital RN E, reported Resident #1 was receiving IV antibiotics as a precaution due to the presence of maggots in his trachea stoma. In an interview on 11/10/2023 at 12:38 p.m., Resident #2, who was roommate to Resident #1, stated Resident #1 had told him Resident #1 had coughed up a maggot. Resident #2 stated he asked Resident #1 if he had told a nurse & Resident #1 stated he had not. Resident #2 told the nurse who came and spoke with Resident #1. Resident #2 stated he had seen flies in their room and the last time he had seen flies was on 11/08/2023. In a telephone interview on 11/11/2023 at 3:06 p.m., CNA H stated she was in the shower with Resident #1 on 11/08/2023 but did not shower him as he preferred to shower himself and she was only there if he needed assistance. CNA H stated Resident #1 told her he thought he coughed up a little worm and she did not see the worm because Resident #1 had killed it. CNA H stated Resident #1 had told his roommate about the worm and his roommate told the nurse about the worm before she could inform the nurse. Further interview on 11/11/2023 at 12:28 p.m., Resident #2 stated he and Resident #1 kept a fly swatter in their room to kill flies; he looked around the room for it but could not find it for the surveyor. In a telephone interview on 11/11/2023 at 2:10 p.m., CNA G stated on 11/08/2023, after Resident #1 went to the hospital, she removed the bedding from his bed, examined his bedding and mattress for signs of a parasite [maggot] but did not see any. CNA G further stated on 11/09/2023, the day after Resident #1 went to the hospital, she saw a fly in his room and killed it with a fly swatter that was in the room but did not tell the administrator or maintenance director about the fly. In an interview on 11/11/23 at 4:39 p.m. LVN C stated she would put gloves on, use a trach kit, remove Resident # 1's inner cannula, which is disposable, and place a new inner cannula in. LVN C stated she would clean around his trach collar and would clean the area with normal saline and she would have Resident #1 extend his neck up so she could clean around the outer cannula. In an interview on 11/12/23 at 3:11 p.m. LVN K stated when she did trach care Resident #1 will sit up on his bed and will lean back so she can see the trach site. LVN K stated she would use a trach care kit, washed her hands, poured the peroxide into 1 compartment and saline in another compartment. She stated she would remove his inner cannula and throw it away since it was disposable, then she would remove the old gauze pad, change gloves and clean around the trach area with the peroxide/saline mixture with a q-tip. LVN K would take a gauze with normal saline to clean around the stoma/trach area. Then she would pat it dry and get another q-tip and clean out the outer collar and change out the neck collar. LVN K stated when Resident #1 leaned back she had good access to the trach stoma and she could see in the stoma and see the hyper granulation tissue. Record review of the facility's Pest Control Company J's Contract, dated 10/26/2018, revealed Flying Insect Light Trap Service Program, up to 1 Insect Light Traps would be provided to the facility, and the glue board in the light would be changed 12 times a year. Record review of the facility's Pest Control Company J's service statement dated 10/05/2023 revealed the facility was treated for roof rats, cockroaches, all entry/exit doors were treated and did not indicate if the facility was treated for flying insects. Record review of the facility's Pest Control Company J's service statements revealed service was provided to the facility on [DATE], 09/07/2023, 07/12/2023, 06/07/2023, and 05/18/2023. Record review of the facility's Pest Control Company J's service statement for 07/12/2023 revealed the facility was treated for roof rats, cockroaches and only some minor fly and mosquitoes were found during the inspection. Record review of the facility's Pest Control Company J's service statements for 10/05/2023, 09/07/2023, 07/07/2023, and 05/18/2023 revealed the reports did not indicate the facility was treated for flying insects. In an interview on 11/10/2023 at 3:04 p.m., the Maintenance Director stated the facility was serviced monthly by the pest control company, he seldom sees any flies and the facility did not have any wall mounted flying pest control lights. In an interview on 11/11/2023 at 2:46 p.m., the Administrator stated the facility did not have any flying insect lights. When asked how the facility controls flying insects, he stated the facility doors have automatic closures on them, so the door doesn't stay open. In an interview on 11/11/2023 at 3:27 p.m., the Administrator stated other ways the facility controls insects were with housekeeping staff cleaning residents' rooms daily and routine pest control service but occasionally a fly will enter the facility when families bring items for the residents. In an interview on 11/12/2023 at 2:07 p.m., the ADON stated the risk of maggots in the resident's trachea site could result in infection and possibly lead to some respiratory issues. The ADON stated the DON, who was out on medical leave, would monitor the facility's electronic clinical records to ensure the nurses were documenting trachea care was performed and would provide annual skills check-off of the nurse's technique for performing trachea care and upon hire. In an interview on 11/12/23 at 2:45 p.m., the Administrator stated he has not had any grievances about flies or insects from residents. The Administrator stated he could not exactly say what the harm or adverse condition could be of maggots in the trachea site as he was not a clinician, but he could see the possibility of it [a maggot] getting in to his [Resident #1's] lungs and cause a possible infection. Record review of the facility's Abuse Prevention Program policy, revised November 2010, revealed Our residents have the right to be free from abuse, neglect, exploitation, or mistreatment . Under Policy Interpretation and Implementation was 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: b) Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; . Record review of the facility's Pest Control policy, revised May 2008, revealed Our facility shall maintain an effective Pest Control Program. Under Policy Interpretation and Implementation was 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. This was determined to be an Immediate Jeopardy (IJ) on 11/12/2023 at 3:59 p.m. The facility Administrator and ADON were notified. The Administrator was provided with the IJ template on 11/12/2023 at 3:59 p.m. On 11/12/2023 the facility provided a plan of removal titled: Plan for Removal. The plan of removal was accepted on 11/13/2023 at 4:45 p.m. It is documented as follows: On 11/12/2023 the Administrator and ADON notified the Medical Director of immediate jeopardy. On 11/12/2023 Maintenance Director/Designee checked all rooms in the facility to make sure, there were no flies. Administrator contacted Pest Control Company on 11/12/2023 to install bug lights in the facility and will be installed as soon as possible. On 11/09/2023 ADON assessed all residents with wounds that reside at the facility - no findings of pests in the wound or s/s of infection, on 11/12/2023 ADON/Designee re-assessed all residents with wounds that are currently in the facility for any insects inside the rooms or on the residents' wounds. No other residents were identified who had had insects in the rooms or on them. The Medical Director was updated on the assessments. On 11/12/2023 Administrator/Designee completed in-services with Maintenance Director and IDT on clean environment to prevent pest infestation inside the facility and on residents, including pest control policy. ADON/Designee in-service staff on abuse and neglect prevention, and clean environment to prevent pest infestation inside the facility and on residents. Staff were instructed to notify the Maintenance Director or supervisor if noted any pest infestation inside the facility and on residents immediately. All staff, including the Agency, newly hired staff, and PRN will be in-service and will not be allowed to start work till done so. The administrator will ensure all staff have completed in-services and training prior to starting work. The training will be completed by 11/12/2023. Ad-Hoc QAPI meeting was held on 11/12/2023, with the Medical Director, NHA (Nursing Home Administrator), Assistant Director of Nursing, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 11/12/2023, Maintenance Director/Designee will check all rooms in the facility for any flies daily Monday to Friday, and Manager on Duty Saturday and Sunday once a month. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. Regional Nurse Consultant will at least monthly verify that bug lights are working, and glue boards are changed. Facility Administrator will be notified of findings. The Administrator/designee will monitor compliance by completing an audit of five (5) residents' rooms per week for four (4) weeks to make sure the environment is clean to prevent pest infestation inside and on residents. This will be initiated on 11/12/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The Administrator will be responsible for ensuring this plan is completed on 11/12/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. The facility's POR Verification was as follows: Observation on 11/13/2023 at 2:03 p.m. revealed a wall mounted flying insect light trap was placed by exterior exit door on B Wing across from RM B4 and B6 that led to the center courtyard. Observation on 11/13/2023 at 2:10 p.m. revealed the Service Technician I from Pest Control Company J, had a white can that he was spraying around the door frame of one of the exit doors into the center courtyard from the big dining room at the end of B Wing. In an interview on 11/13/2023 at 2:15 p.m., Service Technician I from Pest Control Company J revealed the white spray can contained a fly bait which he was spraying the door frames and the seams to kill any flies in the facility. In an interview on 11/14/2023 at 8:50 a.m., the ADON stated she assessed residents who had wounds for maggot infestation on 11/09/2023 and on 11/12/2023; and were seen by the wound care physician and the nurses documented a progress note in the residents' clinical record for assessments done on 11/12/2023. In an interview on 11/14/2023 at 9:25 a.m., the ADON stated all the employees except for one, who was out sick, had been in-serviced on Pest Management and Abuse Prevention Program. The ADON stated the maintenance director did rounds in residents' rooms to check for insects. The ADON stated on 11/12/2023 she checked every resident and their rooms for insects and did not find any. In an interview on 11/14/2023 at 9:45 a.m., the Regional Nurse Consultant verified she had conducted the audit of the flying insect light on 11/13/2023. In an interview on 11/14/2023 at 11:38 a.m., the Medical Director stated he was notified of the immediate jeopardy situation at the facility, and he was informed wound assessments had been completed on residents with wounds on 11/12/23 with no negative findings found. In an interview on 11/14/2023 at 11:50 a.m., the Maintenance Director reported he would check the residents' rooms in the morning and initial on the dated Resident Roster their room had been checked. In an interview and observation on 11/14/2023 at 11:53 a.m., the Maintenance Director showed this surveyor a [NAME] Binder that was in a clear, acrylic holder behind the A Wing Nurse's station. The binder was labeled A Wing Maintenance and Pest Sightings Log. Inside the binder was a log sheet staff could record pest sightings and maintenance concerns. In an interview and observation on 11/14/2023 at 11:54 a.m., the Maintenance Director showed this surveyor a Black Binder that was in a clear, acrylic holder behind the B Wing Nurse's station. The binder was labeled B Wing Maintenance and Pest Sightings Log. Inside the binder was a log sheet staff could record pest sightings and maintenance concerns. In an interview on 11/14/2023 at 1:22 p.m., the Administrator stated he called the Medical Director on 11/12/23 and left a message, and then on 11/13/23 the Administrator and ADON went to his office to discuss the situation. The Administrator stated the Maintenance Director will use a daily room roster with the current date to initial off when residents' rooms had been checked for insects. The Administrator stated employees were in-serviced on 11/12/2023 in person or by phone on Pest Management, reporting signs of any pest to the maintenance director and recording on the logbook kept at the nurse's stations. The Administrator stated an Ad Hoc QA meeting was held on 11/12/23 and the IJ situation was discussed with members of the QA committee. The Administrator stated he will audit 5 resident rooms in addition to the monitoring of resident rooms done by the Maintenance Director and record the room audits he does on an audit log. The Administrator stated the company's RDO would be in the facility once a month and he would be checking to ensure the facility was doing the monitoring logs and interventions listed in the POR. During interviews conducted on 11/14/23 between 10:15 a.m. and 3:00 p.m., 34 of 48 staff members (including 12 Certified Nurse Aides, 1 Medication Aides, 4 LVNs, 3 RNs, 3 Administrative Staff, 5 Dietary Staff, 6 Housekeeping/Laundry, and 1 Activity Director) were interviewed and confirmed they received education on abuse, neglect, clean environment, pest control policy, and what to do if insects were found. Record review of the Quality Assessment and Performance Improvement Plan signature page, dated 11/12/2023, revealed an Ad Hoc meeting was held to discuss the incident of Resident #1 on 11/12/2023 at 6:00 PM. In attendance was the Medical Director, Administrator, ADON, and the MDS Nurse. Record review of an undated Audit: Light Audit sheet revealed on 11/13/2023 it was checked to verify the flying insect light was in place, was working and a glue board was in place by Regional Nurse Consultant. Record review of the In-service Training Sign-in Sheet for Clean Environment & Pest Control Policy presented to the IDT on 11/13/2023 revealed 8 IDT members were in-serviced on the facility's Pest Control Policy. Record review of the In-service Training Sign-in Sheet for Pest Management presented to employees on 11/12/2023 revealed 48 employees were in-serviced on the facility's Pest Control Policy and any pest sitting such flies, bugs, etc. must be documented in pest binder located at each nurse's station. Record review of the In-service Training Sign-in Sheet for Abuse & Neglect presented to employees on 11/12/2023 revealed 48 employees were in-serviced on the facility's Abuse Prevention Program. Record review of a list of 16 residents with wounds, dated 11/12/2023, revealed in a hand-written note at the bottom that all the residents had been assessed, no noted concerns or infections noted. Record review of a list of 15 residents with wounds, dated 11/09/2023, revealed in a hand-written note at the bottom that all the residents had been assessed, no noted concerns or infections noted. Record review of 15 of the 15 residents with wounds who were in the facility revealed they all had a wound assessment completed on 11/12/2023 except for one resident, who refused the wound assessment but did consent to a wound assessment the following day. Record review of a Daily Census Report dated 11/12/2023, in the facility's POR binder, revealed next to each residents' name was the ADON's initials and handwritten at the top was check for insects in room or on resident by ADON. Record review of a Daily Census Report dated 11/12/2023, 11/13/2023, and 11/14/2023 in the facility's POR binder revealed next to each residents' name was the Maintenance Director's initials and handwritten at the top was room Inspections for active flies conducted by Maintenance Director. Record review of Pest Control J's service invoice dated 11/13/2023 revealed a technician was in the facility from 1:52 p.m. to 2:30 p.m. and applied spot treatment of Pressurized Fly Bait in the facility. On 11/14/2023 at 3:18 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity of actual harm with a potential for more than minimal harm due to the facility's need to monitor the implementation and effectiveness of its POR. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests for 5 of 6 residents (Resident #1, #2, #3, #5, and #6), in that: 1. The facility failed ensure Resident #1's room was free from flies. Resident #1 was hospitalized on [DATE] for maggot infestation around the tracheostomy and acute on chronic respiratory failure. Resident #1's stoma was suctioned around the trach until it was cleared of all maggots. A bronchoscopy was performed and cleared clots. Resident #1 was admitted to ICU for continued mechanical ventilation. 2. Resident #3, and Resident #5 had a flies in their room as they ate their breakfast and lunch tray on 11/10/2023. 3. Resident #6 had a fly on his shirt while he was eating his noon meal in the dining room on 11/11/2023. 4. Flies were observed in the hallway on A Wing and B Wing on 11/13/2023. An IJ was identified on 11/12/2023. The IJ template was provided to the facility on [DATE] at 3:59 p.m While the IJ was removed on 11/14/2023 at 3:18 p.m., the facility remained out of compliance at a scope of isolation and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice could lead to the spread of diseases and have an adverse effect on the resident's mental health. The findings were: 1. Record review of Resident #1's clinical record revealed he was admitted to the facility on [DATE], readmitted on [DATE] and discharged on 11/8/2023. Resident #1's diagnoses included tracheostomy (an incision in the windpipe [trachea] for a direct airway to the lungs which results in a stoma for a tracheal tube to allow a person to breath or receive oxygen), chronic respiratory failure (inadequate oxygen and carbon dioxide exchange in the longs), heart disease and morbid obesity (complex chronic condition of excess body weight that can lead to serious health issues). Record review of Resident #1's most recent MDS, a Quarterly assessment dated [DATE], revealed his BIMS (Brief Interview of Mental Status) was 13 out of 15, indication his cognitive decision making skills were intact; and required tracheostomy care. Record review of Resident #1's Care Plans for Problem area of Resident #1 is at risk for pneumonia, respiratory infection related to tracheotomy created on 07/20/2023. Under Approaches was Practice methods of infection control while doing trach care and teach Resident to practice methods of trach care. Record review of Resident #1's nurses' note, dated 11/8/23 by LVN C, revealed Patient reported during shower this afternoon, after coughing. He noted a bug that had fallen from his trach area. Upon assessment, at first no maggots were visible. Patient was then asked to extend his neck upwards where site was more visible and stretched. Maggots were then seen coming out of tracheostomy. Cleansed area with normal saline. Trach care administered. ADON aware. Orders given to send out to Hospital per NP. Administrator contacted RP. Record review of Resident #1's nurse's note, dated 11/8/23 by ADON, revealed This nurse and admin. [administrator] contacted RP in regard to maggots being found in trachea site. RP was informed that resident would be sent to Hospital. RP was understanding of the situation with no concerns stated at this time. Record review of Resident #1's SBAR note dated 11/08/2023 revealed the resident showed no signs of distress and it was noted small bugs appeared to be crawling in the trachea site and the resident was sent to the hospital. Record review of Resident #1's Hospital Emergency Provider Report, dated 11/08/2023 at 1712 (5:12 p.m.) revealed the chief complaint was maggots in trach. Record review of Resident #1's Hospital History & Physical, dated 11/08/2023 at 1942 (7:42 p.m.) revealed Patient is a [AGE] year-old male with past medical history of chronic hypoxic respiratory failure/obstructive sleep apnea/obesity hypoventilation syndrome status post chronic tracheostomy, morbid obesity ., . chronic diastolic heart failure ., who presented to the ER from nursing home for complaints of maggots over the tracheostomy area. Patient states that he noticed some maggots over the area and came to the ER for evaluation, patient denies any fevers, chills or any other complaints. Upon ER presentation, patient was found with adequate vital signs, afebrile [without fever] and with mild central vascular congestion. On examination, patient with multiple maggots over tracheostomy site . Record review of Resident #1's Hospital Critical Care Consult Note, dated 11/08/2023 at 2005 (10:05 p.m.), revealed the resident was admitted to the hospital for maggot infestation around tracheostomy .In ED [Emergency Department], patient was noted to have multiple maggots around his tracheostomy site. With RT [Respiratory Therapy] at bedside, patient was sedated/paralyzed then stoma was suctioned around trach until it was cleared of all maggots. Tracheostomy was then changed however during procedure, patient sustained superficial trauma causing bleeding. As such, bronchoscopy was subsequently performed and cleared of clots. Patient was then upgraded to the ICU for continued sedation/mechanical ventilation. Under Diagnosis was [AGE] year old male .was admitted to the hospital for maggot infestation around tracheostomy, and acute on chronic respiratory failure. Current medications administered in the hospital included Zosyn (an IV antibiotic). In an interview on 11/10/2023 at 11:09 a.m., LVN C stated Resident's #1's roommate (Resident #2) informed her Resident #1 told him Resident #1 had coughed up a maggot. LVN C stated she went to Resident #1's room, spoke to Resident #1 about what his roommate mentioned to her, and Resident #1 stated he had coughed in the shower and a maggot came out, but he had thrown it away. LVN C changed his trach collar, had the resident raise his chin up in a hyperextension position and she saw some small maggots trying to crawl out of his stoma (trach site) but did not see in on the resident's inner cannula. She immediately notified the ADON. In an interview on 11/10/2023 at 3:54 p.m., the ADON stated LVN C informed her Resident #1 had maggots around his trach site, so she came and examined Resident #1. The ADON said she first had Resident #1 lean his head back and she did not see any insects around his trach site until she used her hands to pull the skin on his neck that was around the trach site back and she saw what looked like maggots around the stoma site. The ADON notified Resident #1's physician who gave orders to send the resident to the hospital, notified the resident's responsible party and the administrator. In an interview on 11/11/2023 at 8:03 a.m. with Hospital RN D, she stated Resident #1 arrived on the night shift and maggots were suctioned from his trach site. In an interview on 11/11/2023 at 8:32 a.m. with Resident #1 in the hospital revealed he could not vocalize but could mouth his responses. When asked if he ever saw any insects in the facility, Resident #1 mouthed roaches and flies. When asked who he told about the flies, Resident #1 mouthed Administrator. When asked if he would ever go outside, Resident #1 mouthed no. 2. Record review of Resident #2's undated face sheet revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke), cognitive communication deficit (problems with communication due to medical condition), high blood pressure, anxiety disorder, and depressive episodes. Record review of Resident #2's most recent MDS, an Other Payment assessment dated [DATE], revealed his BIMS score was 10 out of 15, indication his cognitive skills for daily decision making were moderately impaired. In an interview on 11/10/2023 at 12:38 p.m., Resident #2, who was roommate to Resident #1, stated Resident #1 had told him that Resident #1 had coughed up a maggot. Resident #2 stated he has seen flies in their room and the last time he had seen flies was on 11/08/2023. Further interview on 11/11/2023 at 12:28 p.m., Resident #2 stated he and Resident #1 kept a fly swatter in their room to kill flies; he looked around the room for it but could not find it for the surveyor. In a telephone interview on 11/11/2023 at 2:10 p.m., CNA G stated on 11/09/2023, the day after Resident #1 went to the hospital, she saw a fly in his room and killed it with a fly swatter that was in the room but did not tell the administrator or maintenance director about the fly. CNA G stated she had seen flies in the facility at times and we have a lot of smokers who go in and out of the facility. In a telephone interview on 11/11/2023 at 3:06 p.m., CNA H stated Resident #1's room was close to the activity area which had an exterior door which staff and visitors would enter the facility through, and she thought the flies might come in through that door. CNA H stated when she does see a fly, she will get a fly swatter or a book to kill the fly. 2. Record review of Resident #3's undated face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included arthritis (pain in joints), congestive heart failure (impairment of the heart to pump blood resulting in fluid around the heart), low back pain, difficulty breathing, and diabetes (chronic uncontrolled blood sugar levels). Record review of Resident #3's most recent MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 14 out of 15, indication her cognitive skills for daily decision making were intact. In an interview on 11/10/2023 at 10:29 a.m., Resident #3 stated she saw a fly that morning (11/10/2023) fly around her breakfast tray. Observation on 11/10/2023 at 10:29 a.m., of Resident #3's room revealed there were no visible flies. Observation on 11/10/2023 at 10:41 a.m., a fly flew around the surveyor's computer while she stood on A Wing Hall outside Resident #3's room. Further interview on 11/10/2023 at 12:33 p.m. with Resident #3 revealed there had been a fly in her room flying around her noon meal tray when she was eating. Observation on 11/10/2023 at 12:33 p.m. of Resident #3's room revealed there were no visible flies. 4. Record review of Resident #5's undated face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included acute bronchitis (respiratory infection), anxiety disorder, pain, vitamin deficiency and depression. Record review of Resident #5's MDS's revealed the admission MDS had not yet been completed. In an interview on 11/10/2023 at 11:05 a.m., Resident #5 stated she had a fly that was flying around her breakfast tray that morning. Observation on 11/10/2023 at 11:05 a.m. of Resident #5's room revealed there were no visible flies. In an interview on 11/13/2023 at 2:11 p.m., Resident #5 stated she saw a fly this morning (11/13/2023) right around breakfast time, he likes to come out then. Observation on 11/13/2023 at 2:11 p.m. of Resident #5's room revealed there was no visible fly in the room. 5. Record review of Resident #6's undated face sheet revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, stroke with paralysis on one side, dementia, high blood pressure, and depressive disorder. Record review of Resident #6's most recent MDS, an Other Payment Assessment, dated 10/02/2023 revealed his BIMS score was 7 out of 15 indication his cognitive skills for daily decision making were severely impaired. Observation on 11/11/2023 from 12:16 p.m. to 12:22 p.m. revealed in the big dining room on B Wing, Resident #6 sat in a wheelchair wearing a white top. On the left sleeve of Resident #6's top was a fly. 6. Observation on 11/13/2023 at 2:05 p.m. revealed a fly flew around the overbed table and computer while the surveyor stood on B Wing hallway between rooms B4 and B6. Observation on 11/13/2023 at 2:21 p.m. revealed a fly flew in front of the surveyor's face as she stood in the hallway on A Wing outside of RM A19. Record review of the facility's Pest Control Company J's Contract, dated 10/26/2018, revealed Flying Insect Light Trap Service Program - up to 1 Insect Light Traps would be provided to the facility and the glue board in the light would be changed 12 times a year. Record review of the facility's Pest Control Company J's service statement dated 10/05/2023 revealed the facility was treated for roof rats, cockroaches, all entry/exit doors were treated and did not indicate if the facility was treated for flying insects. Record review of the facility's Pest Control Company J's service statements revealed service was provided to the facility on [DATE], 09/07/2023, 07/12/2023, 06/07/2023, and 05/18/2023. Record review of the facility's Pest Control Company J's service statement for 07/12/2023 revealed the facility was treated for roof rats, cockroaches and only some minor fly and mosquitoes found during the inspection. Record review of the facility's Pest Control Company J's service statements for 10/05/2023, 09/07/2023, 07/07/2023, and 05/18/2023 revealed the reports did not indicate the facility was treated for flying insects. Observations on 11/10/2023 from 10:15 a.m. to 4:55 p.m. revealed no Insect Light Trap was observed in the facility. In an interview on 11/10/2023 at 3:04 p.m., the Maintenance Director stated the facility was serviced monthly by the pest control company, he seldom sees any flies and the facility did not have a wall mounted flying pest control lights. In an interview on 11/11/2023 at 2:46 p.m., the Administrator stated the facility did not have any flying insect lights. When asked how the facility controls flying insects, he stated the facility doors have automatic closures on them, so the door doesn't stay open. In an interview on 11/11/2023 at 3:27 p.m., the Administrator stated other ways the facility controls insects were with housekeeping staff cleaning residents' rooms daily and routine pest control service but occasionally a fly will enter the facility when families bring items for the residents. Record review of the facility's Pest Control policy, revised May 2008, revealed Our facility shall maintain an effective Pest Control Program. Under Policy Interpretation and Implementation was 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. This was determined to be an Immediate Jeopardy (IJ) on 11/12/2023 at 3:59 p.m. The facility Administrator and ADON were notified. The Administrator was provided with the IJ template on 11/12/2023 at 3:59 p.m. On 11/12/2023 the facility provided a plan of removal titled: Plan for Removal. The plan of removal was accepted on 11/13/2023 at 4:45 p.m. It is documented as follows: On 11/12/2023 the Administrator and ADON notified the Medical Director of immediate jeopardy. On 11/12/2023 Maintenance Director/Designee checked all rooms in the facility to make sure, there were no flies. Administrator contacted Pest Control Company on 11/12/2023 to install bug lights in the facility and will be installed as soon as possible. On 11/09/2023 ADON assessed all residents with wounds that reside at the facility - no findings of pests in the wound or s/s of infection, on 11/12/2023 ADON/Designee re-assessed all residents with wounds that are currently in the facility for any insects inside the rooms or on the residents' wounds. No other residents were identified who had had insects in the rooms or on them. The Medical Director was updated on the assessments. On 11/12/2023 Administrator/Designee completed in-services with Maintenance Director and IDT on clean environment to prevent pest infestation inside the facility and on residents, including pest control policy. ADON/Designee in-service staff on abuse and neglect prevention, and clean environment to prevent pest infestation inside the facility and on residents. Staff were instructed to notify the Maintenance Director or supervisor if noted any pest infestation inside the facility and on residents immediately. All staff, including the Agency, newly hired staff, and PRN will be in-service and will not be allowed to start work till done so. The administrator will ensure all staff have completed in-services and training prior to starting work. The training will be completed by 11/12/2023. Ad-Hoc QAPI meeting was held on 11/12/2023, with the Medical Director, NHA (Nursing Home Administrator), Assistant Director of Nursing, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 11/12/2023, Maintenance Director/Designee will check all rooms in the facility for any flies daily Monday to Friday, and Manager on Duty Saturday and Sunday once a month. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. Regional Nurse Consultant will at least monthly verify that bug lights are working, and glue boards are changed. Facility Administrator will be notified of findings. The Administrator/designee will monitor compliance by completing an audit of five (5) residents' rooms per week for four (4) weeks to make sure the environment is clean to prevent pest infestation inside and on residents. This will be initiated on 11/12/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The Administrator will be responsible for ensuring this plan is completed on 11/12/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. The facility's POR Verification was as follows: Observation on 11/13/2023 at 2:03 p.m. revealed a wall mounted flying insect light trap was placed by exterior exit door on B Wing across from RM B4 and B6 that led to the center courtyard. Observation on 11/13/2023 at 2:10 p.m. revealed the Service Technician I from Pest Control Company J, had a white can that he was spraying around the door frame of one of the exit doors into the center courtyard from the big dining room at the end of B Wing. In an interview on 11/13/2023 at 2:15 p.m., Service Technician I from Pest Control Company J revealed the white spray can contained a fly bait which he was spraying the door frames and the seams to kill any flies in the facility. In an interview on 11/14/2023 at 8:50 a.m., the ADON stated she assessed residents who had wounds for maggot infestation on 11/09/2023 and on 11/12/2023; and were seen by the wound care physician and the nurses documented a progress note in the residents' clinical record for assessments done on 11/12/2023. In an interview on 11/14/2023 at 9:25 a.m., the ADON stated all the employees except for one, who was out sick, had been in-serviced on Pest Management and Abuse Prevention Program. The ADON stated the maintenance director did rounds in residents' rooms to check for insects. The ADON stated on 11/12/2023 she checked every resident and their rooms for insects and did not find any. In an interview on 11/14/2023 at 9:45 a.m., the Regional Nurse Consultant verified she had conducted the audit of the flying insect light on 11/13/2023. In an interview on 11/14/2023 at 11:38 a.m., the Medical Director stated he was notified of the immediate jeopardy situation at the facility, and he was informed wound assessments had been completed on residents with wounds on 11/12/23 with no negative findings found. In an interview on 11/14/2023 at 11:50 a.m., the Maintenance Director reported he would check the residents' rooms in the morning and initial on the dated Resident Roster their room had been checked. In an interview and observation on 11/14/2023 at 11:53 a.m., the Maintenance Director showed this surveyor a [NAME] Binder that was in a clear, acrylic holder behind the A Wing Nurse's station. The binder was labeled A Wing Maintenance and Pest Sightings Log. Inside the binder was a log sheet staff could record pest sightings and maintenance concerns. In an interview and observation on 11/14/2023 at 11:54 a.m., the Maintenance Director showed this surveyor a Black Binder that was in a clear, acrylic holder behind the B Wing Nurse's station. The binder was labeled B Wing Maintenance and Pest Sightings Log. Inside the binder was a log sheet staff could record pest sightings and maintenance concerns. In an interview on 11/14/2023 at 1:22 p.m., the Administrator stated he called the Medical Director on 11/12/23 and left a message, and then on 11/13/23 the Administrator and ADON went to his office to discuss the situation. The Administrator stated the Maintenance Director will use a daily room roster with the current date to initial off when residents' rooms had been checked for insects. The Administrator stated employees were in-serviced on 11/12/2023 in person or by phone on Pest Management, reporting signs of any pest to the maintenance director and recording on the logbook kept at the nurse's stations. The Administrator stated an Ad Hoc QA meeting was held on 11/12/23 and the IJ situation was discussed with members of the QA committee. The Administrator stated he will audit 5 resident rooms in addition to the monitoring of resident rooms done by the Maintenance Director and record the room audits he does on an audit log. The Administrator stated the company's RDO would be in the facility once a month and he would be checking to ensure the facility was doing the monitoring logs and interventions listed in the POR. During interviews conducted on 11/14/23 between 10:15 a.m. and 3:00 p.m., 34 of 48 staff members (including 12 Certified Nurse Aides, 1 Medication Aides, 4 LVNs, 3 RNs, 3 Administrative Staff, 5 Dietary Staff, 6 Housekeeping/Laundry, and 1 Activity Director) were interviewed and confirmed they received education on abuse, neglect, clean environment, pest control policy, and what to do if insects were found. Record review of the Quality Assessment and Performance Improvement Plan signature page, dated 11/12/2023, revealed an Ad Hoc meeting was held to discuss the incident of Resident #1 on 11/12/2023 at 6:00 PM. In attendance was the Medical Director, Administrator, ADON, and the MDS Nurse. Record review of an undated Audit: Light Audit sheet revealed on 11/13/2023 it was checked to verify the flying insect light was in place, was working and a glue board was in place by Regional Nurse Consultant. Record review of the In-service Training Sign-in Sheet for Clean Environment & Pest Control Policy presented to the IDT on 11/13/2023 revealed 8 IDT members were in-serviced on the facility's Pest Control Policy. Record review of the In-service Training Sign-in Sheet for Pest Management presented to employees on 11/12/2023 revealed 48 employees were in-serviced on the facility's Pest Control Policy and any pest sitting such flies, bugs, etc. must be documented in pest binder located at each nurse's station. Record review of the In-service Training Sign-in Sheet for Abuse & Neglect presented to employees on 11/12/2023 revealed 48 employees were in-serviced on the facility's Abuse Prevention Program. Record review of a list of 16 residents with wounds, dated 11/12/2023, revealed in a hand-written note at the bottom that all the residents had been assessed, no noted concerns or infections noted. Record review of a list of 15 residents with wounds, dated 11/09/2023, revealed in a hand-written note at the bottom that all the residents had been assessed, no noted concerns or infections noted. Record review of 15 of the 15 residents with wounds who were in the facility revealed they all had a wound assessment completed on 11/12/2023 except for one resident, who refused the wound assessment but did consent to a wound assessment the following day. Record review of a Daily Census Report dated 11/12/2023, in the facility's POR binder, revealed next to each residents' name was the ADON's initials and handwritten at the top was check for insects in room or on resident by ADON. Record review of a Daily Census Report dated 11/12/2023, 11/13/2023, and 11/14/2023 in the facility's POR binder revealed next to each residents' name was the Maintenance Director's initials and handwritten at the top was room Inspections for active flies conducted by Maintenance Director. Record review of Pest Control J's service invoice dated 11/13/2023 revealed a technician was in the facility from 1:52 p.m. to 2:30 p.m. and applied spot treatment of Pressurized Fly Bait in the facility. On 11/14/2023 at 3:18 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity of actual harm with a potential for more than minimal harm due to the facility's need to monitor the implementation and effectiveness of its POR. .