Other·January 31, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during an ABBREVIATED SURVEY for Complaint: CA00646193. Representing the California Department of Public Health by Federal ID: 38641 RN/HFEN and 39982 RN/HFEN. The abbreviated survey was limited to the specific incident investigated and does not represent the findings of a full inspection of the facility. Investigation for Complaint CA00646193 was substantiated with four deficiencies identified at

F684, F838, and F925. Facility Capacity: 68 Census: 63 Resident Sample: 9 An Immediate Jeopardy Situation (IJ) was called on 7/19/19, at 2:15 p.m. with the facility Administrator and Director of Nursing in the area of CFR 483.25 Quality of Care when the facility did not assess the environment and implement interventions necessary to minimize flies in the facility. This situation resulted in Resident 1's left foot found infested with maggots and eight residents with wounds at potential risk. The IJ was lifted when an acceptable IJ Removal Plan was given and implemented on 7/21/19, at 10:45 a.m., with the facility Administrator and Director of Nursing. Facility was found in substandard quality of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 1 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care and was not in substantial compliance with the federal regulations.

F684 SS=K Quality of Care CFR(s): 483.25

F684 07/31/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for four of four sampled residents (Residents 1, 6, 7, and 8) when: 1. Resident 1's burn wound to the left foot was infested with maggots and no documentation of wound appearance or wound size was completed by Licensed Vocational Nurse (LVN) 3 on 7/12/19, one day prior to the infestation of maggots. 2. Residents 6, 7, and 8 were not identified to be at high risk for possible infestation of maggots to their wounds. The facility was aware of an increased number of flies in the facility since May 2019 and did not conduct an environmental risk assessment (a review of the facility's points of entrance for pests to enter the facility) for flies in order to implement interventions to prevent flies FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 2 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE affecting wounds (cross reference F925). These failures resulted in Resident 1's burn wound to the left foot to be found infested with maggots on 7/13/19 with subsequent hospitalization to treat the maggot infestation and associated pain and suffering and the potential for Residents 6, 7, and 8's wounds to become infested with maggots. Because of the actual serious harm to Resident 1 and the potential serious harm to Residents 6, 7, and 8 from not having additional interventions in place to prevent maggot infestation to their wounds an Immediate Jeopardy Situation (IJ) was called on 7/19/19 at 2:15 p.m., with the facility Administrator (ADM) and Director of Nursing (DON). The facility submitted an acceptable IJ Removal Plan on 7/20/19, to conduct a skin assessment of residents with wounds for maggots or infections, conduct licensed nurses training and education on wound management including performing dressing changes, wound care documentation and monitoring, weekly communication to physicians regarding wound care, conduct an environmental assessment of the facility to ensure all screens to windows and doors were closed, recommendation for additional pest control measures to minimize the number of flies in the facility, implement training and education regarding fly prevention to reduce the flies in the facility, and address the potential risks flies can cause to a resident with wounds. The components of the IJ Removal Plan were validated as implemented and the IJ situation was removed on 7/21/19, at 10:45 a.m., with the ADM and DON. Findings: During a concurrent observation and interview with Resident 1, on 7/17/19, at 11:50 a.m., in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 3 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's hospital room, she was sitting up in bed with her legs extended on the bed. Resident 1 stated she had fallen at home on 6/12/19 and was on the patio cement for about two and one-half hours. Resident 1 stated she went to the hospital for care related to the burns she suffered to both lower legs and breast. Resident 1 stated on 6/20/19 she was then transferred to the skilled nursing facility (SNF) for continued wound care of the burns. Resident 1 stated on the day she was again hospitalized (7/13/19) the nurses did her dressing changes to her legs and feet. Resident 1 stated she experienced burning pain to the left foot on 7/13/19. Resident 1 stated "I hate flies. Flies were so bad [in her room at the SNF] that I would cover up my head so the flies wouldn't get on me. I have a fly swatter in my room [in the SNF] to kill them." During a review of the facility's clinical record for Resident 1, the facesheet (a document with personal identifiable information) indicated Resident 1 was admitted to the facility on 6/20/19 with diagnoses which included biliary cirrhosis (chronic liver disease characterized by damage to the small bile ducts), burn of chest wall, second degree burn (involves the outer layer of skin and part of the dermis layer of skin) of left foot and left lower limb. During a concurrent observation and interview with Resident 9, on 7/17/19, at 1:36 p.m., in Resident 9's room, there was an orange fly swatter next to Resident 9's bed. Resident 9 stated he sometimes had flies in his room. Resident 9 stated the facility had a problem with flies "for a long time" and the facility had not done anything to decrease the amount of flies in the facility. Resident 9 stated the smoking patio door was constantly opened and closed and he could hear the patio door from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 4 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE his room. Resident 9 stated the door being opened caused flies to come into the facility and into his room. During an observation, on 7/17/19, between 1:41 p.m. and 2:20 p.m., there were flies observed on Station 2 nursing station, in the hallway next to room 7 and DON office. During an interview with Certified Nursing Assistant (CNA) 3, on 7/17/19, at 1:59 p.m., she stated she had taken care of Resident 1 when she was in the facility. CNA 3 stated Resident 1 was alert and able to understand simple commands from staff. CNA 3 stated Resident 1 required extensive assistance (resident involved with activity and staff provide weight bearing support) with bed mobility. CNA 3 stated on 7/13/19 before lunch time around 10 a.m., Registered Nurse (RN) 1 told her to get the charge nurse for Resident 1. CNA 3 stated she went to get Licensed Vocational Nurse (LVN) 4 and told her to go to Resident 1's room. CNA 3 stated she went into Resident 1's room after getting LVN 4 and stated she saw one leg that did not have a bandage on. CNA 3 stated she did not know which leg it was. CNA 3 stated she resumed working with other residents once the charge nurse came to the room. During an interview with CNA 3, on 7/17/19, at 2:10 p.m., she stated she was aware of the increase of flies in the facility. CNA 3 stated Resident 1 had cookies and snacks on her bedside table which would attract flies into the room. CNA 3 stated, "The flies are just there in the room. Two to three flies. When you walk in the room you see them flying. That's why I take out my trash [trash from residents' rooms]. The patio door is always being opened." CNA 3 stated since May when it became warmer, the patio door fan was turned on because warmer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 5 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE temperatures attract more flies in the facility. During a concurrent interview with RN 1 and record review of Resident 1's progress notes and treatment orders, on 7/17/19, at 2:23 p.m., she stated on 7/13/19 around 10 a.m., she was at Nursing Station 1 when CNA 4 told her that Resident 1's right lower extremity dressing was loose. RN 1 stated she changed the dressing to the right leg and during the dressing change, Resident 1 complained of burning pain to the left foot. RN 1 stated when she took the dressing off the left foot, she observed the top of the left foot with "so many maggots" and more than what she documented in the progress note on 7/13/19. RN 1 stated, "The maggots were covering the whole wound on the left foot." RN 1 stated the dressing to the left foot was not covering the toes. RN 1 stated she went to her treatment cart and obtained normal saline. RN 1 stated she then flushed the wound with normal saline and removed the maggots from the wound bed. RN 1 stated she pressed on the blackened part of the skin on the top of the left foot and three to four maggots came out of the wound bed. RN 1 stated she told CNA 3 to get LVN 4. RN 1 stated she called the DON and told her about what she observed on Resident 1's left foot wound. RN 1 stated she completed the treatment order for the left foot because she did not want the resident to be sent out to the hospital with no wound dressing on her left foot. RN 1 stated Resident 1 was transferred to the hospital per Resident 1's request. RN 1 reviewed the physician's treatment order dated 7/1/19 which indicated, " ...Burns to left foot, ankle, anterior [front] calf: Cleanse with normal saline, pat dry, apply xeroform (non-stick sterile wound gauze used to treat burns), cover with ABD [abdominal] pad (absorbent sterile dressing), and wrap with kerlix (woven gauze used to cover wounds) every day shift every FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 6 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE other day for 14 days." RN 1 stated the last treatment to the left foot was on Resident 1's shower day, 7/12/19. RN 1 stated LVN 3 performed the dressing change on 7/12/19. RN 1 stated the charge nurses were responsible to complete the treatment orders for Resident 1's burns to her right and left lower extremities and right breast. RN 1 stated she was assigned as the facility treatment nurse for the past three to four months and completed the treatment orders for residents in the facility with pressure ulcers. During an interview with RN 1, on 7/17/19, at 2:50 p.m., she stated she had seen flies in Resident 1's room. RN 1 stated "I try to put a fan in the room to push the flies away. She even had a fly swatter." During a review of the clinical record for Resident 1, the "Nursing Home to Hospital Transfer Form" dated 7/13/19 by LVN 4, indicated " ... Key Clinical Information Reason (s) for transfer Other-left foot wound noted with redness and maggots ... Additional Relevant Information Tx [treatment] nurse went in to change bandages to wounds when resident stated "they [dressing] are [loose] and I feel a burning sensation." Upon removing bandages wound noted with redness around area accompanied with maggots in wound ..." During a concurrent interview with RN 1 and record review of Resident 1's daily skilled documentation, on 7/17/19, at 3 p.m., RN 1 stated she only assessed the lower extremities and did not assess Resident 1's wound to the right breast for maggots before transferring to the hospital. RN 1 reviewed the clinical record for Resident 1's most recent wound measurements and stated there were no wound measurements documented for Resident 1's wounds to the right and left lower FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 7 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE extremities and right breast. RN 1 reviewed the Daily Skilled Documentation dated 7/12/19 at 2:49 p.m. by LVN 3 which indicated, "... Narrative nurses note... Resident [1] is on charting for burns to bilateral [both] feet and right thigh and right breast did all treatments as ordered d/t [due to] resident having shower. Tolerated well. No redness or swelling. right foot has mass amount of eschar [black, dead tissue]. resident is extensive ADLs [activities of daily living] ... Resident tolerated Tx [treatment] well. Will cont [continue] to monitor ..." RN 1 stated the narrative note did not detail what the left foot wound bed appearance was nor the treatment done for the left foot. RN 1 stated LVN 3 should have documented the left foot treatment and assessment in the note, but did not. During a review of the clinical record for Resident 1, the care plan dated 6/22/19, indicated "[Resident 1] has actual impairment for skin integrity for burns to left foot, ankle and anterior thigh ... Goal [Resident 1] will be free from complications from burns to left foot, ankle and anterior thigh through next review date ... Target Date: 10/7/19 ...Interventions Any changes in color, size, or smell notify [doctor] immediately ..." During a concurrent interview with LVN 3 and record review of Resident 1's daily skilled documentation and progress notes, on 7/17/19, at 3:29 p.m., LVN 3 stated she did wound treatments for Resident 1. LVN 3 stated the charge nurse who did the wound treatment would complete a nursing note regarding the healing process of the wound treated. LVN 3 reviewed the clinical record for wound measurements for Resident 1's burns and stated there were no documented measurements. LVN 3 stated measurements were used to monitor if the wounds were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 8 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE healing. LVN 3 stated licensed nurses would not know if the wounds were getting better if there were no measurements. LVN 3 stated she treated Resident 1's wounds on 7/12/19 after her shower between 1:30 p.m. and 1:45 p.m. LVN 3 stated she did not notice any maggots on the left foot wound bed. LVN 3 stated she wrapped the left foot with kerlix and left the tips of the left toes open to air. LVN 3 reviewed the Daily Skilled Documentation dated 7/12/19 which indicated, "Resident [1] got shower today and writer moved on to treatment for residents bilateral legs and upper right thigh and right breast at [1:30 p.m.] Right leg and foot still has dry eschar noted in wound bed. left leg eschar was moist, no s/sx [signs or symptoms] of infection no redness warmth or swelling noted around wound bed. Upper right thigh granulated [new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process] and epithelial tissues [thin tissues that cover all the exposed surfaces of the body] noted in wound bed. Right side breast eschar moist noted, edges are granulating. Cleaned with NS [normal saline] and pat dry apply Xeroform and non adherent pad covered ABD pad and wrapped with kerlix." LVN 3 stated she did not include the left foot in the assessment note because it looked the same as the last time she had seen it. LVN 3 stated she should have documented what the wound bed appeared like on the day she treated her on 7/12/19. LVN 3 reviewed the progress note dated 7/12/19 and stated she did not include the left foot wound assessment in the progress note. LVN 3 stated there should have been documentation of what the wound to the left foot looked like during the dressing change. LVN 3 stated there were flies in the facility and in Resident 1's room. LVN 3 stated there were a lot of flies and would see more flies between 12 p.m. to 1 p.m. when it would get warmer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 9 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE outside the facility. LVN 3 stated residents complained about flies and did not know what the facility was doing to minimize the flies in the facility besides closing the doors or keeping the rooms clean. LVN 3 stated Resident 1 would have snacks in her room and that could have caused flies to go into her room. During an interview with Resident 2 in her room, on 7/18/19, at 11:59 a.m., she stated, "There is a lot of flies in the room. It's been a couple of weeks. In the evening at 5:30 p.m., there's a lot of flies. I told my CNA about it. I don't remember her name. She works in the evening and morning [shift] ... I was worried they were going to make me sick. I don't know where the flies come from ... They [the facility] spray [chemicals] but [flies] still come in." During an interview with the Housekeeping Supervisor (HKS), on 7/18/19, at 12:05 p.m., she stated she had observed an increased amount of flies in the facility for the past weeks. HKS stated she informed the Maintenance Supervisor (MS) several times verbally. During an interview with CNA 1, on 7/18/19, at 12:08 p.m., she stated, "I noticed a lot of flies in the past week. I don't know where they came from." CNA 1 pointed at the patio door near the kitchen and stated, "Probably from the door [flies come inside the facility]. Residents come in and out. Maybe that's how the flies came in. I told the Maintenance guy verbally. I don't know what he did but I told him verbally." During a concurrent interview with LVN 4 and record review of Resident 1's progress notes, on 7/18/19, at 12:10 p.m., she stated she was the charge nurse for Resident 1 on 7/13/19. LVN 4 reviewed the progress note dated 7/13/19 at 10:36 a.m. which indicated, " ... upon entering [Resident 1's room] wound noted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 10 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to have been cleaned by tx [treatment] nurse but couple maggots were coming out of wound which were then cleansed again. Wound was also noted with slight redness ..." LVN 4 stated she had assessed the left foot, but did not assess the right leg nor right breast for maggots before Resident 1 transferred to the hospital. LVN 4 stated it only takes one fly to become infected with maggots or infections to the wound. LVN 4 stated "We have flies everywhere." LVN 4 stated she thought that since the left foot was wrapped that a fly could not get inside. LVN 4 stated Resident 1 was at risk for infections from the maggots. LVN 4 stated she had noticed the flies in Resident 1's room and the flies coming in through the patio door. LVN 4 stated Resident 1's room was next to the kitchen and it was warm from the heat of the kitchen that can attract flies. LVN 4 stated the residents were always in and out of the patio door all day and employees during the night shift use the door. LVN 4 stated she would see between two to three flies in Resident 1's room and sometimes in the bathroom flying around. LVN 4 stated residents complained about the flies and she would try to get rid of them by using a newspaper. LVN 4 stated there was a fan above the patio door that turns on when opened to prevent flies from getting inside. LVN 4 stated she would verbally notify the MS about the flies in the facility and did not know what was done to decrease the flies in the facility. During a concurrent observation and interview with Restorative Nursing Assistant (RNA), on 7/18/19, at 12:12 p.m. in the facility's hallway, a fly was observed entering the patio door near the kitchen. RNA stated, "There's a fly just right now ... I noticed a lot of flies during the summer here ... I did not tell the charge nurse because everybody [facility staff] knows there are flies here." RNA stated he had not informed the MS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 11 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE he had observed several flies in the facility. During an interview with Resident 3, on 7/18/19, at 12:28 p.m., she stated, "There's a lot of flies in the morning and every night. The nurses know. I feel upset about the flies. They [the facility] are not doing anything about it." During an interview with Resident 4, on 7/18/19, at 12:30 p.m., she stated, "Flies, they are everywhere here. It's terrible. It doesn't matter, day, evening, night, there's a lot of flies in the facility. They go inside my room. They are everywhere. It's just terrible. Sometimes it goes to my food and I just don't eat it. I don't know where the flies came from or what disease they would bring. All the nurses and staff knew about it. I don't have to be telling them about flies. They should do something about it. It makes me so upset seeing a lot of flies. Please do something about it." During an interview with Resident 5, on 7/18/19, at 12:35 p.m., she stated, "There's a lot of flies in the building. It's terrible because they go inside my room. They come in to my food. They get in the food before [residents] do. It's so hard to get things done in this place. The staff knows about how the flies get bad here and they don't do anything. It makes me so upset seeing flies in the room." During an interview with CNA 2, on 7/18/19, at 1 p.m., she stated, "I have been here for 14 years as a CNA. I noticed a lot of flies here and there. It's in the dining room, hallways and sometimes in the residents' rooms. I know [Resident 1]. I took care of her but I called in [sick] that day they found the maggots [in Resident 1's wound bed]. It's terrible and [maggots] grow big. I saw some flies in [Resident 1's] room. That's why she has the fly swatter. [Resident 1's] son brought her the fly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 12 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE swatter. With the flies, [staff] never told the Maintenance [Supervisor] because he knows about the flies. There is a fan blower for the flies on top of the [patio] door but it has been here for a long time. I didn't see anything new that the Maintenance did with the flies. It's still the same ... Everybody knows about the flies..." During an interview with LVN 4, on 7/18/19, at 1:05 p.m., she stated on 7/13/19 around 9:40 a.m., CNA 3 asked her to go to Resident 1's room. LVN 4 stated when she entered Resident 1's room, RN 1 was on the phone and pointed to Resident 1's left foot. LVN 4 stated she saw two maggots between the left toes and next to the top of the wound bed. LVN 4 stated she contacted the physician by fax and notified him the resident requested to go to the hospital. LVN 4 stated RN 1 cleansed the wound and wrapped the foot before the resident went to the hospital. LVN 4 stated she did not see how many maggots were in the dressing. LVN 4 stated there was a bedside trash can used to put the dressings and maggots inside. LVN 4 stated CNA 4 threw the bag of dressings and maggots away, and could not estimate how many maggots there were. During an interview with Housekeeping Aide (HKA) 1, on 7/18/19, at 1:21 p.m., HKA 1 stated she had been working in the facility for a month and she had noticed a lot of flies in the facility especially when the weather became hot and humid. HKA 1 stated she had not notified the MS she observed flies in the facility. HKA 1 stated, "Everybody knows about the flies." During an interview with CNA 4, on 7/18/19, at 1:35 p.m., she stated Resident 1 complained about the flies in her room located near the patio door. CNA 4 stated Resident 1 had snacks in her room on the bedside table that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 13 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE would attract flies. CNA 4 stated Resident 1's family member brought Resident 1 a fly swatter for her to use in the facility. CNA 4 stated flies were everywhere in the facility. CNA 4 stated the patio door was opened and closed all the time during the day by residents. CNA 4 stated she would see one or two flies in Resident 1's room. CNA 4 stated on 7/13/19 she had seen a fly on Resident 1's pillow and on the curtain. CNA 4 stated Resident 1 had a fly swatter on the floor next to her bed to kill the flies. CNA 4 stated she would try to kill the flies in the room and clean the resident's area such as removing food that did not have a cover. CNA 4 stated flies would increase during the latter part of the day. CNA 4 stated management knew about the increase in flies because everyone in the facility talked about it. CNA 4 stated sometimes it is impossible to keep the flies out of the facility because it takes some residents extra time to propel in or out the patio door. CNA 4 stated the patio door will stay open for a good five minutes before it closed. CNA 4 stated she had not communicated to anyone specifically in the facility about the increase in flies. CNA 4 stated in the past three months, rooms 1 through 7 had more flies than in the back rooms in the facility. CNA 4 stated during the day when it became hot or humid, the flies would increase and residents would complain about the flies. CNA 4 stated she was not aware of any interventions the facility was implementing to minimize the flies in the facility. During an interview with CNA 4, on 7/18/19, at 1:45 p.m., she stated on 7/13/19, around 9 a.m., she performed care for Resident 1. CNA 4 stated the left foot dressing had an open area through the gauze to her toes. CNA 4 stated Resident 1 had told her that her foot was burning and noticed the dressings were loose to the right leg. CNA 4 told RN 1 about the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 14 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE loose dressing and then told LVN 4. CNA 4 stated about an hour later RN 1 treated Resident 1's wounds. CNA 4 stated when she came back from lunch around 10:30 a.m., Resident 1 was being taken out of the facility by EMS. CNA 4 stated she went to Resident 1's room and stripped the room by removing the linens. CNA 4 stated she saw a small maggot at the foot board of the bed when removing the linens. CNA 4 stated the trash bag that had the gauze and maggots in it was tied in a knot. CNA 4 stated she threw away three bags from Resident 1's room into the main trash can outside the facility. During an interview with CNA 5, on 7/18/19, at 1:50 p.m., she stated she gave Resident 1 a shower on 7/12/19. CNA 5 stated Resident 1 had dressings to both legs and would put a plastic bag around the dressings. CNA 5 stated she noticed the flies in the facility and increase in flies in the facility in the last couple of months. CNA 5 stated last year and this year has been worse with the number of flies and the flies increase with the warmer weather. CNA 5 stated the smoking patio area was where residents came in and out of the facility. CNA 5 stated MS in-serviced staff to keep the doors closed. During an interview with the Activities Director (AD), on 7/18/19, at 2:30 p.m., he stated the flies in the facility have been bad in the last month. The AD stated there should not be flies in the facility. The AD stated he told dietary and nursing about the increase of flies he had seen. The AD stated the front door did not close all the way which could cause flies to come into the facility. The AD stated he would see one to two flies in the residents' rooms. The AD stated Resident 1 should not have maggots in her wound bed and the incident could have been prevented if the facility was proactive and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 15 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE installed an additional air curtain (a fan installed above a door frame used to decrease flying insects from entering an opened door) on top of the main door entrance. The AD stated the main front door should have been fixed so it would close automatically and prevent more flies from coming inside the facility and the residents' rooms. During a telephone interview with LVN 2, on 7/18/19, at 2:49 p.m., she stated three weeks ago when she worked during the evening shift, she noticed an increase number of the flies in the facility. LVN 2 stated she has seen two or more flies in resident rooms and at the nursing stations. LVN 2 stated Resident 1's room was warmer and would attract flies. LVN 2 stated on 7/13/19, she went to Resident 1 to give her pain medication because she had complained of burning to the left leg. LVN 2 stated she administered pain medication to Resident 1 at 3 a.m. LVN 2 stated Resident 1's dressing to the left foot had her toes visible. LVN 2 stated staff knew about the flies and she did not tell management about the increase number of flies in the facility. LVN 2 stated the facility did not do enough for the resident to have kept the flies away from Resident 1's wounds. LVN 2 stated the infestation of the maggots could have been avoided and Resident 1 could be harmed emotionally from seeing the maggots in her wound. During an interview with MS, on 7/18/19, at 3:13 p.m., he stated he noticed an increase in flies in the facility when the weather became warmer. The MS stated staff communicated verbally to him about pest issues and he had a log for the staff to notify him. The MS stated the facility had air curtains to reduce the risk of the flies from coming into the facility. The MS stated the residents come in and out of the patio door and flies came inside the facility. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 16 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE MS stated the front door did not have an air curtain because he would have to remodel the top of the door frame for the air curtain to fit. The MS stated there was an emergency door used by staff to take out the trash and to get oxygen tanks. The MS stated the trash can outside the facility was picked up daily from the city. The MS stated the flies were coming from outside, but did not know from where. The MS stated residents eat outside and that will attract flies. The MS stated the back patio was attracting a lot of flies and the back patio door was opened and closed all the time causing flies to come inside. The MS stated he visually checked the screens to the windows and patio doors, but did not document his environmental checks. The MS stated the screen door was not going to prevent flies from coming into the facility unless the glass door was closed. The MS stated the pest control vendor last visited the facility on 7/16/19. The MS showed the receipt from the pest control service vendor which indicated the fly glue pads were 25% full. The MS stated two months ago, the staff turned off the air curtain by the patio door. The MS stated he educated staff not to turn off the air curtain and that the air curtain should be on nonstop. The MS stated he disabled the offswitch on the air curtain so no one could turn it off. The MS stated there were flies at night and if the air curtain was off, the flies would come into the facility. The MS stated he did not have any other ideas to minimize the increased flies in the facility. The MS stated he had seen residents with fly swatters. The MS stated the facility did not allow the residents to have fly swatters because it was an infection control issue if they kill the fly and not clean up afterwards. The MS stated he did not know about the maggots until today (7/18/19) and he should have been told about the maggots since he was responsible for pest control in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 17 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a facility tour with the MS, on 7/18/19, at 3:44 p.m., the front door to the facility was observed to have a gap between the door frame and the door. The MS stated the front door was loose and needed to be adjusted. There were two visitors who exited the front door and the front door did not fully close. The MS measured the gap and stated the gap was 42" long from the top of the door frame by 3/8 of an inch-wide gap. The MS identified an Ultraviolet (UV) light next to the front door and opened the UV light hood. The MS took out two glue pads used in the UV light. There were approximately 16 large flies on one glue pad and approximately three large flies on one glue pad. The MS observed the UV light next to shower room F and opened the UV light hood. There were approximately eight large flies on one glue pad. The MS observed the UV light next to room 14 and opened the UV light hood. There were approximately 25 large flies on one glue pad and approximately eight large flies on one glue pad. The MS observed the UV light next to the emergency door and opened the UV light hood. There were approximately 12 large flies and multiple smaller gnats on one glue pad. The MS stated the outside area in the back of the facility could be the source where flies were coming into the facility. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4 p.m., there was an opened sliding glass door observed in the therapy room. There was no screen door on the door track. There was a screen door observed placed on the right side of the sliding glass door propped against the wall. The MS stated the screen door should be on the track and therapy should not have the sliding glass door open without the screen. During a concurrent interview and facility tour FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 18 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with the MS, on 7/18/19, at 4:06 p.m., room 6's screen door did not fit on the track and did not close fully. The MS stated the screen door needed to be adjusted. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4:09 p.m., room 5's screen door did not fit on the track and did not close fully. The MS stated the screen door needed to be adjusted. During a facility tour with the MS, on 7/18/19, at 4:15 p.m., the MS observed the UV light next to the kitchen and opened the UV light hood. There were approximately 74 large flies on one glue pad. There were two flies observed coming in from the opened patio door. During an interview with the ADM, on 7/18/19, at 4:28 p.m., he stated he was made aware of the maggots in Resident 1's wound on Monday, 7/15/19. The ADM stated flies have been an issue in the facility off and on. The ADM stated the area surrounding the facility had more flies when it heats up outside. The ADM stated the environmental interventions the facility had for pest control were air curtains on the patio door and kitchen exit door, pest control services, and the UV lights with the glue pads. The ADM stated the Interdisciplinary Team (a group of individuals including, but not limited to the DON, Social services, and MD to discuss a resident's plan of care) met on Monday, 7/15/19, regarding the incident on 7/13/19 and stated MS was not involved in the meeting. The ADM stated the maggots in the wound was a nursing issue and not an environmental issue. The ADM did not think about reporting the unusual occurrence to the California Department of Public Health (CDPH) because the resident was already out to the hospital. The ADM stated he should have reported this incident to CDPH. The ADM stated the staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 19 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were educated on keeping the screen doors closed to minimize the flies. During an interview with the DON, on 7/18/19, at 4:41 p.m., stated on 7/13/19, RN 1 called her and told her Resident 1 did not look good. The DON stated she called the facility back about 30 minutes later to get more details from RN 1. The DON stated RN 1 told her the wound was hot to touch. The DON stated she became aware the wound had maggots on 7/15/19 when she reviewed nursing documentation. The DON stated in the IDT meeting, the staff present were the ADM, Minimum Data Set Coordinator (MDSC), and herself. The DON stated IDT did not identify the wound being infested with maggots as an environmental issue. The DON stated MS did not know about the maggots in the resident's wound until today, 7/18/19. The DON stated a fly should not have been able to lay an egg on the wound bed if the dressing was wrapped properly. The DON stated this incident should have been reported to CDPH, but was not. The DON stated the ADM was guiding her on what to report to CDPH. The DON stated the treatment nurse was responsible for pressure ulcers in the facility, but should be involved with all wounds. The DON stated the licensed nurses should be assessing and documenting wounds after treatment was completed including measurements of the wound. The DON stated a couple of weeks ago the flies became an issue. The nurses at night were keeping the emergency door open and staff were inserviced to keep the door closed. During an observation, on 7/19/19, at 7:30 a.m., the front door was not fully closed and had a gap opening in the closed position. During a concurrent interview and record review of Resident 6's treatment orders with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 20 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Director of Staff Development (DSD) 1, on 7/19/19, at 7:50 a.m., she stated Resident 6 had a wound to his left heel. DSD 1 reviewed the treatment order for Resident 6 which indicated, "Cleanse open skin to left heel with NS [normal saline] pat dry apply [santyl, debriding ointment] and cover with betadine [solution used to disinfect skin] and [gauze] then wrap with kerlix may use coban [nonwoven, breathable dressing that adheres to itself] every day shift ..." and "Left great toe: Cleanse with betadine, apply calcium alginate [dressing used in healing wounds], cover with [gauze] and wrap with kerlix PRN [as needed] soiling or dislodging ..." During a concurrent observation and interview with DSD 1, on 7/19/19, at 7:50 a.m., in Resident 6's room, Resident 6 had a black sock on his left foot. The DSD removed the sock and observed a dressing to the left heel wrapped in kerlix. Resident 6's left great toe was covered with a dressing in place dated 7/18/19. During an interview with DSD 1 and MDSC, on 7/19/19, at 8:10 a.m., DSD 1 stated she noticed flies in the facility. The MDSC stated she inserviced staff on keeping the doors and windows closed. DSD 1 stated the fly problem was not a consistent issue in the facility. The MDSC stated management did not think the flies in the facility was a problem. DSD 1 stated the facility did not see the flies in the facility as a major issue. The MDSC stated management should have been aware of the risks of infection from flies for residents being treated for wound care. During a telephone interview with pest control technician (PCT) 1 on 7/19/19, at 8:18 a.m., he stated he was not aware the facility had increased number of flies during the past FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 21 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE weeks. PCT 1 stated, "Prior to yesterday, I was not aware of the flies. We installed UV lights about a year ago but after that, I haven't heard of anything about the flies. [The facility] could have done more to prevent flies like making sure staff should close the door at night. There should be more air curtains in the kitchen and main front door especially [since] it's the front door and people are going inside and out all the time." During a concurrent interview and record review of Resident 7's and Resident 8's treatment orders with DSD 1, on 7/19/19, at 8:04 a.m., she stated Resident 7 had an open sore to the right shin [front of the leg below the knee]. DSD 1 reviewed the treatment order for Resident 7 which indicated, "Cleanse open sore to Right shin with NS [normal saline], Pat Dry, apply oil emulsion, Apply non-adherent pad, wrap with kerlix every other day every even shift every other day ..." DSD 1 stated Resident 8 had a wound to his right leg. DSD 1 reviewed the treatment order for Resident 8 which indicated "Venous stasis ulcer to right lower extremity: Cleanse with normal saline, pat dry, apply A&D ointment, cover with dry ... gauze secured with tape, wrap with [kerlix], and cover with Coban every evening shift every Mon, Wed, Fri, Sat ..." During a concurrent observation and interview with Resident 7, on 7/19/19, at 8:18 a.m., Resident 7 was sitting in a wheelchair outside her room. The MDSC asked Resident 7 if she could look at her dressings in her room and Resident 7 agreed. The MDSC lifted Resident 7's pant legs up. There was a kerlix dressing wrapped around the right lower leg dated 7/19. Resident 7 stated the nurse changed her dressing this morning. During a concurrent observation and interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 22 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with Resident 8, on 7/19/19, at 8:23 a.m., Resident 8 was sitting in a wheelchair next to his bed. DSD 1 removed Resident 8's sock to the right foot and lifted his pant leg up. Resident 8 had a dressing to the right lower leg to the right foot wrapped in Coban. Resident 8 stated there were flies sometimes in his room when he had meals. Resident 8 stated flies would land on his shirt or pant leg sometimes. Resident 8 stated everyone in the facility knew about the flies and nothing was done about it. During an interview with MS, on 7/19/19, at 8:36 a.m., he stated he did not check the UV light glue pads. The MS stated that was the responsibility of the pest control vendor. The MS stated he could check the glue pads more often and make a log to document the increase need to change the glue pads. The MS stated he did not keep inspection logs for the glue pads located inside the UV lights. During an interview with the ADM and the DON, on 7/19/19, at 8:45 a.m., the DON stated the management team did not conduct an environmental inspection of the facility after the maggots were identified on 7/13/19 to identify where the flies were coming from. The DON stated she considered the maggots in the wound as a nursing issue due to improper dressing application. The DON stated the flies were not an issue. The DON stated when selecting rooms for new admission to the facility, she did not consider the environment as a risk for residents with wounds. The DON stated she did not consider the risk of increase number of flies can impose on residents with wounds. The DON stated the facility should have moved residents who had wounds or dependent residents away from areas with increased flies. The ADM stated he told MS to look into the increased flies in the rooms on 7/17/19. The ADM stated MS should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 23 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE changing the glue pads at least once a week, but was not. The ADM stated he never considered putting the risk flies impose on residents with wounds or dependent residents on the facility assessment. During a concurrent interview with the ADM and facility document review, on 7/19/19, at 9:18 a.m., he provided a copy of the facility assessment. The ADM stated there was no pest control assessment completed during the facility assessment revision on 3/11/19. The ADM stated the facility did not have pest control as an identified concern during Quality Assurance and Performance Improvement (QAPI) meetings. The ADM stated the facility assessment can be updated as needed and pest control was not considered an issue. During a concurrent interview and facility document review with DSD 1, on 7/19/19, at 9:27 a.m., she stated she did room rounds every day to check resident's rooms and to speak with residents. DSD 1 stated she inspected and documented resident rooms twice a month. DSD 1 stated she will randomly check a resident's room for cleanliness of the room. DSD 1 stated the last rooms she inspected was room 8 on 7/7/19 and room 10 on 7/12/19. DSD 1 reviewed her documentation for the last time she inspected Resident 1's room and stated she could not find documentation of the last inspection. During a concurrent interview and facility document review with DSD 1, on 7/19/19, at 9:38 a.m., she reviewed the facility assessment with the revision date of 3/11/19 and stated she was involved with the revision of the facility assessment. DSD 1 stated she did not bring to attention the flies during the revision of the facility assessment. DSD 1 stated she should have included the pest control issue regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 24 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the increase flies in the facility during the revision of the facility assessment and will moving forward. During a concurrent interview with LVN 4 and record review of Resident 6 and Resident 7's treatment orders, on 7/19/19, at 10:07 a.m., she stated Resident 6 had a physician order which indicated may use coban on the wound to the left foot. LVN 4 stated coban would be used to make the kerlix dressing secure. LVN 4 stated the licensed nurses do the wound care for Resident 7 on Tuesday, Thursday, Saturday, and Sunday. LVN 4 stated on Monday, Wednesday, and Friday, Resident 7 went to a wound specialist. LVN 4 stated Resident 6 had socks or his shoes on that would cover the foot. LVN 4 reviewed the treatment order for Resident 7 and stated she did not have an order for coban to be used to cover the kerlix dressing to the bilateral lower extremities. LVN 4 stated Resident 7 had knee high socks that would cover the kerlix dressing. LVN 4 stated she was not aware of any kind of measures put in place after Resident 1 transferred to the hospital for maggots in the wound to ensure other residents with wounds were safe from flies and maggots. LVN 4 stated she did not know if there were skin assessments done on residents with wounds to identify possible maggots in the wounds. During an interview with LVN 5, on 7/19/19, at 10:28 a.m., she stated the licensed nurses continued with the care for the other residents with wounds after Resident 1 transferred to the hospital. LVN 5 stated, "Everyone has different types of wounds. We just make sure there are no flies in the area when we do treatments." LVN 5 stated she made sure there was no insects or flies around wounds, but no other changes were done as preventative measures for residents in the facility who required wound FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 25 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care. During an interview with the DON, on 7/19/19, at 10:39 a.m., she stated the licensed nurses need to be more aware of the environment for flies when completing wound treatments. The DON stated if the treatment was working for the residents with wounds, the licensed nurses were not going to implement additional measures to ensure pest did not get into the wounds. The DON stated there was no focused skin assessments completed to identify if other residents had maggots in their wounds. The DON stated the issue with Resident 1's wound was the dressing to the left foot was not properly wrapped which resulted in the wound becoming infected with maggots. During a telephone interview with Medical Doctor (MD), on 7/19/19, at 11:44 a.m., he stated he was the primary care physician for Resident 1. The MD stated he was notified of the maggots in Resident 1's wound bed by fax (facsimile) on 7/13/19. The MD stated the fax indicated Resident 1 had maggots and was requesting to go to the hospital. The MD stated the fax was a FYI (for your information) because the facility sent the resident out to the hospital. The MD stated flies in the facility can lay eggs on residents' wounds and cause a risk for infection to the resident. The MD stated the treatment orders to use xeroform for Resident 1's burns were appropriate treatments. The MD stated he did not recommend Resident 1 to see a wound specialist because he did not consider there was anything else that could be done for the burns. The MD stated he would have expected the licensed nurses to measure the wounds to identify if the wounds were healing or getting worse. Because of the actual serious harm to Resident 1 and the potential serious harm to residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 26 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with wounds from not having additional interventions in place to prevent maggot infestation to their wounds an Immediate Jeopardy Situation (IJ) was called on 7/19/19 at 2:15 p.m., with the facility Administrator (ADM) and Director of Nursing (DON). The facility submitted an acceptable IJ Removal Plan on 7/20/19, at 9:30 a.m., to conduct a skin assessment of residents with wounds for maggots or infections, conduct licensed nurses training and education on wound management including performing dressing changes, wound care documentation and monitoring, weekly communication to physicians regarding wound care, conduct an environmental assessment of the facility to ensure all screens to windows and doors were closed, recommendation for additional pest control measures to minimize the number of flies in the facility, implement training and education regarding fly prevention to reduce the flies in the facility, and address the potential risks flies can cause to a resident with wounds. The components of the IJ Removal Plan were validated as implemented and the IJ situation was removed on 7/21/19, at 10:45 a.m., with the ADM and DON. During a telephone interview with Emergency Medical Technician (EMT), on 7/19/19, at 3:17 p.m., she stated she arrived at the SNF on 7/13/19 at 10:20 a.m. The EMT stated there were three to four maggots on the gurney after transporting Resident 1 to the emergency room (ER). The EMT stated the hospital ER nurse stated there were six to seven maggots on the left foot upon entrance to the ER. During a review of the hospital record for Resident 1, the ED (Emergency Department) Physician Notes Final Report dated 7/13/19, indicated " ...Chief Complaint ED: Wound ...PT [patient] brought in by EMS [emergency medical service] from [SNF]. Pt is receiving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 27 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wound care there for burns that happened one month ago. Per EMS the wound nurse noted maggots to the wound on the LLE [left lower extremity] ...History of Present Illness ... Symptoms since visit: pain, redness, severe maggots ... presents to the ED via EMS with complaint of maggots in wound onset of 1 day. Pt was seen here June 12th for 2nd degree burns and blisters after falling into a kiddy pool on a hot day. Pt has no other sx [symptoms]. Pt notes wound nurse changed her dressing today and found maggots, nurse attempted to remove most of them before calling EMS ... Review of Systems ... Skin symptoms: Burns, maggots in wound ... Physical Examination ... Skin ... multiple [maggots] ..." During a concurrent interview and skin assessment review with the DON, on 7/19/19, at 3:59 p.m., she stated DSD 2 and herself completed skin assessments on all residents in the facility who had wound treatment orders to assess for infections or maggots in the wounds. The DON stated there were no maggots found in any of the wound assessments. The DON stated she notified each physician regarding the residents in the facility with wounds about maggots being identified in a resident's wound. During an interview with DSD 1, on 7/19/19, at 4:10 p.m., she stated she had in-serviced two licensed nurses who were in the facility regarding wound care. During an interview with the ADM, on 7/19/19, at 5:30 p.m., he stated two additional UV lights and a fly strip will be installed by pest control services before Friday, 7/27/19. The ADM stated he ordered the additional air curtain to be installed above the front door entrance with expected delivery and installation on 7/27/19. During an interview with CNA 6, on 7/20/19, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 28 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10:01 a.m., she stated she was in serviced today, 7/20/19, regarding the facility's fly prevention program. CNA 6 stated she was told to keep the doors to the facility closed. CNA 6 stated if she sees flies in the facility, she would notify MS by documenting the occurrence in the pest control binder located by the MS office. CNA 6 stated she was educated on how flies can lay eggs on resident wounds and the risk of infection flies pose on residents with wounds. CNA 6 stated she needed to keep her residents' rooms clean and for trash to be taken out. CNA 6 stated she would document in the MS binder if she noticed screen door off the track. CNA 6 stated she would notify the charge nurse if she noticed a wound dressing loose on a resident. During an interview with CNA 3, on 7/20/19, at 10:08 a.m., she stated she was in serviced today, 7/20/19, regarding the facility's fly prevention program. CNA 3 stated she was educated on assisting residents trying to come in and out of the patio door to lessen the amount of time the door was opened. CNA 3 stated she was to document in the MS binder if she were to see an increase in flies in the facility. CNA 3 stated she was educated on providing oral care to dependent resident because flies could be attracted to residents' opened mouths. CNA 3 stated she was told to keep her assigned residents rooms clean to decrease the amount of flies landing on residents in the rooms. CNA 3 stated she was educated about the risks flies and maggots for resident with wounds. CNA 3 stated she would tell the MS and document in the MS binder if there was screen door that was off track and not closing properly. During an interview with CNA 7, on 7/20/19, at 10:26 a.m., she stated she was in serviced today, 7/20/19, regarding the facility's fly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 29 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prevention program and wounds. CNA 7 stated she would notify her charge nurse and the DSD if she seen an increase in flies in the facility. CNA 7 stated she would document the occurrence of flies in the MS binder. CNA 7 stated she needed to keep the residents' rooms clean to decrease flies from going into resident rooms. CNA 7 stated she was taught the risks of flies in the facility was maggots forming on wounds and possible infections. CNA 7 stated she would try fixing the screen door if it was off track and not closing properly. CNA 7 stated she would notify the MS and document in the MS binder. CNA 7 stated she would notify the charge nurse if she noticed a resident's wound dressing was loose. CNA 7 stated she would cover the wound before leaving the resident to notify the charge nurse. During an interview with HKA 2, on 7/20/19, at 10:31 a.m., she stated she was in serviced yesterday, 7/19/19, regarding the fly prevention program. HKA 2 stated she was to document in the binder outside the MS office regarding if she sees flies in the residents' rooms. HKA 2 stated staff were to assist residents who were coming in and out of the patio door to reduce the amount of flies that enter in the facility. HKA 2 stated staff were told not to unplug the air curtain and the UV lights. HKA 2 stated the air curtain blows down to keep the flies out of the facility. HKA 2 stated the risk for flies coming into the facility was flies laying eggs on residents and causing maggots. HKA 2 stated she would notify MS about broken screen doors in the MS binder. During an interview with MS, on 7/20/19, at 10:45 a.m., he stated he was in serviced on checking and logging screen doors closing properly. MS stated he was in serviced on checking and logging UV lights in the facility for replacing the glue pads and notifying the pest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 30 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE control services if there was an increase number of flies in the facility. MS stated he need to check the functionality of the air curtains in the facility were working properly. MS stated he has to keep environmental logs of the equipment used for the fly prevention program. During a concurrent observation and interview with MS, on 7/20/19, at 11:08 a.m., he stated he installed weather stripping to the front door and changed the door stop outside to enable to front door to close properly. The front door had white weather stripping along the door frame and door to cover any gaps. The door was opened and closed with no gaps. In the therapy room, MS opened the sliding glass door and observed the screen door on the track closed properly. Rooms 7, 6, and 5 screen doors had no gap between the screen door and door frame. During a concurrent observation and interview with the DON, on 7/21/19, at 9:44 a.m., in Resident 6's room, Resident 6 was lying in bed with his shoes on. The DON removed Resident 6's left foot shoe and sock. The left foot had coban dressing covering the foot. The dressing was dated 7/21/19. During a concurrent observation and interview with the DON, on 7/21/19, at 9:48 a.m., in Resident 7's room, she was sitting in her wheelchair with her shoes on. The DON pulled down Resident 7's socks to the bilateral legs. The bilateral legs had kerlix dressing dated 7/21/19. Resident 7 stated the nurses did her dressing change this morning. The DON pulled up the socks to cover the dressing. During an interview with MDSC, on 7/21/19, at 9:53 a.m., she stated she was charge nurse and treatment nurse assigned today on Station FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 31 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. MDSC stated she was in serviced on the facility's fly prevention program and wound management. MDSC stated she was educated on the need to document what the wound looks like, the measurements of the wound, if medications were given prior to the wound treatment, and what the dressings were used during the treatment. MDSC stated the change nurses need to reassess wounds after 14 days to ensure treatment was still required. MDSC stated the importance of measuring wounds was to know what the healing stages were for the wound being treated. MDSC stated when the resident's wound heals, the charge nurses will have a monitoring order in place for 14 days to ensure the wound did not come back during that 14-day time period. MDSC stated the physician orders wound treatment orders to be individualized for each resident. MDSC stated if she sees an increase in flies to notify MS by documenting in the MS binder. During an interview with Cook 1, on 7/21/19, at 10:09 a.m., she stated she was in serviced on 7/20/19 regarding the fly prevention program. Cook 1 stated if she sees flies or insects in the facility, she was to report it to MS and document it in the pest control binder. Cook 1 stated she was in serviced of the importance of reporting when there was an increase number of flies in the facility and the risk of infections flies can cause to residents. Cook 1 stated flies can cross contaminate infections and harm residents. During a concurrent interview and email correspondence review with the ADM, on 7/21/19, at 10:42 a.m., he provided an email from the pest control company regarding the additional services being installed and added to the monthly services to the facility. The facility will have two UV lights installed and one fly bait station by 7/26/19. The facility will have added FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 32 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to the routine monthly services spot treatment inside and outside the facility near garbage areas and entrances and fly granular bait to shift flies away from entrances. Professional reference review titled, "Myiasis FAQs" dated 4/1/14, retrieved from https://www.cdc.gov/parasites/myiasis/faqs.htm l, indicated, " ... Myiasis is infection with a fly larva ... There are several ways for flies to transmit their larvae to people ... Some flies deposit their larvae on or near a wound or sore, depositing eggs in sloughing-off dead tissue ... How can I prevent infection with myiasis ... Cover your skin to limit the area open to bites from flies ... protect yourself by using window screens and mosquito nets ..." Professional reference review titled, "Myiasis" dated 1/12, retrieved from the American Society For Microbiology, https://cmr.asm.org/content/25/1/79, indicated, " ... Wound myiasis occurs when fly larvae infest open wounds ... Wound myiasis is most often initiated when flies oviposit [lay eggs] in necrotic [dead], hemorrhaging [bleeding], or pus-filled lesions ... The presence of necrosis is also an important factor ... In human cases, there is usually only one offending species in the lesion ... A lack of hygiene ... in the presence of an open wound, are the most important predisposing factors for human wound myiasis... A lack of adequate medical ... care of the elderly ... and other helpless patients, especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation... Local destruction, invasion into deep tissues, and secondary infection are possible complications of myiasis ... Prevention ... Individual actions should also be implemented and include ... making sure wounds are cleaned and dressed regularly ... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 33 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Appropriate precautions will help avoid infestations. The use of screens and mosquito nets is essential to prevent flies from reaching the skin ... Other general precautions include wearing long-sleeved clothing, covering wounds ..." The job description titled "Charge Nurse" undated, indicated "... The primary purpose of your job position is to provide direct nursing care to the residents... Duties and Responsibilities... Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing service department...Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care... Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner... Administer professional services such as... applying and changing dressings/bandages...as required..." The facility policy and procedure titled "Wound Care" dated 10/10, indicated, " ... The purpose of this procedure is to provide guidelines for the care of wounds to promote healing ... Documentation ... 6. All assessment date (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound ... Reporting ... 2. Report other information in accordance with facility policy and professional standards of practice ..."

F838 SS=F Facility Assessment CFR(s): 483.70(e)(1)-(3)

F838 07/31/2019 §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 34 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 35 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and communitybased risk assessment, utilizing an all-hazards approach. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to review and update the facility wide assessment that included the equipment and services needed to care for its residents with wound treatments and wound dressings when the facility identified problems with increased amount of flies in the facility during summer season and did not include specific measures to prevent flies from coming in contact to residents with wound treatments and wound dressings. This failure resulted in the facility not being prepared with the resources and services to prevent flies from infecting wounds. Findings: During a concurrent observation and interview with Resident 9, on 7/17/19, at 1:36 p.m., in Resident 9's room, there was an orange fly swatter next to Resident 9's bed. Resident 9 stated he sometimes had flies in his room. Resident 9 stated the facility had a problem FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 36 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with flies "for a long time" and the facility had not done anything to decrease the amount of flies in the facility. Resident 9 stated the smoking patio door was constantly opened and closed and he could hear the patio door from his room. Resident 9 stated the door being opened caused flies to come into the facility and into his room. During an observation, on 7/17/19, between 1:41 p.m. and 2:20 p.m., there were flies observed on Station 2 nursing station, in the hallway next to room 7 and DON office. During a concurrent interview with RN 1 and record review of Resident 1's progress notes and treatment orders, on 7/17/19, at 2:23 p.m., she stated on 7/13/19 around 10 a.m., she was at Nursing Station 1 when CNA 4 told her that Resident 1's right lower extremity dressing was loose. RN 1 stated she changed the dressing to the right leg and during the dressing change, Resident 1 complained of burning pain to the left foot. RN 1 stated when she took the dressing off the left foot, she observed the top of the left foot with "so many maggots" and more than what she documented in the progress note on 7/13/19. RN 1 stated, "The maggots were covering the whole wound on the left foot." RN 1 stated the dressing to the left foot was not covering the toes. RN 1 stated she went to her treatment cart and obtained normal saline. RN 1 stated she then flushed the wound with normal saline and removed the maggots from the wound bed. RN 1 stated she pressed on the blackened part of the skin on the top of the left foot and three to four maggots came out of the wound bed. RN 1 stated she told CNA 3 to get LVN 4. RN 1 stated she called the DON and told her about what she observed on Resident 1's left foot wound. RN 1 stated she completed the treatment order for the left foot because she did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 37 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not want the resident to be sent out to the hospital with no wound dressing on her left foot. RN 1 stated Resident 1 was transferred to the hospital per Resident 1's request. RN 1 reviewed the physician's treatment order dated 7/1/19 which indicated, " ...Burns to left foot, ankle, anterior [front] calf: Cleanse with normal saline, pat dry, apply xeroform (non-stick sterile wound gauze used to treat burns), cover with ABD [abdominal] pad (absorbent sterile dressing), and wrap with kerlix (woven gauze used to cover wounds) every day shift every other day for 14 days." RN 1 stated the last treatment to the left foot was on Resident 1's shower day, 7/12/19. RN 1 stated LVN 3 performed the dressing change on 7/12/19. RN 1 stated the charge nurses were responsible to complete the treatment orders for Resident 1's burns to her right and left lower extremities and right breast. RN 1 stated she was assigned as the facility treatment nurse for the past three to four months and completed the treatment orders for residents in the facility with pressure ulcers. During a concurrent interview and record review with the Administrator (ADM) and the Director of Nursing (DON) on 7/19/19, at 8:56 a.m., the ADM stated all staff in the facility were aware of the increased number of flies during summer season. The ADM and DON stated they were aware Resident 1 was hospitalized due to maggots infecting the wound on her left foot. The ADM stated the facility did not address the issue regarding increased number of flies during the monthly Quality Assurance and Performance Improvement (QAPI- a systematic, comprehensive and data driven approach to maintaining and improving safety and quality in nursing homes) meetings. The ADM stated, "We did not include it [problem with flies] in our facility assessment, not the flies. I didn't think FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 38 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE about it." The ADM stated the Maintenance Supervisor (MS) was not aware of the incident with Resident 1's wounds infected with maggots. The ADM stated the MDR should have been made aware of the incident since it was his responsibility to inspect the facility for pests and flies so he could contact the facility's contracted pest control company. The ADM stated the purpose of the facility assessment was to determine what resources and competencies are needed to care for the residents in the facility. The DON stated everybody in the facility including the residents were aware of the increased number of flies in the facility during summer season and the facility did not assess and identify how residents with wound treatments and wound dressings could have a potential problem when there are flies in the facility. The DON stated, "We need to be proactive and not reactive especially if we know summer is coming and it's going to be hot and humid so we can be more aware of the temperature changes and perform environmental inspection." The facility document titled, "Requirements of Participation La Sierra Care Center" dated 3/11/19, indicated, "Purpose: The Facility Assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day and emergency operations ... It should provide the basis for decisions regarding quality programs, staffing ... The facility assessment must address or include ... the care required by the resident population considering the types of diseases, conditions... the physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 39 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F925 Maintains Effective Pest Control Program CFR(s): 483.90(i)(4)

F925 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/31/2019 §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to maintain an effective pest control program when there were increased number of flies in the facility (cross reference F684). This failure resulted in Resident 1's burn wound to the left foot to be found infested with maggots on 7/13/19 with subsequent hospitalization to treat the maggot infestation and associated pain and suffering. Findings: During a concurrent observation and interview with Resident 1, on 7/17/19, at 11:50 a.m., in Resident 1's hospital room, she was sitting up in bed with her legs extended on the bed. Resident 1 stated she had fallen at home on 6/12/19 and was on the patio cement for about two and one-half hours. Resident 1 stated she went to the hospital for care related to the burns she suffered to both lower legs and breast. Resident 1 stated on 6/20/19 she was then transferred to the skilled nursing facility (SNF) for continued wound care of the burns. Resident 1 stated on the day she was again hospitalized (7/13/19) the nurses did her dressing changes to her legs and feet. Resident 1 stated she experienced burning pain to the left foot on 7/13/19. Resident 1 stated "I hate flies. Flies were so bad [in her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 40 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE room at the SNF] that I would cover up my head so the flies wouldn't get on me. I have a fly swatter in my room [in the SNF] to kill them." During a review of the facility's clinical record for Resident 1, the facesheet (a document with personal identifiable information) indicated Resident 1 was admitted to the facility on 6/20/19 with diagnoses which included biliary cirrhosis (chronic liver disease characterized by damage to the small bile ducts), burn of chest wall, second degree burn (involves the outer layer of skin and part of the dermis layer of skin) of left foot and left lower limb. During a concurrent observation and interview with Resident 9, on 7/17/19, at 1:36 p.m., in Resident 9's room, there was an orange fly swatter next to Resident 9's bed. Resident 9 stated he sometimes had flies in his room. Resident 9 stated had a problem with flies "for a long time" and the facility had not done anything to decrease the amount of flies in the facility. Resident 9 stated the smoking patio door was constantly opened and closed and he could hear the patio door from his room. Resident 9 stated the door being opened caused flies to come into the facility and into his room. During an observation, on 7/17/19, between 1:41 p.m. and 2:20 p.m., there were flies observed on Station 2 nursing station, in the hallway next to room 7 and DON office. During an interview with Certified Nursing Assistant (CNA) 3, on 7/17/19, at 2:10 p.m., she stated she was aware of the increase of flies in the facility. CNA 3 stated Resident 1 had cookies and snacks on her bedside table which would attract flies into the room. CNA 3 stated, "The flies are just there in the room. Two to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 41 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE three flies. When you walk in the room you see them flying. That's why I take out my trash [trash from residents' rooms]. The patio door is always being opened." CNA 3 stated since May when it became warmer, the patio door fan was turned on because warmer temperatures attract more flies in the facility. During a concurrent interview with Registered Nurse (RN) 1 and record review of Resident 1's progress notes, on 7/17/19, at 2:23 p.m., she stated on 7/13/19 around 10 a.m., she was at Nursing Station 1 when CNA 4 told her that Resident 1's right lower extremity dressing was loose. RN 1 stated she changed the dressing to the right leg and during the dressing change, Resident 1 complained of burning pain to the left foot. RN 1 stated when she took the dressing off the left foot, she observed the top of the left foot with "so many maggots" and more than what she documented in the progress note on 7/13/19. RN 1 stated, "The maggots were covering the whole wound on the left foot." RN 1 stated the dressing to the left foot was not covering the toes. RN 1 stated she went to her treatment cart and obtained normal saline. RN 1 stated she then flushed the wound with normal saline and removed the maggots from the wound bed. RN 1 stated she pressed on the blackened part of the skin on the top of the left foot and three to four maggots came out of the wound bed. During an interview with RN 1, on 7/17/19, at 2:50 p.m., she stated she had seen flies in Resident 1's room. RN 1 stated "I try to put a fan in the room to push the flies away. She even had a fly swatter." During an interview with Licensed Vocational Nurse (LVN) 3, on 7/17/19, at 3:29 p.m., LVN 3 stated there were flies in the facility and in Resident 1's room. LVN 3 stated there were a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 42 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE lot of flies and would see more flies between 12 p.m. to 1 p.m. when it would get warmer outside the facility. LVN 3 stated residents complained about flies and did not know what the facility was doing to minimize the flies in the facility besides closing the doors or keeping the rooms clean. LVN 3 stated Resident 1 would have snacks in her room and that could have caused flies to go into her room. During an interview with Resident 2 in her room, on 7/18/19, at 11:59 a.m., she stated, "There is a lot of flies in the room. It's been a couple of weeks. In the evening at 5:30 p.m., there's a lot of flies. I told my CNA about it. I don't remember her name. She works in the evening and morning [shift] ... I was worried they were going to make me sick. I don't know where the flies come from ... They [the facility] spray [chemicals] but [flies] still come in." During an interview with the Housekeeping Supervisor (HKS), on 7/18/19, at 12:05 p.m., she stated she had observed an increased amount of flies in the facility for the past weeks. HKS stated she informed the Maintenance Supervisor (MS) several times verbally. During an interview with CNA 1, on 7/18/19, at 12:08 p.m., she stated, "I noticed a lot of flies in the past week. I don't know where they came from." CNA 1 pointed at the patio door near the kitchen and stated, "Probably from the door [flies come inside the facility]. Residents come in and out. Maybe that's how the flies came in. I told the Maintenance guy verbally. I don't know what he did but I told him verbally." During an interview with LVN 4, on 7/18/19, at 12:10 p.m., LVN 4 stated "We have flies everywhere." LVN 4 stated she did not think the licensed nurses could have done anything else for Resident 1 to prevent flies from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 43 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE infesting the wound with maggots. LVN 4 stated she thought that since the left foot was wrapped that a fly could not get inside. LVN 4 stated Resident 1 was at risk for infections from the maggots. LVN 4 stated she had noticed the flies in Resident 1's room and the flies coming in through the patio door. LVN 4 stated Resident 1's room was next to the kitchen and it was warm from the heat of the kitchen that can attract flies. LVN 4 stated the residents were always in and out of the patio door all day and employees during the night shift use the door. LVN 4 stated she would see between two to three flies in Resident 1's room and sometimes in the bathroom flying around. LVN 4 stated residents complained about the flies and she would try to get rid of them by using a newspaper. LVN 4 stated there was a fan above the patio door that turns on when opened to prevent flies from getting inside. LVN 4 stated she would verbally notify the MS about the flies in the facility and did not know what was done to decrease the flies in the facility. During a concurrent observation and interview with Restorative Nursing Assistant (RNA), on 7/18/19, at 12:12 p.m. in the facility's hallway, a fly was observed entering the patio door near the kitchen. RNA stated, "There's a fly just right now ... I noticed a lot of flies during the summer here ... I did not tell the charge nurse because everybody [facility staff] knows there are flies here." RNA stated he had not informed the MS he had observed several flies in the facility. During an interview with Resident 3, on 7/18/19, at 12:28 p.m., she stated, "There's a lot of flies in the morning and every night. The nurses know. I feel upset about the flies. They [the facility] are not doing anything about it." During an interview with Resident 4, on 7/18/19, at 12:30 p.m., she stated, "Flies, they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 44 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE are everywhere here. It's terrible. It doesn't matter, day, evening, night, there's a lot of flies in the facility. They go inside my room. They are everywhere. It's just terrible. Sometimes it goes to my food and I just don't eat it. I don't know where the flies came from or what disease they would bring. All the nurses and staff knew about it. I don't have to be telling them about flies. They should do something about it. It makes me so upset seeing a lot of flies. Please do something about it." During an interview with Resident 5, on 7/18/19, at 12:35 p.m., she stated, "There's a lot of flies in the building. It's terrible because they go inside my room. They come in to my food. They get in the food before [residents] do. It's so hard to get things done in this place. The staff knows about how the flies get bad here and they don't do anything. It makes me so upset seeing flies in the room." During an interview with CNA 2, on 7/18/19, at 1 p.m., she stated, "I have been here for 14 years as a CNA. I noticed a lot of flies here and there. It's in the dining room, hallways and sometimes in the residents' rooms. I know [Resident 1]. I took care of her but I called in [sick] that day they found the maggots [in Resident 1's wound bed]. It's terrible and [maggots] grow big. I saw some flies in [Resident 1's] room. That's why she has the fly swatter. [Resident 1's] son brought her the fly swatter. With the flies, [staff] never told the Maintenance [Supervisor] because he knows about the flies. There is a fan blower for the flies on top of the [patio] door but it has been here for a long time. I didn't see anything new that the Maintenance did with the flies. It's still the same ... Everybody knows about the flies..." During an interview with Housekeeping Aide (HKA) 1, on 7/18/19, at 1:21 p.m., HKA 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 45 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated she had been working in the facility for a month and she had noticed a lot of flies in the facility especially when the weather became hot and humid. HKA 1 stated she had not notified the MS she observed flies in the facility. HKA 1 stated, "Everybody knows about the flies." During an interview with CNA 4, on 7/18/19, at 1:35 p.m., she stated Resident 1 complained about the flies in her room located near the patio door. CNA 4 stated Resident 1 had snacks in her room on the bedside table that would attract flies. CNA 4 stated Resident 1's family member brought Resident 1 a fly swatter for her to use in the facility. CNA 4 stated flies were everywhere in the facility. CNA 4 stated the patio door was opened and closed all the time during the day by residents. CNA 4 stated she would see one or two flies in Resident 1's room. CNA 4 stated on 7/13/19 she had seen a fly on Resident 1's pillow and on the curtain. CNA 4 stated Resident 1 had a fly swatter on the floor next to her bed to kill the flies. CNA 4 stated she would try to kill the flies in the room and clean the resident's area such as removing food that did not have a cover. CNA 4 stated flies would increase during the latter part of the day. CNA 4 stated management knew about the increase in flies because everyone in the facility talked about it. CNA 4 stated sometimes it is impossible to keep the flies out of the facility because it takes some residents extra time to propel in or out the patio door. CNA 4 stated the patio door will stay open for a good five minutes before it closed. CNA 4 stated she had not communicated to anyone specifically in the facility about the increase in flies. CNA 4 stated in the past three months, rooms 1 through 7 had more flies than in the back rooms in the facility. CNA 4 stated during the day when it became hot or humid, the flies would increase and residents would complain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 46 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE about the flies. CNA 4 stated she was not aware of any interventions the facility was implementing to minimize the flies in the facility. During an interview with CNA 5, on 7/18/19, at 1:50 p.m., CNA 5 stated she noticed the flies in the facility and increase in flies in the facility in the last couple of months. CNA 5 stated last year and this year has been worse with the number of flies and the flies increase with the warmer weather. CNA 5 stated the smoking patio area was where residents came in and out of the facility. CNA 5 stated MS in-serviced staff to keep the doors closed. During an interview with the Activities Director (AD), on 7/18/19, at 2:30 p.m., he stated the flies in the facility have been bad in the last month. The AD stated there should not be flies in the facility. The AD stated he told dietary and nursing about the increase of flies he had seen. The AD stated the front door did not close all the way which could cause flies to come into the facility. The AD stated he would see one to two flies in the residents' rooms. The AD stated Resident 1 should not have maggots in her wound bed and the incident could have been prevented if the facility was proactive and installed an additional air curtain (a fan installed above a door frame used to decrease flying insects from entering an opened door) on top of the main door entrance. The AD stated the main front door should have been fixed so it would close automatically and prevent more flies from coming inside the facility and the residents' rooms. During a telephone interview with LVN 2, on 7/18/19, at 2:49 p.m., she stated three weeks ago when she worked during the evening shift, she noticed an increase number of the flies in the facility. LVN 2 stated she has seen two or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 47 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE more flies in resident rooms and at the nursing stations. LVN 2 stated Resident 1's room was warmer and would attract flies. LVN 2 stated staff knew about the flies and she did not tell management about the increase number of flies in the facility. LVN 2 stated the facility did not do enough for the resident to have kept the flies away from Resident 1's wounds. LVN 2 stated the infestation of the maggots could have been avoided and Resident 1 could be harmed emotionally from seeing the maggots in her wound. During an interview with MS, on 7/18/19, at 3:13 p.m., he stated he noticed an increase in flies in the facility when the weather became warmer. The MS stated staff communicated verbally to him about pest issues and he had a log for the staff to notify him. The MS stated the facility had air curtains to reduce the risk of the flies from coming into the facility. The MS stated the residents come in and out of the patio door and flies came inside the facility. The MS stated the front door did not have an air curtain because he would have to remodel the top of the door frame for the air curtain to fit. The MS stated there was an emergency door used by staff to take out the trash and to get oxygen tanks. The MS stated the trash can outside the facility was picked up daily from the city. The MS stated the flies were coming from outside, but did not know from where. The MS stated residents eat outside and that will attract flies. The MS stated the back patio was attracting a lot of flies and the back patio door was opened and closed all the time causing flies to come inside. The MS stated he visually checked the screens to the windows and patio doors, but did not document his environmental checks. The MS stated the screen door was not going to prevent flies from coming into the facility unless the glass door was closed. The MS stated the pest control vendor last visited FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 48 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the facility on 7/16/19. The MS showed the receipt from the pest control service vendor which indicated the fly glue pads were 25% full. The MS stated two months ago, the staff turned off the air curtain by the patio door. The MS stated he educated staff not to turn off the air curtain and that the air curtain should be on nonstop. The MS stated he disabled the offswitch on the air curtain so no one could turn it off. The MS stated there were flies at night and if the air curtain was off, the flies would come into the facility. The MS stated he did not have any other ideas to minimize the increased flies in the facility. The MS stated he had seen residents with fly swatters. The MS stated the facility did not allow the residents to have fly swatters because it was an infection control issue if they kill the fly and not clean up afterwards. The MS stated he did not know about the maggots until today (7/18/19) and he should have been told about the maggots since he was responsible for pest control in the facility. During a concurrent interview and facility tour with the MS, on 7/18/19, at 3:44 p.m., the front door to the facility was observed to have a gap between the door frame and the door. The MS stated the front door was loose and needed to be adjusted. There were two visitors who exited the front door and the front door did not fully close. The MS measured the gap and stated the gap was 42" long from the top of the door frame by 3/8 of an inch-wide gap. The MS identified an Ultraviolet (UV) light next to the front door and opened the UV light hood. The MS took out two glue pads used in the UV light. There were approximately 16 large flies on one glue pad and approximately three large flies on one glue pad. The MS observed the UV light next to shower room F and opened the UV light hood. There were approximately eight large flies on one glue pad. The MS observed the UV FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 49 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE light next to room 14 and opened the UV light hood. There were approximately 25 large flies on one glue pad and approximately eight large flies on one glue pad. The MS observed the UV light next to the emergency door and opened the UV light hood. There were approximately 12 large flies and multiple smaller gnats on one glue pad. The MS stated the outside area in the back of the facility could be the source where flies were coming into the facility. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4 p.m., there was an opened sliding glass door observed in the therapy room. There was no screen door on the door track. There was a screen door observed placed on the right side of the sliding glass door propped against the wall. The MS stated the screen door should be on the track and therapy should not have the sliding glass door open without the screen. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4:06 p.m., room 6's screen door did not fit on the track and did not close fully. The MS stated the screen door needed to be adjusted. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4:09 p.m., room 5's screen door did not fit on the track and did not close fully. The MS stated the screen door needed to be adjusted. During a facility tour with the MS, on 7/18/19, at 4:15 p.m., the MS observed the UV light next to the kitchen and opened the UV light hood. There were approximately 74 large flies on one glue pad. There were two flies observed coming in from the opened patio door. During an interview with the ADM, on 7/18/19, at 4:28 p.m., he stated he was made aware of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 50 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the maggots in Resident 1's wound on Monday, 7/15/19. The ADM stated flies have been an issue in the facility off and on. The ADM stated the area surrounding the facility had more flies when it heats up outside. The ADM stated the environmental interventions the facility had for pest control were air curtains on the patio door and kitchen exit door, pest control services, and the UV lights with the glue pads. The ADM stated the Interdisciplinary Team (a group of individuals including, but not limited to the DON, Social services, and MD to discuss a resident's plan of care) met on Monday, 7/15/19, regarding the incident on 7/13/19 and stated MS was not involved in the meeting. The ADM stated the maggots in the wound was a nursing issue and not an environmental issue. The ADM did not think about reporting the unusual occurrence to the California Department of Public Health (CDPH) because the resident was already out to the hospital. The ADM stated he should have reported this incident to CDPH. The ADM stated the staff were educated on keeping the screen doors closed to minimize the flies. During an interview with the DON, on 7/18/19, at 4:41 p.m., DON stated she became aware Resident 1's wound had maggots on 7/15/19 when she reviewed nursing documentation. The DON stated in the IDT meeting, the staff present were the ADM, Minimum Data Set Coordinator (MDSC), and herself. The DON stated IDT did not identify the wound being infested with maggots as an environmental issue. The DON stated MS did not know about the maggots in the resident's wound until today, 7/18/19. The DON stated a fly should not have been able to lay an egg on the wound bed if the dressing was wrapped properly. The DON stated this incident should have been reported to CDPH, but was not. The DON stated the ADM was guiding her on what to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 51 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE report to CDPH. The DON stated the treatment nurse was responsible for pressure ulcers in the facility, but should be involved with all wounds. The DON stated the licensed nurses should be assessing and documenting wounds after treatment was completed including measurements of the wound. The DON stated a couple of weeks ago the flies became an issue. The nurses at night were keeping the emergency door open and staff were inserviced to keep the door closed. During an observation, on 7/19/19, at 7:30 a.m., the front door was not fully closed and had a gap opening in the closed position. During an interview with DSD 1 and MDSC, on 7/19/19, at 8:10 a.m., DSD 1 stated she noticed flies in the facility. The MDSC stated she inserviced staff on keeping the doors and windows closed. DSD 1 stated the fly problem was not a consistent issue in the facility. The MDSC stated management did not think the flies in the facility was a problem. DSD 1 stated the facility did not see the flies in the facility as a major issue. The MDSC stated management should have been aware of the risks of infection from flies for residents being treated for wound care. During a telephone interview with pest control technician (PCT) 1 on 7/19/19, at 8:18 a.m., he stated he was not aware the facility had increased number of flies during the past weeks. PCT 1 stated, "Prior to yesterday, I was not aware of the flies. We installed UV lights about a year ago but after that, I haven't heard of anything about the flies. [The facility] could have done more to prevent flies like making sure staff should close the door at night. There should be more air curtains in the kitchen and main front door especially [since] it's the front door and people are going inside and out all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 52 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the time." During an interview with Resident 8, on 7/19/19, at 8:23 a.m., Resident 8 stated there were flies sometimes in his room when he had meals. Resident 8 stated flies would land on his shirt or pant leg sometimes. Resident 8 stated everyone in the facility knew about the flies and nothing was done about it. During an interview with MS, on 7/19/19, at 8:36 a.m., he stated he did not check the UV light glue pads. The MS stated that was the responsibility of the pest control vendor. The MS stated he could check the glue pads more often and make a log to document the increase need to change the glue pads. The MS stated he did not keep inspection logs for the glue pads located inside the UV lights. During an interview with the ADM and the DON, on 7/19/19, at 8:45 a.m., the DON stated the management team did not conduct an environmental inspection of the facility after the maggots were identified on 7/13/19 to identify where the flies were coming from. The DON stated she considered the maggots in the wound as a nursing issue due to improper dressing application. The DON stated the flies were not an issue. The DON stated when selecting rooms for new admission to the facility, she did not consider the environment as a risk for residents with wounds. The DON stated she did not consider the risk of increase number of flies can impose on residents with wounds. The DON stated the facility should have moved residents who had wounds or dependent residents away from areas with increased flies. The ADM stated he told MS to look into the increased flies in the rooms on 7/17/19. The ADM stated MS should be changing the glue pads at least once a week, but was not. The ADM stated he never FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 53 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE considered putting the risk flies impose on residents with wounds or dependent residents on the facility assessment. During a concurrent interview with the ADM and facility document review, on 7/19/19, at 9:18 a.m., he provided a copy of the facility assessment. The ADM stated there was no pest control assessment completed during the facility assessment revision on 3/11/19. The ADM stated the facility did not have pest control as an identified concern during Quality Assurance and Performance Improvement (QAPI) meetings. The ADM stated the facility assessment can be updated as needed and pest control was not considered an issue. During a concurrent interview and facility document review with DSD 1, on 7/19/19, at 9:38 a.m., she reviewed the facility assessment with the revision date of 3/11/19 and stated she was involved with the revision of the facility assessment. DSD 1 stated she did not bring to attention the flies during the revision of the facility assessment. DSD 1 stated she should have included the pest control issue regarding the increase flies in the facility during the revision of the facility assessment and will moving forward. During a review of the hospital record for Resident 1, the ED (Emergency Department) Physician Notes Final Report dated 7/13/19, indicated " ...Chief Complaint ED: Wound ...PT [patient] brought in by EMS [emergency medical service] from [SNF]. Pt is receiving wound care there for burns that happened one month ago. Per EMS the wound nurse noted maggots to the wound on the LLE [left lower extremity] ...History of Present Illness ... Symptoms since visit: pain, redness, severe maggots ... presents to the ED via EMS with complaint of maggots in wound onset of 1 day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 54 of 55 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055271 (X3) DATE SURVEY COMPLETED 07/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA SIERRA CARE CENTER 2424 M St Merced, CA 95340 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Pt was seen here June 12th for 2nd degree burns and blisters after falling into a kiddy pool on a hot day. Pt has no other sx [symptoms]. Pt notes wound nurse changed her dressing today and found maggots, nurse attempted to remove most of them before calling EMS ... Review of Systems ... Skin symptoms: Burns, maggots in wound ... Physical Examination ... Skin ... multiple [maggots] ..." Review of the job description titled "Maintenance Supervisor" undated, indicated "... Duties and Responsibilities... Assist the Director in setting maintenance standards. Assist in developing procedures for performing daily maintenance tasks... Perform administrative requirements (i.e. [in other words], completing necessary forms, reports, etc. [so forth]) and submit to the Director as necessary... Implement recommendations from the Infection Control, Safety, and QA [Quality Assurance] Committees, etc., as directed/necessary... Recommend equipment and supply needs to the Director..." Review of the the facility policy and procedure titled "Pest Control" dated 5/08, indicated, " ...Our facility shall maintain an effective pest control program ... 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects... 6. Maintenance service assist, when appropriate and necessary, in providing pest control services ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D7H911 Facility ID: CA040000027 If continuation sheet 55 of 55