Health inspection·November 13, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan with resident-specific interventions for 1 of 3 sampled residents (Resident 1) related to non-compliance with care and refusal to wear protective foam boots (designed to protect patient's feet-heels, ankles).This failure resulted in the development of maggots in the dorsal (upper side) wound of Resident 1's left foot and was transferred to the hospital for further evaluation and treatment. During a concurrent interview and record review, on 9/24/25, at 11:24 a.m. with the Director of Nursing (DON), the DON stated, The resident (Resident 1) was admitted on [DATE] with 10 plus wounds. All were pre-existing wounds upon admission. Resident 1's History and Physical dated 9/3/25, revealed Resident 1 was admitted to the facility on [DATE]. Diagnoses included PAD (Peripheral Artery Disease [a condition where arteries that carry blood to the arms, legs, and feet become narrow or blocked]) with associated chronic venous stasis (condition where blood pools in the veins, primarily the legs, due to impaired blood flow back to the heart) and chronic BLE (both lower extremities) wounds. During a review of the Treatment Administration Record (TAR), for the month of September 2025, treatment order indicated, Notes: To left dorsal foot dark necrotic area: Cleanse area, pat dry, paint on betadine, cover with non-adherent pad and cover with kerlix, change daily and as needed if soiled or dislodged.During a review of the Clinical Notes Report, dated 9/2/25, it indicated that Resident has refused to wear foam boots to BLE for heel protection at this time. MD aware and order is discontinued. During a review of the Clinical Notes Report, History and Physical Exam by the doctor, dated 9/3/25, indicated, Of note, boots ordered/recommended but he is refusing them. Further record review revealed that no care plan was developed for the refusal of foam boots, and when the physician discontinued the order, there was no evidence that showed the facility attempted to find alternative ways to protect Resident 1's foot wound and dressing.During a review of the Clinical Notes dated 9/22/25, it indicated, MD (name) made aware of wound and new verbal orders to send resident to (name of hospital) where resident originally was seen for BLE wounds for further evaluation.During a record review of hospital records titled ED Physician Notes, dated 9/22/25, it indicated, States they have noticed maggots on his left foot and The left foot has a 5 cm. x 7 cm. area of dry necrosis with maggots in the wound.During a telephone interview, on 9/24/25, at 12:29 p.m., with the Charge Nurse (CN), CN stated she performed treatments for Resident 1's wounds on the left dorsal foot for 2 consecutive days on 9/21/25 and 9/22/25; there was nothing out of the ordinary observed on 9/21/25. CN further stated that on 9/22/25, when cleansing solution was applied to the wound bed, there was bubbling and a single grain like object crawled out of the wound. CN also stated the DON and the physician were notified of her findings and observation. During an interview on 9/24/25, at 1:50 p.m., with the Administrator (ADM) and the DON, when asked how maggots developed in Resident 1's wound, DON stated Resident 1 was non-compliant with care and often left his room's sliding door open, sitting either inside or outside his Page 1 of 2 056189 056189 11/13/2025 San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room. The ADM stated, because of this non-compliance, flies might have crawled past the kerlix gauze wrapped around the wound as it loosens/gets dislodged with movement. The DON concurred with the Administrator.During a record review of an article by the National Institute for Health, (undated), titled The Stages of Maggot Development , indicated, Maggots hatch from eggs in a wound within hours to a day and begin feeding, progressing through three larval stages over several days, during which they grow significantly and liquefy dead tissue for consumption. 056189 Page 2 of 2