Health inspection·September 21, 2023

42 CFR § 483.24 (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; 42 CFR § 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 person-centered care plan, and the residents' choices. 42 CFR §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 42 CFR § §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. 22 CCR § 72315 - Nursing Service - Patient Care (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors. Title 22 CCR § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/18/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care and treatment. The facility failed to ensure Resident 1, who was totally dependent on staff for care, was provided care which showed evidence of good personal hygiene, including oral hygiene to prevent complications including infection and as per facility’s policies. As a result, on 7/16/2023, at 12:00 p.m. Family Member 1 found four (4) live maggots (larvae [worm-like creatures], which emerge from the eggs deliberately laid by certain types of flies and feed from the host’s dead or living tissues) in Resident 1’s mouth. According to the Centers for Disease Control and Prevention (https://www.cdc.gov/parasites/myiasis), myiasis is the infection of a fly larva (maggot) in human tissue. A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1, a 45-year-old male, on 10/24/2011 and readmitted on 11/17/2022, with diagnoses that included quadriplegia (loss of movement to all four limbs [arms and legs] of the body due to damage to the spinal cord), tracheostomy (a surgically created stoma [hole] in your trachea [windpipe] that provides an alternative airway for breathing) and gastrostomy (a surgical opening through the skin of the abdomen to the stomach). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 6/27/2023 indicated Resident 1 was unable to communicate and was dependent on all activities of daily living (ADLs such as repositioning in bed, transfers, feeding, persona hygiene, dressing, and bathing). A review of Resident 1’s Change of Condition (a change in resident’s baseline status) form, dated 7/16/2023 and timed at 12:49 p.m., indicated on 7/16/2023, FM 1 notified Registered Nurse 1 (RN 1) that while she was cleaning Resident 1’s mouth, FM 1 found maggots on the toothbrush. During an interview with FM 1 on 7/18/2023 at 11:30 a.m., FM 1 stated that she was visiting Resident 1 on 7/16/2023 at around 12:00 p.m. and was brushing his teeth with a toothbrush when she saw movement in Resident 1’s mouth. FM 1 stated that when she removed the toothbrush from Resident 1’s mouth, there were two live maggots on the toothbrush. FM 1 stated Respiratory Therapist 1 (RT 1) was in the room and she showed RT 1 the live maggots. FM 1 stated that after RT 1 left the room to get RN 1, FM 1 was able to use the toothbrush to remove two additional live maggots from Resident 1’s mouth. FM 1 stated Resident 1 has his mouth open most of the time so anything could have gotten in his mouth. During an interview with RT 1 on 7/18/2023 at 1:40 p.m., RT 1 stated that on 7/16/2023 at approximately 12:00 p.m. to 12:30 p.m., RT 1 went into Resident 1’s room to provide respiratory care. RT 1 stated he observed FM 1 providing oral care to Resident 1 with a toothbrush as FM 1 usually does during her visits. RT 1 stated FM 1 started screaming and called RT 1’s attention to Resident 1’s side table. RT 1 stated he observed two live maggots on the side table. RT 1 stated FM 1 told him that maggots came from Resident 1’s mouth. RT 1 stated he left the room to call RN 1. During an interview with RN 1 on 7/18/2023 at 3:40 p.m., RN 1 stated on 7/16/2023 at approximately 12:00 p.m. to 12:30 p.m. she was alerted by RT 1 that there was a situation with Resident 1. RN 1 stated FM 1 was at Resident 1’s bedside and showed RN 1 two live maggots on a toothbrush and then showed RN 1 Resident 1’s bedside table that had two additional live maggots. RN 1 stated FM 1 told her that the four (4) live maggots were found inside Resident 1’s mouth and FM 1 was able to remove the maggots with the toothbrush. During a concurrent observation and interview inside Resident 1’s room on 7/18/2023 at 3:55 p.m., of Resident 1’s oral care with Certified Nursing Assistant 2 (CNA 2), CNA 2 was observed providing oral care to Resident 1 using a mouth swab (a tool used to clean the inside of the mouth) and mouthwash. Resident 1 was observed biting down when CNA 2 inserted the mouth swab into his mouth. CNA 2 stated that Resident 1 often bites down during oral care making it hard for CNA 2 to reach all the areas inside the resident’s mouth with the mouth swab. CNA 2 stated staff documents oral care provided to a resident in the Documentation Survey Report form under Personal Hygiene. CNA 2 stated that when she has a hard time providing oral care to Resident 1, she documents NA (not applicable) in the Documentation Survey Report form under Personal Hygiene. A review of Resident 1’s Documentation Survey Report form for July 2023 indicated that facility staff documented Not Applicable (NA- meaning the activity did not apply to the resident and was not done) for evening shift (3:00 p.m. to 11:00 p.m.) under Personal Hygiene on the following dates: 1. 7/3/23 2. 7/5/23 3. 7/9/23 4. 7/10/23 5. 7/11/23 6. 7/12/23 7. 7/16/23 During an interview and concurrent record review of Resident 1’s Documentation Survey Report form for July 2023 on 7/26/2023 at 1:45 p.m. with the DON, the DON stated that there were several entries marked as NA under the category of personal hygiene. The DON stated CNAs are supposed to perform oral care on residents once per shift, as needed, and then document on the Documentation Survey Report form. The DON further stated that they do not have a system in place to assess the adequacy of the oral care provided by the CNAs. During a concurrent observation and interview inside Resident 1’s room on 8/8/2023 at 11:17 a.m., of Resident 1’s oral care with Certified Nursing Assistant 3 (CNA 3), CNA 3 was observed providing oral care to Resident 1 using a mouth swab and mouthwash. Resident 1 was observed biting down when CNA 3 inserted the mouth swab into Resident 1’s mouth. CNA 3 stated that Resident 1 will usually close his mouth during oral care, so CNA 3 is unable to really see what she is doing inside the resident’s mouth. CNA 3 stated that she tries her best to clean the inside of Resident 1’s mouth. During a concurrent interview and record review with the DON on 8/8/2023 at 12:55 p.m., Resident 1’s care plans from 11/17/2023 to 7/15/2023 were reviewed. The DON stated she was aware of Resident 1’s tendency to close his mouth during oral care. The DON stated there was no care plan in place to address Resident 1’s tendency to close his mouth during oral care. The DON stated there should have been a care plan developed to address Resident 1’s tendency to close his mouth during oral care so that interventions could have been created and implemented, which could then direct the nursing team on how to care for Resident 1. During a follow-up interview with the DON on 8/9/2023 at 1:08 p.m., the DON stated she was aware that Resident 1 closes his mouth during oral care. The DON stated that she was aware that CNAs were not always able to visualize Resident 1’s mouth during oral care. The DON stated the only assessments done on Resident 1's mouth was being conducted by the dentist during Resident 1’s monthly visits. The DON stated new interventions were put into place because of the presence of maggots inside Resident 1’s mouth which occurred on 7/16/2023. The DON stated there was “room for improvement” and will be more pro-active with regards to providing Resident 1 with adequate oral care. A review of the facility’s policy and procedure titled, “Activities of Daily Living,” last revised on 1/1/2020, indicated that residents who are unable to carry out ADLs independently will receive the assistance necessary to maintain good personal and oral hygiene. A review of the facility’s policy and procedure titled, “Oral Care,” last revised on 11/1/2017, indicated it is the policy of the facility to ensure all residents receive appropriate oral care daily. The policy and procedure also indicated it is the responsibility of each staff member within the nursing department to ensure good oral care is provided for each resident. A review of the facility’s policy and procedure titled, “Grooming,” last revised on 7/1/2015, indicated it is the policy of the facility to work with residents to improve their ability to groom him/herself and with the appropriate types and amount of assistance. Residents should perform oral care/mouth care twice daily. The facility failed to ensure Resident 1, who was totally dependent on staff for care, was provided care which showed evidence of good personal hygiene, including oral hygiene to prevent complications including infection and as per facility’s policies. As a result, on 7/16/2023, at 12:00 p.m. Family Member 1 found four (4) live maggots in Resident 1’s mouth. According to the Centers for Disease Control and Prevention (https://www.cdc.gov/parasites/myiasis), myiasis is the infection of a fly larva (maggot) in human tissue. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result Resident 1.