Health inspection·December 12, 2025

§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; and §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. § 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. 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 10/22/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) has maggots. On 10/23/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined the facility failed to: 1. Ensure Resident 1, who was a ventilator dependent, received personal hygiene care, including regularly scheduled showers and bed baths, to prevent maggots' infestation around tracheostomy and a Stage III pressure injury to the left lateral (relating to or situated on the side) side of the resident's neck. 2. Ensure Resident 1 was provided with regularly scheduled showers and bed baths to promote the resident's cleanliness in accordance with the facility's policy and procedure (P&P) titled, "Bath, Shower/Tub," dated 2018, which indicated, "The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin." 3. Ensure Resident 1 was provided oral care every shift per care plan titled, "titled "Respiratory" dated 5/22/2025. As a result, Resident 1 developed maggots around the tracheostomy site and a Stage III pressure injury to the left lateral side of the neck requiring transfer to an acute care hospital (GACH) on 10/23/2025 for further evaluation and treatment and had poor oral care which placed Resident 1 at risk of oral infection, airway obstruction (when something blocks the path for air to get into their lungs, making it hard to breathe) and compromised respiratory status (trouble breathing). A review of Resident 1's Admission Record, indicated Resident 1 a 74-year-old female, who was initially admitted to the facility on 1/5/2024 and readmitted on 3/7/2025 with diagnoses including acute respiratory failure, chronic kidney disease, dependence on renal dialysis, and dysphagia. A review of Resident 1's Care Plan titled "Respiratory" dated 5/22/2025, indicated to provide oral care every shift including lips, teeth, tongue, buccal wall (inner lining of the cheek), and pharynx (cavity behind the nose and mouth). A review of Resident 1's History and Physical (H& P) dated 5/25/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] resident assessment tool) dated 9/14/2025, indicated Resident 1 was dependent on oral hygiene, toileting hygiene, shower/bath, and personal hygiene. During an observation on 10/23/2025 at 10:30 a.m. in Resident 1's room, Resident 1 was observed lying in bed with a tracheostomy in and a gastrostomy tube (GT) in place. Resident 1 was non-verbal and not responsive to environmental surroundings. Resident 1's mouth was observed unclean with a thick, yellowish coating noted on the tongue and inner lips and dried secretions around the corners of the mouth. Resident 1's lips were dry and cracked. During an interview on 10/23/2025 at 11:00 a.m., a Certified Nurse Assistant (CNA) 1 stated that during his morning shift (7 am to 3 pm shift) he was responsible for 14 residents residing on the sub-acute unit. CNA 1 stated that he could not complete his assignments due to the acuity of the residents on the sub-acute unit. CNA 1 stated that he has brought his concerns to the Administrator. CNA 1 stated that despite raising his concerns, no changes had been made to address staffing levels, and he continued to have trouble completing all assigned care tasks, including providing scheduled showers and bed baths. CNA 1 stated that the Respiratory Therapist (RT) 1 discovered approximately 20 maggots around Resident 1's tracheostomy site on 10/22/2025 at approximately 7:00 a.m. CNA 1 stated Registered Nurse (RNS) 2 asked him to provide Resident 1 with a shower immediately on 10/22/2025. CNA 1 stated that he was assisted by CNA 2 and RT 4 as the resident was a ventilator dependent. CNA 1 stated that during the shower, CNA 1 observed two to three additional maggots around the left side of Resident 1's neck. CNA 1 stated that both the outgoing RNS 2 and the incoming day shift (RNS 3 were aware that maggots had been observed on Resident 1 by RT 1 on 10/22/2025. CNA 1 stated that Resident 1's scheduled shower days were Mondays and Thursday and a bed bath on other five days of the week. CNA 1 stated that at times, residents were not showered as scheduled due to the number of residents assigned to each CNAs and due to the residents' acuity and workload demands. CNA 1 stated that due to reduced staffing levels or increased resident care needs, some resident showers were delayed or missed. CNA 1 stated that when residents do not receive their scheduled showers or bed baths, it can lead to poor hygiene, skin breakdown, and a risk of infection. CNA 1 stated inadequate hygiene may attract pests, potentially resulting in infestations, such as maggots. During an interview on 10/23/2025 at 12:00 p.m., the License Vocational Nurse (LVN) 1 stated that residents were scheduled to receive showers twice a week and bed baths five days week. LVN 1 stated CNAs were responsible for providing hygiene care, while LVNs and the treatment nurse were responsible for ensuring that care was completed and properly documented. CNAs documented skin inspection on Resident Shower Sheet, which was then reviewed and signed by the treatment nurse for validation. LVN 1 stated the importance of hygiene care was to prevent skin breakdown, infections, and infestations, including maggots. LVN 1 stated that Respiratory Therapists (RTs) were responsible for providing oral care every shift and as needed. LVN 1 stated that oral care was essential to prevent infections, mouth sores, and bacterial buildup, which can lead to further health complications. LVN 1 stated that on 10/22/2025 she did not assess Resident 1's mouth during her shift due to workload demands and forgot to perform the assessment. A review of Resident 1's Skin Inspection On Resident Shower Sheet dated 10/5/2025, 10/12/2025 and 10/22/2025 indicated Resident 1 received a shower. During a concurrent interview and record review on 10/23/2025 at 12:24 p.m. with Treatment Nurse (TN) 1, in the social services office, Resident 1's SNF Wound Care Note dated 10/2025 was reviewed. TN 1 stated that Resident 1 initially developed moisture-associated skin damage (MASD-occurs when skin becomes red, sore, or broken due to prolonged exposure to moisture) on the left lateral side of the neck on 9/3/2025. TN 1 stated that during an assessment on 10/10/2025, She identified that the wound had deteriorated and was now classified as a Stage III pressure injury (a full-thickness skin loss that extends into the subcutaneous tissue (fat layer). TN 1 stated that this Stage III pressure injury was attributed to the resident's tracheostomy ties (secure the tracheostomy tube). TN 1 stated on 10/10/2025, Stage III pressure wound measured 3.0 centimeters (cm) in length by 2.0 cm in width and by 0.3 cm in depth. A review of Resident 1 Skin Assessment dated 10/16/2025 indicated Resident 1 had a Stage III pressure injury to the left lateral neck due to friction from the tracheostomy tie. The assessment indicated the wound was with scattered openings and 100 % granulation tissue with moderate serosanguinous drainage. The treatment order dated10/16/2025...was to cleanse left lateral neck with normal saline, apply Santyl, collagen powder and cover with dry dressing daily and as necessary (PRN). During a concurrent observation and interview on 10/23/2025 at 12:35 p.m. with Respiratory Therapist (RT) 2, in the social services office, RT 2 stated oral care must be performed every shift and as needed as a part of comprehensive tracheostomy management. RT 2 stated that proper oral hygiene was critical to prevent the buildup of secretions, bacterial growth, oral infections, and respiratory complications such as ventilator-associated pneumonia. RT 2 stated that inadequate oral care may lead to skin breakdown in the oral cavity RT 2 stated that she last assessed Resident 1 at approximately 7:15 a.m. on 10/22/2025 and noted Resident 1 required oral care at that time. RT 2 stated she only performed suctioning and did not complete oral care due to workload demands and other assignment responsibilities. During the interview, RT 2 was shown a photograph of Resident 1's oral cavity. RT 2 reviewed the image taken on 10/23/2025 at 10:30 a.m. and stated that Resident 1's oral hygiene appeared poor and unacceptable. During a concurrent interview and record review on 10/23/2025 at 12:45 p.m. with Registered Nurse Supervisor (RNS) 1, in social services office, Resident 1's electronic health record (EHR) was reviewed. RNS 1 stated that there was no documentation indicating the presence of maggots or any related concerns. RNS 1 stated that if maggots at the tracheostomy site had existed, it should have been documented using the SBAR (Situation, Background, Assessment, and Recommendation) communication tool, included in the Nursing Progress Notes, and reported to the physician and the resident's family. RNS 1 stated that proper documentation and timely reporting were critical for ensuring effective communication among care team members, enabling the physician to make informed treatment decisions, keeping the family informed of significant changes, and ensuring regulatory oversight to protect resident safety. RNS 1 stated that failure to document or report such concerns could result in delayed or inadequate care, worsening the wound, increased risk of infection, and potential non-compliance with state and federal regulations. A review of Resident 1's Documentation Survey Report titled "Oral Care" section for 10/2025, the report indicated that oral care was not documented as provided as follows: 1. On 7 am-3 pm of 10/4/2025, 10/5/2025, 10/10/2025, 10/14/2025, 10/16/2025, 10/19/2025, 10//20/2025, 10/21/2025, and 10/22/2025. 2. On 3 pm -11 pm of10/19/2025 and 10/23/2025. 3. On 11 pm -7 am of 10/2/2025, 10/11/2025, and 10/21/2025. During a telephone interview, on 10/23/2025 at 2:30 p.m., with Resident 1's medical doctor (MD) 1, MD 1 stated that he was informed by Registered Nurse Supervisor (RNS) 3 on 10/22/2025 that Resident 1 had maggots present around her tracheostomy site and within the left side of the neck's pressure injury wound. MD 1 was unable to recall the exact time he was contacted by RNS 3. MD 1 stated based on the information provided by RNS 3 he ordered Resident 1's transfer to a general acute care hospital (GACH) on 10/22/2025 for further evaluation and treatment. During a concurrent interview and review on 10/23/2025 at 3:03 p.m., with the Director of Staff Development (DSD), in the social services office, Resident 1's Skin Inspection Sheets dated October 2025 were reviewed. The DSD stated that Resident 1 showers were documented as provided on 10/5/2025, 10/12/2025, and 10/22/2025. The DSD stated that Resident 1 did not receive scheduled showers on 10/6/2025, 10/9/2025, 10/13/2025, 10/16/2025, 10/20/2025, and 10/23/2025, which was significant lapse in personal hygiene care. The DSD stated that Resident 1's scheduled shower days were Mondays and Thursdays, with bed baths to be provided on non-shower days. CNAs were responsible for administering both showers and bed baths. The DSD stated that failure to provide regular bathing can lead to skin breakdown, infection, and an increased risk of infection, including maggot infestation, especially in residents with open or compromised skin. The DSD stated that poor hygiene can contribute to resident discomfort and negatively impact dignity. During a concurrent interview and record review on 10/23/2025 at 3:35 p.m. with the Director of Nursing (DON) in social services office, Resident 1's Physician's Order Summary Report dated 10/22/2025 at 10:54 a.m., was reviewed. The Physician's Order Summary Report dated indicated to transfer Resident 1 to GACH for evaluation of wound on the left side of the neck. The DON stated she was first informed by RNS 3 on 10/22/2025 at approximately 10:00 a.m. that Resident 1 had maggots present around the tracheostomy site and in the left side of the neck wound. The DON stated she assessed the resident but did not observe any maggots at that time. The DON stated that she was aware of the maggot concern when the transfer order was written. The DON stated that, given the nature of the incident, there should have been an incident report, progress notes documenting the change in condition, and an update to the resident's care plan. During an interview on 10/24/2025 at 10:04 p.m., with Certified Nurse Assistant (CNA) 2, in social services office, CNA 2 stated that she assisted CNA 1 with Resident 1's shower on the morning of 10/22/2025. CNA 2 stated that during the shower, she observed at least three maggots on the left side of the resident's chest. CNA 2 stated that due to the high acuity of residents in the sub-acute unit, she is sometimes unable to fully bathe residents, which negatively impacts their hygiene care. CNA 2 stated that inadequate bathing can compromise a resident's dignity and personal comfort. CNA 2 stated that failure to provide consistent hygiene care may violate residents' rights to cleanliness and respectful treatment. CNA 2 stated that missed hygiene care increases the risk of skin breakdown, infection, and other complications, and may contribute to a decline in overall health and quality of care for residents. During an interview on 10/24/2025 at 11:21 a.m. with RNS 2, in social services office, RNS 2 stated that on 10/22/2025 at approximately 7:00 a.m., she was informed by RT 1 that Resident 1 had maggots present around the tracheostomy site and a pressure injury located on the left lateral side of Resident 1's neck. RNS 2 stated RT 1 reported discovering the maggots on 10/22/2025 while performing routine tracheostomy care and estimated seeing approximately 20 maggots. RNS 2 stated that she immediately assessed Resident 1 and observed small white objects moving around both the tracheostomy site and the wound area. RNS 2 acknowledged that although she was aware of the presence of maggots, she did not report the incident because she had to leave work. RNS 2 stated that the presence of maggots can lead to infection and pain. During an interview on 10/24/2025 at 11:54 a.m., RNS 3 stated that RNS 2 informed her during shift change on 10/22/2025 at approximately 7:30 a.m. that Resident 1 had maggots present around Resident 1's tracheostomy site. RNS 2 stated that Respiratory Therapist (RT) 1 had observed white objects moving in the area during tracheostomy care and later confirmed they were maggots. RNS 3 stated that she immediately went to Reside