Health inspection·August 7, 2025

F684 § 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, including but not limited to the following: T22 § 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. T22 § 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. T22 § 72637- General Maintenance (f) The facility shall be maintained free from vermin and rodents through operation of a pest control program. The pest control program shall be conducted in the main patient buildings, all outbuildings on the property and all grounds. On 6/23/25, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility Reported Incident regarding quality of care, resident safety and infection control. As a result of the investigation, the CDPH determined the facility failed to ensure Resident 1 received care and services to prevent maggot infestation inside Resident 1's right ear, right nostril and mouth, by failing to: a. Ensure Certified Nurse Assistant (CNA) 4 obtained help from licensed nurses (Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs) and/or Respiratory Therapists (RTs) in the facility's Sub Acute Unit to provide oral care to Resident 1 in accordance with the facility's Policies and Procedure (P&P) titled " Mouth Care," and "Activities of Daily Living” to prevent the buildup of thick white material on Resident 1's tongue and dried reddish-brown dirt on Resident 1's teeth and the gums. b. Ensure facility's doors were closed and the screen doors were intact to prevent flies going inside the facility in accordance with the facility's P&P titled, "Pest Control." As a result, on 6/20/25, an in-house Dialysis Technician (DT) 1, LVN 1 and RN 1 noticed five to eight maggots coming from Resident 1's right ear, right nostril, and mouth. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 6/20/25, at 4:20 pm, and was diagnosed with septic shock. A review of Resident 1's Admission Record indicated the facility admitted Resident 1, a 70-year-old male on 6/13/25 with diagnoses including metabolic encephalopathy, respiratory failure, attention to tracheostomy and end stage renal disease (ESRD), and dependent on renal dialysis. A review of Resident 1's Physician's Order, dated 6/12/25, indicated bedside dialysis on Monday, Wednesday, and Friday, once a day for ESRD. A review of Resident 1's Physician History and Physical, dated 6/14/25, indicated Resident 1 was on mechanical ventilation secondary to pulmonary edema. A review of Resident 1's Interdisciplinary Team Conference Record, dated 6/16/25, at 8:34 pm, indicated Resident 1 required total assistance with bed mobility, toileting, dressing, and bathing. A review of Resident 1's Minimum Data Set (MDS) dated 6/17/25, indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 was dependent on staff for oral hygiene, toileting, bathing, and personal hygiene. A review of Resident 1's untimed Situation Background Assessment Recommendation (SBAR) form, dated 6/20/25, indicated DT 1 observed several whitish moving objects coming from Resident 1's right nostril, mouth and right ear. A review of Resident 1's Progress Note (PN), dated 6/20/25, indicated on 6/20/25, at 1:30 p.m., Treatment Nurse 1 (TN1) informed RN 1 of whitish moving bodies from Resident 1's mouth. The PN indicated RN 1 assessed Resident 1's mouth and removed the whitish moving bodies from the mouth, right ear, and right nostril. The PN indicated Resident 1 was transferred to GACH 1 on 6/20/25 at 4:20 PM. A review of Resident 1's GACH 1 Intensive Care Discharge Summary (ICDS), dated 7/1/25, indicated Resident 1 had hypotension and tachycardia upon arrival at the Emergency Department (ED). The ICDS indicated Resident 1 was given medications to increase Resident 1's blood pressure. The ICDS indicated Resident 1 was non-responsive to painful stimuli in the ED with multi-organ failure. The ICDS indicated Resident 1 was placed on comfort care. The ICDS indicated Resident 1 had discharge diagnoses including septic shock, severe sepsis, and meal worm in naris. During an observation on 6/24/25, at 12:01pm, the facility's trash dumpster located outside of the facility, in front of the back double door, near the Sub-Acute Unit (SAU) was uncovered. The dumpster's lid was open and overflowing with trash. During an interview on 6/24/25, at 12:05 pm, with CNA 3, CNA 3 stated CNA 3 saw flies in some of the residents' rooms. CNA 3 stated all the screen doors needed to be closed and fly lights should be working. CNA 3 stated CNA 3 saw flies inside of the facility this morning (6/24/25). During an observation inside of the conference room, on 6/24/25, at 1:45 pm, one live fly was flying up and down in the conference room. During an interview on 6/24/25, at 2:15 pm, with the Maintenance Assistant (MA), the MA stated, it was important that nurses report right away when they see pests or flies due to some residents not being able to move and the flies and gnats could get on the residents. During an observation in the conference room on 6/25/25, at 9:45 am, one live gnat was observed flying inside the conference room. During an observation in the hallway on 6/25/25, at 11:33 am, one live fly was flying back and forth from the hallway. During an interview on 6/26/25, at 9:10 am, with the Assistant Director on Nursing (ADON), the ADON stated in the SAU where Resident 1 was housed, oral care was done by RTs, and licensed nurses. The ADON stated CNAs only clean the outside of the residents' (residents in the SAU) mouths. The ADON stated oral care to residents in the SAU must be done every shift and as needed. The ADON stated the oral care must be documented on the RT flow sheet and nurses' notes. The ADON stated suctioning was done by RTs or licensed nurses. The ADON stated it was important to check the windows and ensure the doors were closed to prevent flies and insects from going into the facility and into the residents' rooms, lay eggs and develop maggot infestation on the residents. The ADON stated, in the SAU, residents were immobile, unresponsive and unable to protect themselves nor remove the bugs/pests. The ADON stated, “this time of the year [summer month]” with the hot weather, there would be a lot of bugs/pests that could go inside the facility. The ADON stated licensed nursing staff should ensure oral care was provided to the residents, especially those residents with tracheostomy and or on ventilator. During an interview on 6/26/15, at 9:38 am, with RN 1, RN 1 stated Resident 1 was transferred to GACH 1 on 6/20/25 and had not returned to the facility. RN 1 stated, on 6/20/25 during Resident 1's dialysis session, DT 1, Resident 1's family member and TN 1 saw two little white moving objects coming out of Resident 1's right nostril, one coming outside Resident 1's right ear, and five coming out of Resident 1's mouth. RN 1 stated it was important not to have flies in the facility because the residents in the SAU could not move on their own and flies could lay eggs inside their mouth and tracheostomy. RN 1 stated, she had not performed oral care to Resident 1 in the morning of 6/20/25 due to Resident 1's dialysis session. During an interview with LVN 1 on 6/26/25, at 10:45 am, LVN 1 stated, Resident 1 slept with Resident 1's mouth wide open. LVN 1 stated Resident 1"always" kept Resident 1's mouth open. LVN 1 stated Resident 1 had a thick white layer on Resident 1's tongue that was not easily removed when LVN 1 provided oral care to Resident 1 on 6/20/25. LVN 1 stated there were flies in the SAU hallway. LVN 1 stated, after Resident 1 was found with maggots on 6/20/25, flies could still be seen in the facility. LVN1 stated, on 6/20/25, at 4:30 pm, the dialysis RN supervisor came to inform LVN 1 that DT 1 noticed "worms/maggots" coming out from Resident 1's nose. LVN 1 stated, LVN 1 accompanied TN 1 to assess Resident 1 and found one worm hanging from Resident 1's right nostril. LVN 1 stated TN 1 went to get RN 1. LVN 1 stated RN 1 removed the worms and had to dig into Resident 1's mouth to remove all of them (5 maggots). LVN 1 stated there was also one worm on the right side of Resident 1's pillow and others in Resident 1's nose. LVN 1 stated RN 1 described the moving objects from Resident 1's mouth and nose as "whitish moving objects," but the RN Dialysis Supervisor and DT 1 stated they were worms/maggots. During an interview on 6/26/25, at 2:26 pm, with CNA 4, CNA 4 stated CNA 4 took care of Resident 1 on the night shift (11pm-7am) of 6/19/25. CNA 4 stated CNA 4 performed oral care for Resident 1, but CNA 4 only cleaned around Resident 1's lips. CNA 4 stated CNA 4 did not clean the inside of Resident 1's mouth because Resident 1's mouth was closed. CNA 4 stated CNA 4 did not ask the assigned RT or licensed nurses assigned to care for Resident 1 to assist CNA 4 with oral care due to Resident 1's mouth "looked" clean from the outside. During an interview on 6/26/25, at 2:35 pm, with DT 1, DT 1 stated, on 6/20/25 during Resident 1's dialysis session, while talking to Resident 1's family member, DT 1 noticed something was moving on Resident 1's beard, and something coming out of Resident 1's nostrils. DT 1 stated "it was a maggot or something like a worm". DT 1 called Dialysis RN and Dialysis RN saw more than five worms coming out of Resident 1's nostrils. DT 1 stated Resident 1 kept Resident 1's mouth "open all the time." DT 1 stated, DT 1 did not check the inside of Resident 1's mouth and DT 1 assumed Resident 1's mouth was clean. A review of the facility's P&P titled, "Mouth Care," revised 2/2018 indicated to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent oral infection. The P&P indicated for staff to thoroughly wipe the roof of a resident's mouth, inside the cheeks, the tongue, and teeth with an applicator. The P&P indicated to change the applicators frequently and to moisten the inside of the resident's mouth, tongue and lips using a prepared swab or water-soluble lubricant (lubricant that dissolves in water. A review of the facility P&P titled, "Activities of Daily Living (ADL) Supporting," revised 3/2018 indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLS. The P&P indicated residents who are unable to carry out ADL independently will receive the services necessary to maintain good grooming and personal and oral hygiene. A review of the facility's P&P titled, "Pest Control", revised 5/2018 indicated the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. The P&P indicated windows are screened at all times. The facility failed to ensure Resident 1 received care and services to prevent maggot infestation inside Resident 1's right ear, right nostril and mouth, by failing to: a. Ensure CNA 4 obtained help from licensed nurses and/or RT in the facility's Sub Acute Unit to provide oral care to Resident 1 in accordance with the facility's P&P titled " Mouth Care," and "Activities of Daily Living” to prevent the buildup of thick white material on Resident 1's tongue and dried reddish-brown dirt on Resident 1's teeth and the gums. b. Ensure facility's doors were closed and the screen doors were intact to prevent flies going inside the facility in accordance with the facility's P&P titled, "Pest Control." As a result, on 6/20/25, DT1, LVN 1, and RN 1 noticed five to eight maggots coming from Resident 1's right ear, right nostril, and mouth. Resident 1 was transferred to GACH 1 on 6/20/25, at 4:20 pm, and was diagnosed with septic shock. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1. 2