Meadow Creek Post-acute

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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., with RNS 3, RNS 3 stated that she was informed during shift change on 10/22/2025 at approximately 7:30 a.m. by RNS 2 that Resident 1 had maggots were 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 Resident 1's room to inspect the bed area, as

the resident was being showered at the time. RNS 3 stated at approximately 8:00 a.m. on 10/22/2025, she notified the Medical Doctor (MD 1), Director of Nursing (DON), and the facility Administrator via a group text message. RNS 3 stated she informed MD 1 that maggots had been found around Resident 1's tracheostomy site. RNS 3 stated she did not document the incident in the resident's electronic health record (EHR), did not complete a Situation, Background, Assessment, and Recommendation (SBAR) form, and did not submit a change of condition report. RNS 3 stated that she informed Resident 1's family member about the hospital transfer but stated that she did not inform her that Resident 1 was being transferred for re-evaluation of her wound and maggots infestation. RNS 3 stated that she was instructed by the DON not to disclose the presence of maggots to the resident's family member. RNS 3 stated that her response to the incident was not consistent with facility policy or nursing standards of practice.During a review of facility's policy and procedure (P&P) titled Resident Rights revised 2/2021, the P&P indicated Resident rights to be free from abuse, neglect.During a review of facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 9/2022, the P&P indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Cross reference F-F677

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Creek Post-Acute

7039 Alondra Blvd Paramount, CA 90723

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm

Shower/Tub, dated 2018, the P&P 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. During a review of the facility's policy and procedure (P&P) titled, Tracheostomy: Tube Suctioning with a in-Line Catheter, [undated], the P&P indicated, Purpose: To maintain a clear and patent airway. To protect the resident from cross infection or contamination of the airway.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Creek Post-Acute

7039 Alondra Blvd Paramount, CA 90723

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

information. 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 11:54 a.m., with RNS 3, stated she informed MD 1 that maggots had been found around Resident 1's tracheostomy site. RNS 3 stated she did not document the incident in the resident's electronic health record (EHR), did not complete a SBAR form, and did not submit a change of condition report. RNS 3 stated that she informed Resident 1's family member about the hospital transfer but stated that she did not inform her that Resident 1 was being transferred for re-evaluation of her wound and maggots' infestation. RNS 3 stated that her response to the incident was not consistent with facility policy or nursing standards of practice. During a review of the facility's policy and procedure (P&P) titled, Change in

a Resident's Condition or Status, dated 2021, the P&P indicated, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.During a

review of the facility's Job Description: Registered Nurse (RN), [undated], the Job Description indicated, Ensures the appropriate and timely documentation of resident care activities.During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents-Investigating and Reporting, dated 2017, the P&P indicated, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiated and document investigation of the accident or incident.Cross reference F-F677 and F-F609

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Creek Post-Acute

7039 Alondra Blvd Paramount, CA 90723

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 8/2019 was reviewed. The IP stated that poor oral hygiene and inadequate personal hygiene can create conditions conducive to bacterial growth and odor, which may attract flies. The IP stated that if flies are drawn to a resident due to poor hygiene, they may lay eggs on the skin or within wound areas, which could subsequently develop into maggots if not promptly identified and treated. The IP stated that he was not aware of any current system in place to ensure that staff are adhering to the artificial nail policy. The IP stated that staff wearing artificial nails pose an infection control risk to the residents, especially those who are severely ill or immunocompromised. The IP stated that artificial fingernails can harbor bacteria, fungi, and other microorganisms even after handwashing, which may increase the risk of cross-contamination and infection transmission during resident care. The IP stated that for residents with open wounds, tracheostomies, or ventilators, exposure to bacteria from contaminated nails could lead to serious infections, delayed wound healing, or sepsis (infection in the blood).During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 2019, the P&P indicated, Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and is prohibited among those caring for severely ill or immunocompromised residents. The infection preventionist maintains the right to request the removal of artificial fingernails at any time if he or she determines that

they present an unusual infection control risk.

Event ID:

Facility ID:

If continuation sheet