Complaint·October 18, 2023

Resident sustained unexplained burn(s) while in care: On 12/30/2021, LPA interviewed Executive Director (ED) Marife Duewel. ED stated resident R1 usually had shower around 4:00PM - 8:00PM, twice per week, but R1 did not have shower on 12/24/2021. ED stated R1 needed 2 caregivers to help with the shower. ED stated R1's right hand was found blisters before breakfast on 12/25/2021. R1 was sent to hospital after assessment. ED stated R1's right hand was paralyzed, was unable to stand up by self, and electrical blankets were not allowed in the facility. ED stated no hot coffee spilled on R1's right hand. On the same day, LPA interviewed 3 staff (S1 - S3). 3 out of 3 stated R1 was normal before breakfast on 12/25/2021 and on the previous day 12/24/2021, there were no incidents such as hot water or hot coffee spilled on R1's right hand. S2 stated it might be the issue of infection or allergy on R1's right hand. On 12/30/2021, LPA toured R1's room, there were no electric blankets observed. LPA measured the temperature of water of R1's bathroom, and it was 107-degree Fahrenheit . LPA measured the hot water temperature of a common bathroom, and it was 119-degree Fahrenheit. On 1/31/2023, LPA interviewed staff S4. S4 stated he/she was on duty on 12/25/2021 morning shift, and found R1's right hand had blisters, but not on the whole right arm, before breakfast in the dining room. S4 stated there was no hot water or hot coffee spilled on R1's right hand. S4 stated he/she did not know that R1's right hand's blisters were due to burn, infection, or allergy. Based on reviewing of R1's medical documents, R1's right hand was paralyzed, R1 needed help for showering, R1 was non-ambulatory, and R1 needed help to transfer. The department has investigated the above allegation. Based on the observations, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ED. A copy of this report was provided to ED. Page 2 of 2.