Health inspection·June 25, 2025

The following reflects the findings of the California Department of Public Health during an ABBREVIATED Survey for Complaint Number: CA00963029 which resulted in Dual Enforcement, a Class B Citation (Event ID YKE111). Representing the California Department of Public Health: Surveyor 48853 , HFEN. 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 resident's choices. Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled patients (Patient 1) attained and maintained the highest practicable physical well-being. * The facility failed to ensure Patient 1's colostomy bag was emptied according to the standards of practice when CNA 1 poured hot water in the colostomy bag. While the hot water was being poured, the colostomy bag touched the patient's skin, resulting in Patient 1 sustaining a burn on the left thigh and requiring pain medication administration and wound treatment. This failure had caused the burn to the patient's skin and the patient to experience pain and need wound treatment. Findings: Review of facility's P&P titled Ostomy Care - Colostomy, Urostomy, and Ileostomy revised 12/19/22, showed it is the policy of the facility to ensure that patients who require colostomy, urostomy, or ileostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the patient's goal and preference. Review of the facility's lesson plan titled Emptying an Ostomy bag (undated) showed: 1. When applicable, direct care staff will empty the ostomy bag if bowel or air is noted. Supplies must be gathered prior to performing the task such as: wipes, toilet tissue, disposable bag, 2. Once supplies are obtained, direct care staff will wash hands and apply gloves. Then, place the disposable bag over the clamp at the bottom of the ostomy bag. This will ensure all of the contents in the ostomy bag are captured inside the disposable bag. Direct care staff will then, unclamp the clip and begin pushing the bowel or air down towards the opening with your gloved finger slowly, preventing any potential damage to the bag. Once all air or bowel is removed, wipe the ends of the opening and apply clamp. Ensure the clamp is closed. 4. Dispose of the disposable bag. Remove gloves and wash hands. 5. Direct care staff members will notify direct supervisor if patient asks for changing of the pouch or cleaning the inside of the pouch or any other care that direct care staff is not obligated to perform. 6. It is never appropriate for direct care staff to perform such tasks that are not within their scope. These may include, but are not limited to: a. Changing of the pouch. b. Cleaning of the stoma. c. Putting fluids into the pouch. Medical record review for Patient 1 was initiated on 5/20/25. Patient 1 was admitted to the facility on 3/5/24. Review of Patient 1's H&P examination dated 3/5/25, showed the patient had capacity to understand and make decisions. Review of Patient 1's MDS quarterly assessment dated 3/12/25, showed a BIMS summary score of 14, indicating the patient was cognitively intact. Review of Patient 1's Order Summary Report as of 5/20/25, showed the following physician's orders: - dated 9/26/24, for colostomy care, wash with soapy water, rinse, and pat dry as needed. - dated 9/27/24, for colostomy care, wash with soapy water, rinse, and pat dry every day shift. - dated 9/26/24, may change the colostomy bag as needed. - dated 9/26/24, may change the colostomy bag every day shift - dated 5/19/25, for the left upper thigh blister, cleanse with NS, pat dry, apply Xeroform and cover with dry dressing every day shift. Review or Patient 1's eINTERACT Change in Condition Evaluation dated 5/16/25, showed at 1455 hours, Patient 1 had a change in condition with symptoms of redness to the left outer hip and left lower abdomen. Review of Patient 1's Wound Progress Note dated 5/19/25, showed the burn was present on the left thigh with blister and wound status open. The wound measurements were as follows: area was 12.5 cm², perimeter was 17.6 cm, length was 6.6 cm, width was 2.1 cm, max depth was 0.1 cm, mean depth was 0.0 cm, and volume was 0.0 cm3. The Body % Burned Total showed 18%. On 5/20/25 at 1333 hours, an interview was conducted with Patient 1. Patient 1 stated on the afternoon of 5/16/25, CNA 1 emptied Patient 1's colostomy bag. CNA 1 was not able to empty the bag completely because there were feces left in the bag. Patient 1 further stated CNA 1 left the room and returned with a cup of water. CNA 1 poured the cup of water into the colostomy bag. Patient 1 stated suddenly she felt a burning sensation on her left thigh and abdomen. Patient 1 further stated it was burning so bad that she was yelling to CNA 1, "it's burning, it's burning." However, CNA 1 did not promptly react to Patient 1's response. Patient 1 stated she swatted CNA 1's arm to remove the bag away from her. Patient 1 further stated CNA 1 was apologetic to her and admitted it was his fault to use hot water in cleaning the colostomy bag. Patient 1 stated CNA 1 verbalized he figured the colostomy bag could only be cleaned with hot water. Patient 1 stated the hot water must have burned the skin in her thigh for at least a minute because CNA 1 did not stop. Patient 1 stated her skin was bright red on her abdomen and thigh. Patient 1 stated LVN 1 told her she would be monitored. Patient 1 stated on Sunday afternoon (5/18/25), the redness on her thigh developed to a blister. Patient 1 further stated the nurses did not start the treatment for the blister until Monday (5/19/15). Patient 1 stated the burn still felt painful and sensitive when touched. On 5/20/25 at 1453 hours, an interview was conducted with LVN 1. LVN 1 stated CNA 1 asked him to check Patient 1 on 5/16/25, towards the end of his shift because CNA 1 reported in the process of emptying the colostomy bag, there was a hard feces residue. LVN 1 stated CNA 1 stated he put hot water in the bag which had contact with the patient's skin and caused it to be reddened on the abdomen and left hip area. LVN 1 stated the patient complained of pain and was medicated with acetaminophen 325 mg two tablets orally for the pain scale of 3 (using the pain scale of 0 to 10 with 0 = no pain and 10 = worst pain). On 5/20/25 at 1600 hours, an interview was conducted with the DSD. The DSD stated the CNAs were allowed to empty the ostomy bag in the facility. The DSD stated the CNAs should not put any fluid in the colostomy bag. On 5/21/25 at 1106 hours, a telephone interview was conducted with CNA 1. CNA 1 stated he emptied Patient 1's colostomy bag; however, there were some feces left in the bag. CNA 1 stated he got the water from the water dispenser right by the nursing station and filled the cup halfway. CNA 1 stated he was not paying attention to the temperature of the water because he was in a rush to empty the colostomy bag. CNA 1 stated he put a trash bag against the Patient's thigh, however, did not put a towel on top of the patient's thigh. CNA 1 stated the trash bag was placed next to the patient's skin and colostomy bag. CNA 1 stated he poured all the water in the colostomy bag, then Patient 1 started saying, "Hot! Hot! Hot!" CNA 1 further stated there was redness on the patient's thigh which he reported to LVN 1. On 5/22/25 at 1053 hours, an interview was conducted with the DON. The DON verified CNA 1 emptied the colostomy bag and there were feces remained inside the bag. CNA 1 got hot water, poured it inside the colostomy, rinsed the colostomy bag, in the process, the bag touched the skin and caused the patient to have redness to the left lower abdomen and left hip, and a blister to the left thigh. The blister was observed and treated on 5/19/25. The DON stated the CNAs were not allowed to pour hot water inside the colostomy bag. CNA 1 should have called the charge nurse or treatment nurse. The DON was informed and acknowledged the above findings. This violation had a direct or immediate relationship to the health, safety or security of the patients.