Other·October 21, 2025

F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, medical record review, facility document review, and facility P&P (Policy and Procedures) review, the facility failed to ensure one of three sampled patients (Patient 4) reviewed for safety was free from accident/hazards. * The facility failed to ensure Patients 4 was evaluated to handle and consume hot beverages as per the facility's P&P. * RNAs 1 and 2 failed to notify a licensed nurse immediately after Patient 4 spilled hot tea onto her lap. * The facility failed to ensure Patient 4 was provided the immediate and appropriate interventions when Patient 4 spilled hot tea to her left upper thigh. In addition, the facility failed to obtain a physician's order to properly treat a burn for Patient 4's left thigh. Theses failures resulted in Patient 4 sustaining blisters to her left thigh and delay in the provision of the necessary and appropriate care/interventions which could potentially affect the patient's well-being. Findings: Review of the facility's P&P titled Accidents and Incidents Investigating and Reporting Procedure revised 2/2022 showed: 1. Regardless of how minor an accident or incident may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned, and 2. The nurse supervisor/charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided. Review of the facility's P&P titled Change in a patient's Condition or Status revised 2/2021 showed our facility promptly notifies the patient, his or her attending physician, and the patient representative of changes in the patient's medical/mental condition and/or status. 1. The nurse will notify the patients attending physician or physician on call when there has been a(an) accident or incident involving the patient, 2. The nurse will record in the patient's medical record information relative to the changes in the patient's medical/mental condition or status, 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant information for the provider, including (for example) information prompted by the Interact SBAR (Situation, Background, Assessment and Recommendation- communication tool) Communication Form, and 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the patient's medical/mental condition or status. According to the United States Product Safety Commission, Avoiding Tap Water Scalds (undated), showed most adults will suffer a third-degree burn if exposed to 150-degree Fahrenheit water for two seconds. Burns will also occur with a six-second exposure to 140-degree Fahrenheit water or with a thirty-second exposure to 130-degree Fahrenheit water. Even if the temperature is 120 degrees Fahrenheit, a five-minute exposure could result in third-degree burns. According to the National Library of Medicine dated 8/2023 showed the older adults are particularly susceptible to burn injuries due to increasing dementing illness, sensory impairment, poor mobility, slow reaction times, and medication side effects. Review of the facility's letter to CDPH L&C Program dated 9/5/25, showed on 9/4/25, during routine care, CNA (Certified Nursing Assistant) observed blisters to Patient 4's left upper thigh. The charge nurse and RN (Registered Nurse) supervisor evaluated the patient and observed three blisters to the left upper thigh. Further investigation was conducted, and it was noted that on 9/3/25, during lunchtime in the main dining room, Patient 4 spilled warm tea on her lap. Medical record review for Patient 4 was initiated on 9/9/25. Patient 4 was admitted to the facility on 11/21/24. Patient 4 has a diagnosis of hemiplegia (one side paralysis) and hemiparesis (one sided muscle weakness) affecting the right side, aphasia (impaired ability to understand or form speech) following a cerebral infarction (condition where blood flow to brain was interrupted, causing tissue damage), and generalized muscle weakness. Review of Patient 4's H&P examination dated 11/22/24, showed Patient 4 had no capacity to understand and make medical decisions. Review of Patient 4's Plan of Care initiated on 11/22/24, and revised on 1/24/25, for the OT care plan showed Patient 4 demonstrated a decrease in ADL (Activities of Daily Living) care function due to deficits in strength aphasia (impairment in a person's ability to speak), right sided weakness, deficits in gross motor, and fine motor coordination, aerobic capacity, and balance deficits status post cerebral vascular accident (stroke). Review of Patient 4's MDS (Minimum Data Set- assessment tool) assessment dated 8/28/25, under Section GG-Functional Abilities showed the following: - for Functional Limitation in Range of Motion, showed Patient 4 had impairments on one side for the upper extremities (shoulder, elbow, wrist and hands), and - for Self-Care - Eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food/or liquid once the meal is placed before the patient), showed Patient 4 required supervision or touching assistance (the helper provides verbal cues and /or touching/steadying and/or contact guard assistance as the patient complete the activity). On 9/10/25 at 1216 hours, an observation was conducted for Patient 4. Patient 4 was observed removing her tea bag out of her mug and using both right and left hands to grab the mug and taking sips of her tea. 1. a. Review of the facility's P&P titled Safety of Hot Liquids dated 10/2014 showed the patients will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission, and on change of condition. The patients who prefer how beverages with meals (i.e. coffee, tea, soups, etc.) will not be restricted from these options. Instead, the staff will conduct regular hot liquids safety evaluations as indicated and document the risk factors for scalding and burns in the care plan. Review of the facility's document titled Beverage Preference by Patient dated 9/3/25, showed Patient 4 preferred hot tea for lunch and dinner. Review of Patient 4's medical records did not show Patient 4 was evaluated to handle hot liquids. On 9/12/25 at 1615 hours, an interview was conducted with the Administrator and Administrator Trainee. When asked if an assessment to handle hot beverages should be conducted for all the patients in the facility as per the facility's P&P, the Administrator stated "yes." When asked if the facility conducted the assessment for any patients in the facility, the Administrator stated "no." b. Review of Patient 4's Progress Note dated 9/4/25, showed at approximately 1830 hours, a CNA alerted charge nurse and RN supervisor of the redness on Patient 4's left upper thigh while providing care to the patient. The note further showed Patient 4 had blisters on her left thigh. Two blisters noted to the proximal left thigh, one located medially, measuring 4.5 cm (centimeters) by 1 cm; one located distally, measuring 2 cm by 2 cm; and a third blister noted laterally to mid-thigh, intact with no redness, and measuring 3 cm by 1 cm. On 9/9/25 at 1547 hours, an interview was conducted with RNA (Restorative Nursing Assistant) 1. RNA 1 stated on 9/3/25, when Patient 4 was eating lunch in Dining Room 1, she heard a "glass" fell and was then informed by RNA 2 the tea had spilled onto Patient 4. RNA 1 stated they patted Patient 4 dry, then allowed Patient 4 to finish eating her dessert. RNA 1 stated after Patient 4 consumed her dessert, she was brought back to her room approximately five to 10 minutes later and then she informed CNA 4. When asked if she informed any licensed nurse or supervisor, RNA 1 stated "no." On 9/9/25 at 1559 hours, an interview was conducted with RNA 2. RNA 2 stated on 9/3/25, while Patient 4 was holding her cup of tea, the cup tipped over and everything (tea) went into her lap, floor, and table. RNA 2 stated they patted Patient 4 dry. When asked how she knew it was a tea, RNA 1 stated "it had the tea bag." When asked if she notified anyone, RNA 2 stated "not me, RNA 1 told CNA 4." On 9/10/25 at 0933 hours, a telephone interview was conducted with CNA 3. CNA 3 stated on 9/4/25, she noticed blisters on Patient 4's skin while providing perineal care. CNA 3 stated she immediately notified LVN 2 and RN 1 to see if anyone had reported the blisters on her skin. CNA 3 stated she was not comfortable continuing the perineal care without notifying the licensed nurses as Patient 4's blisters were "huge." On 9/10/25 at 1008 hours, a follow up interview was conducted with RNA 1. When asked what time lunch was served, RNA 1 stated approximately at 1200 hours. When asked the process was when an incident occurred, RNA 1 stated to report it right away. When asked if it was reported right away, RNA 1 stated "no, it was not." On 9/10/25 at 1019 hours, an interview was conducted with CNA 4. CNA 4 stated on 9/3/25, when Patient 4 returned to her room from Dining Room 1, she removed the patient's pants, saw redness on her left thigh, and reported it to RN 2 and Treatment Nurse 1. When asked what time she reported it to the licensed nurses, CNA 4 stated sometime between 1230-1345 hours. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2. RN 2 stated she was notified on 9/3/25, by CNA 4 when Patient 4 spilled hot water on her thigh. However, RN 2 further stated she was not notified at the time the incident had occurred. c. According to the National Library of Medicine titled First Aid for Burns, the Blister Controversy and Acute Washing of the Burn Wound dated 9/2020 showed cooling the burn with cool running tap water has been shown to decrease cellular damage and edema (swelling), reduce the inflammatory reaction with increased healing and decreased need for skin grafting. Although the ideal temperature of water is unknown, the duration shows maximum benefit when done for 20 min and is useful when done up to three hour/s post burn. Cooling the burn with ice is detrimental and can lead to prolonged vasoconstriction (constrict the blood vessels). Other first aid components include immediate removal of clothing and jewelry, but any clothing melted or firmly adherent to the wound should be left to experienced personnel. * Review of Patient 4's Interdisciplinary Progress Note dated 9/5/25, showed during the routine care on 9/4/25, the assigned CNA observed blisters to Patient 4's left upper thigh. The charge nurse and RN supervisor evaluated the patient and observed 3 blisters to the patient's left upper thigh and the surrounding skin was intact. The note further showed on 9/3/25, during lunchtime in the main dining room, Patient 4 spilled warm tea on her lap and upon returning to the patient's room, Patient 4 was evaluated by the nursing staff and noted slight redness to her left upper thigh to which ice was applied to the area. On 9/9/25 at 1603 hours, an interview was conducted with LVN (Licensed Vocational Nurse) 2. When asked if you would pat the patient dry after the hot liquid was spilled, LVN 2 stated "no," we would remove the clothing and apply cold compress. When asked what can happen if you let hot liquid sit on the patient's clothing for five minutes LVN 2 stated "blisters and pain." LVN 2 stated the licensed nurses should have been notified right away rather than waiting until Patient 4 finished eating her dessert. On 9/10/25 at 1019 hours, an interview was conducted with CNA 4. CNA 4 stated on 9/3/25, she was informed by RNA 1 that Patient 4's pants were wet because she spilled hot tea on her lap. CNA 4 stated she proceeded to take Patient 4 to the restroom and noticed redness on her left thigh. When asked if Patient 4 complained of pain, CNA 4 stated "she's a little bit burnt that is why I put ice." On 9/11/25 at 1248 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified on 9/4/25, Patient 4 had three blisters on her left upper thigh. When asked if it is an appropriate treatment to apply ice to a burned skin, RN 1 stated "no," because it can cause vasoconstriction and damage the tissue. On 9/12/25 at 0950 hours, an interview and concurrent medical record review was conducted with MDS Nurse. The MDS Nurse verified the progress notes dated 9/5/25, showed an ice was applied to Patient 4's burn to her left upper thigh. * Review of Patient 4's medical record for the incident on 9/3/25, failed show documented evidence Patient 4's left thigh was assessed, the physician was notified, treatment was obtained and provided, and the patient was monitored. The documentation was not initiated until 9/4/25 at 1830 hours, approximately 30 hours later. On 9/10/25 at 1119 hours, an interview was conducted with Treatment Nurse 1. Treatment Nurse 1 stated CNA 4 had notified her on 9/3/25, close to 1300 hours, of the incident when Patient 4 had spilled hot tea onto her lap and her clothes were warm. When asked if that would be considered a change in condition, Treatment Nurse 1 stated "yes." When asked what the process for a change of condition, Treatment Nurse 1 stated to inform the physician and the patient's family, document, provide the treatment as ordered by the physician, and monitor the patient. Treatment Nurse 1 verified there were no documentation to show a change of condition was initiated on 9/3/25, for Patient 4. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2. RN 2 stated on 9/3/25, when she was notified of Patient 4 spilling hot tea on her thigh. RN 2 stated she assessed her skin, noticed slight redness, and was informed by Treatment Nurse 1 that she applied ice to the area. When asked what Patient 4's leg looked like on the second day, RN 2 stated she developed blisters. When asked what type of burn Patient 4 had, RN 2 stated on the first day it was redness, on the second day it was second to third degree burns. RN 2 verified the physician should have been notified on 9/3/25. This violation had a direct or immediate relationship to the health, safety or security of the patients.