Health inspection·January 21, 2026

The following reflects the findings of the California Department of Public Health during an investigation of facility reported incident 2673419. Facility Reported Incident: 2673419 A deficiency was written for Facility Reported Incident 2673419 at F-tag 689-G. 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. Title 22 CCR §72335 (a)(7) Recipes for all items that are prepared for regular and therapeutic diets shall be available and used to prepare attractive and palatable meals, in which nutritive values, flavor and appearance are conserved. Food shall be served attractively, at appropriate temperatures with appropriate eating utensils and in a form to meet individual needs. Title 22 CCR §72521 (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents to employees of the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. Title 22 CCR §72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 22 CCR §72517 (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (5) Accident prevention and safety measures. On 12/2/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident that had acquired a burn to his left-hand index finger. Resident 1 is a 74-year-old male who was admitted to the facility on 11/2/25 and has diagnoses of acquired absence of right finger(s), polyneuropathy and rheumatoid arthritis. Based on observation, interview, and record review, the facility failed to ensure the temperature for a cup of soup was checked prior to serving the cup of soup to one of three sampled residents (Resident 1) after the soup had been reheated in the microwave by the nursing staff. This failure resulted in Resident 1 sustaining a second degree burn (damages the epidermis [surface of the skin]) and dermis [thick layer of living tissue below the epidermis containing blood vessels, nerve endings, sweat glands, hair follicles and other structures] layers of the skin and is characterized by blistering, deep redness, swelling, and intense pain) to his index finger of the left hand. Findings: During a review of Resident 81's "Admission Record" (AR), the AR indicated Resident 81 was admitted on 8/11/25 and had diagnoses of acquired absence (loss of a body part) of right finger(s), polyneuropathy (damages many nerves in the body, causing a combination of symptoms like numbness, tingling, pain and muscle weakness), and rheumatoid arthritis (disease causing joint redness, swelling, and pain). During a review of Resident 81's "Nursing Readmission Data Collection" (NRDC) dated 11/2/25, the NRDC indicated, "Hot liquids safety. . .contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility) in fingers, hands, wrists, elbows or shoulders. . .weakness and/or paresis (muscular weakness caused by nerve damage or disease) in upper extremities: yes. . .loss of mobility/reduced movement in upper extremities: yes. . .risk determination: yes, the resident is at risk. . .care planning. . .the resident is at risk for hot liquid injury. . .assist resident with hot liquids. . .resident to use cup with lid. . ." During a review of Resident 81's "Minimum Data Set" (MDS-resident assessment tool) dated 11/8/25, the MDS indicated, "Brief Interview for Mental Status" (BIMS) score is 14 (on a scale of 0-15 with scores between 13 to 15 indicating cognitively intact for normal thinking, reasoning and processing of information); Functional Abilities: Functional Limitation in Range of Motion. . .Upper Extremity. . .2 (Impairment on both sides)." During a review of Resident 1's "Change in Condition" (COC) dated 11/15/25, the COC indicated, "burn to L (left) pointer finger. . .11/15/25. . .resident stated that they (Resident 81) were checking on instant soup and wanted to see if it was hot enough so they put their L pointer finger into the bowl, resident stated that due to neuropathy they were unable to tell if it was hot or not due to low sensation, when seeing therapy walk into room resident requested for therapist to call this writing nurse due to having open skin, upon observation skin around left pointer finger from first knuckle up and around nail has been removed, NP (nurse practitioner) & wife made aware." During a review of Resident 81's "Wound Evaluation & Management Summary" (WEMS) dated 11/20/25, the WEMS indicated, "Patient has a history of neuropathy with very limited sensation to his fingers. Patient noticed he dipped his finger into something hot. Noted. . . he shouldn't have done that. This led to a wound to the tip of his first finger left hand. With the wound we did take off the fingernail the wound should go onto heel [sic] just fine. . .non-pressure wound of the left, first finger full thickness (a wound that extends through all layers of the skin). . .trauma/injury. . .wound size (L (length) x W (width) x D (depth)) 2 x 2 x 0.2 cm (centimeters-unit of measurement)" During a review of Resident 81's "Progress Note" (PN) dated 11/20/25, the PN indicated, "Patient has a history of neuropathy to his hands and feet. He noted that he dipped his index finger left hand into a cup of hot soup, he didn't notice that he had dipped it in there. Subsequently he developed a 2nd degree burn/deep 2nd with blistering around his fingernail, at the time we saw the patient we debrided (remove damaged tissue) the blister as the fingernail leaving am [sic] area to the lateral (side) aspect of his finger which still showed evidence of deep tissue injury." During an interview on 12/2/25 at 10:55 a.m. with Administrator, Administrator stated Resident 81 received a burn to his left-hand pointer finger when Certified Nursing Assistant 7 heated up his instant cup of noodle soup in the microwave and Resident 81 stuck his finger in the soup. Administrator stated per facility policy that the temperature should have been taken before it was served to Resident 81 and it was not. During a concurrent observation and interview on 12/2/25 at 11:45 a.m. with Resident 81, in Resident 81's room, Resident 81 had Band-Aids wrapped around his left pointer finger. Resident 81 stated when staff heated up his instant cup of noodle soup, the cup was filled up above the water line and he stuck his finger in it and it burned his finger. Resident 81 stated the soup was heated up in the microwave. During an interview on 12/2/25 at 6:32 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she was assigned to Resident 81 when PT reported that Resident 81's finger was red. LVN 5 stated CNA 7 heated up Resident 81's instant cup of noodle soup in the microwave and Resident 81 stuck his finger in the cup and burned his finger. LVN 5 stated CNA 7 did not take the temperature of the soup prior to giving it to Resident 81. During an interview on 12/2/25 at 6:45 p.m. with CNA 7, CNA 7 stated she heated up Resident 81's instant cup of noodle soup in the microwave for 1 1/2 minutes. CNA 7 stated she did not take the temperature of the soup prior to giving it to Resident 81. During an interview on 12/3/25 at 4:23 p.m. with Physical Therapist (PT), PT stated when he entered Resident 81's room on 11/15/25, Resident 81 was biting on his left pointer finger and covering up blood that was on his finger. PT stated from the top knuckle to the fingertip Resident 81's finger was red. PT stated Resident 81 was burned by a cup of hot noodles and was not aware of the burn due to decreased sensation in his fingertips. During an interview on 12/3/25 at 4:47 p.m. with Registered Dietician (RD), RD stated when heating up the instant cup of noodle soup for Resident 81 the CNA heated up the soup in the microwave and did not take the temperature prior to serving it to Resident 81. RD stated the CNAs were allowed to heat up the resident's food in the microwave at the time of the incident but had not received training on taking the temperatures prior to serving. RD stated Resident 81 wanted to test the temperature of the soup himself and used his finger like a stir stick and did not feel the burning. RD stated the temperature should have been taken prior to serving the soup to Resident 81 for safe consumption. During a review of the facility's policy and procedure (P&P) titled, "Safety of Hot Liquids" dated 02/2020, the P&P indicated, "The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition (mental action of acquiring knowledge and understanding through thought, experience, and the senses) and nerve or musculoskeletal conditions. . .Food service associates shall monitor and maintain foods temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding." During a review of the facility's policy and procedure (P&P) titled, "Food and Beverage Temperature Control" dated 12/24, the P&P indicated, "To ensure the safety of resident and associates, it is critical that all potentially hazardous food and beverages be prepared and maintained at safe temperatures. . .All foods should be cooked to the minimum safe internal cooking temperatures as outlined. . .Use the food and beverage temperature log to ensure all food and beverage holding temperatures are monitored and recorded. . .Food temperature chart. . .soups. . .140-165 °F (Fahrenheit-unit of measurement used to measure temperature). . .Food code temperatures. . .food cooked in microwave oven. . .temperature 165 °F. . . hold covered for 2 minutes after removing. . ." In violation of the above cited standards, the facility failed to ensure Resident 81's soup was served at a safe temperature. This failure resulted in Resident 81 experiencing a 2nd degree burn to his left-hand index finger. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a class "A" citation.