Other·August 23, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during investigation of an entity reported incident. Entity reported incident number: CA00536050. Representing the Department: Health Facilities Evaluator Supervisor 16535. The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of entity reported incident number: CA000536050.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 07/07/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L4B011 Facility ID: CA020000083 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 06/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to assure one (Resident 1) of three sampled residents received supervision to prevent accidents when the resident was served hot tea in a pliable foam cup without a lid that fit. This failure resulted in Resident 1 spilling hot tea on her abdomen and sustaining a second degree burn (involves first two layers of skin which may appear as deep reddening and blistering of the skin) producing pain and the risk of skin infection. Findings: The facility reported an incident on 5/22/17: On 5/16/17 Resident's caregivers reported a wound on her abdomen. The wound was a burn from hot tea spilled on herself, as she was given a foam cup with, "The wrong lid." The Administrator reported that foam cups were not going to be used in the facility any more. Resident 1 was given two tumblers in place of the foam cups. Review of the record on 5//18/17 indicated Resident 1 was admitted on 4/29/17 with diagnoses including multiple sclerosis (a disease damaging the protective coverings of nerves. Symptoms can include vision loss, numbness, dizziness, lack of coordination and weakness). Resident 1 was receiving oxycodone (a narcotic medication) for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L4B011 Facility ID: CA020000083 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 06/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE moderate to severe lower back pain, which could make her light headed and drowsy. Review of the Minimum Data Set Assessment, dated 5/6/17, on 5/23/17 indicated, Resident 1 had a Brief Interview for Mental Status score of 15 (no deficits in mental ability). The assessment indicated Resident 1 needed "supervision" and "setup help" for eating and drinking (food and utensils set up so the resident could feed herself and drink safely). During an interview and observation with Resident 1 on 5/18/17 at 3:20 p.m., Resident 1 lifted her gown and showed a bright red open wound on her abdomen about two inches long with no dressing on it. Resident 1 stated it (the wound) was supposed to have a (brand name film) dressing on the wound. Resident 1 stated it was painful. Resident 1 said she had been served hot tea in a foam cup. Resident 1 stated the cup usually came with a "slitted" top for sipping. Resident 1 took a plain plastic cover that was lying on her table and put it over a foam cup to show the way she was given the hot tea when she got burned. The lid was larger than the cup opening and did not fit. Resident 1 said she spilled the hot tea on herself. Resident 1 stated, was her left hand wasn't working so well and the tea had been placed on the overbed table to her left side. Resident 1 stated someone brought her a cold towel and an ice pack for the burn. Resident 1 stated the burned area blistered, then the skin came off. During an interview with Certified Nurse Assistant (CNA) 1 on 5/17/17 at 3:15 p.m. CNA 1 stated Resident 1 liked to use the foam cup with a lid, rather than a regular coffee cup for tea, because the coffee taste stayed in the cups. CNA 1 did not know when Resident 1 spilled the hot tea. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L4B011 Facility ID: CA020000083 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 06/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the Administrator on 5/18/17 at 3:10 p.m. she stated the temperature of the hot water from the kitchen was 175 to 180 degrees Fahrenheit (F). The Administrator stated no one reported the accident with the hot tea and it was not known when it actually happened. Review of the medical record Progress Notes, written by Registered Nurse (RN) 1, dated 5/16/17 12:55 a.m. indicated, "Situation: skin excoriation to left lower abdomen. Measurement 4.2 cm (centimeters) by 3.1 cm. CNA called writer and reported about the skin issue noted on patient's left lower abdomen...Assessed skin, noted redness, irregular size, skin is excoriated (damaged to the skin, causing redness), no drainage. Surrounding skin is normal. Cleansed affected site and kept dry, patients denies pain or discomfort, no itchiness." A physician's order was obtained, four days later, on 5/201/7 for, "Left lower quadrant cleanse with NS (normal saline-salt water), pat dry apply xeroform dressing (petroleum dressing that doesn't stick to wounds) and cover with foam dressing every day shift every other day." A review of the facility's policy, Guidelines for Hot Beverages, dated 10/31/08, indicated the temperature for coffee was 185 to 200 degrees F, the recommended temperature for brewing black teas..."This temperature can result in a burn if the beverage comes in contact with the skin." Precautions can be implemented to limit the risk of burns from hot beverages. General Guidelines: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L4B011 Facility ID: CA020000083 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 06/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5. When serving hot liquids to residents, consider the following: a. don't overfill drinking cups b. place beverage away from the edge of the table and near resident's dominant hand. 6. Identify residents who may be at greater risk of spilling hot beverages on themselves, which may include but are not limited to: a. residents with tremors (shaking) b. Resident with poor hand control from CVA (stroke), arthritis (inflammation and pain of joints), weakness, etc." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L4B011 Facility ID: CA020000083 If continuation sheet 5 of 5