Health inspection·July 11, 2025

California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Code of Federal Regulation, Title 42, 483.25 Free of Accident Hazards/Supervision/Devices §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. It was determined based on interview and record review, the facility failed to provide an environment free of accident hazards when Patient 1 was served a hot beverage by a Certified Nursing Assistant (CNA 1) without checking the safe serving temperature on April 10, 2025. This failure resulted in the hot beverage spilling on Patient 1 causing a second-degree burn (partial thickness burn - affects both the outer layer and part of the underlying layer of the skin) to third degree burn (most severe type of burn that damages all layers of the skin) on her right breast and shoulder which required transfer to the general acute care hospital (GACH) for medical intervention. A review of Patient 1's admission record indicated Patient 1 was admitted to the facility on February 19, 2025, with diagnoses which included metabolic encephalopathy (a brain disorder that results from a disturbance in metabolism, causing brain dysfunction) and multiple strokes with residual hemiplegia (persistent weakness or paralysis on one side of the body), right side. A review of Patient 1's care plan dated April 22, 2025, indicated, "...The resident [Patient 1] has an ADL [activities of daily living] self-care performance deficit r/t [related to] Hx [history] of cerebral infarction [a type of stroke] with hemiplegia/hemiparesis [weakness or partial loss of strength on one side of the body]...Interventions...Eating: The resident [Patient 1] requires set up assistance with eating..." A review of Patient 1's "Minimum Data Set (MDS - an assessment tool)," dated April 23, 2025, indicated Patient 1 ' s Brief Interview for Mental Status (BIMS - short, structured interview to assess memory, attention, and orientation) score was 13 (cognitively intact). The MDS further indicated Patient 1 required supervision or touching assistance when eating. A review of Patient 1's progress note indicated the following: - On April 10, 2025 at 8:59 a.m., the Licensed Nurse (LN) documented, "...patient got burned related to she spelled (sic.) coffee herself on her right side...patient noted crying and stated she missed cup grip and spilled coffee herself and assessed with slight redness on right arm right breast and right ribcage area and Patient c/o [complaint of] pain 8/10 [pain rating scale of 8 - severe pain] and CNA directed to change clothes to loose hospital gown and pain medication administered by LVN [licensed vocational nurse] and MD [medical doctor] Informed and Staff educated to make rounds every 15 min to assess for further changes..." - On April 10, 2025, at 2:31 p.m., the LN documented, "...Patient had blister [fluid-filled sac beneath or within the skin caused by burn] on right side of arm and breast and c/o pain 10/10 [severe pain] and Np [Nurse Practitioner] made aware and new orders noted and carried out, give extra dose of [pain medication] and send out for Evaluations..." - On April 10, 2025, at 9:42 p.m., the LN documented, "...Resident [Patient 1] returned from [name of hospital] at approximately 8:45...with no new orders. upon arrival, patient was assessed vitals within normal limits with a pain scale 7/10. Ordered pain medication given to patient [Patient 1]. Patient has wounds wrapped on left arm from shoulder to elbow and also wrapped with bandage on left breast. skin assessment was done no new marks or bruises noted. care plan on going..." A review of Patient 1's hospital admission records dated April 10, 2025, indicated, "...ER [emergency room] visit...F [female]...presenting with burn to right arm and breast. She reports that at her facility somebody dropped hot coffee on her arm and her breast and she has sustained a burn that occurred earlier today...Physical Examination...Skin: Burn over proximal medial [inner upper part of the right arm, near the shoulder and close to the chest] right arm and right breast with bullae [fluid filled blisters] over the right breast and abrading skin over the right elbow...Patient is presenting with burn to right arm as well as right breast...Burns appear to be superficial partial versus deep partial thickness burn [2nd degree burn]...She will require wet to dry dressing and follow up with the burn clinic as an outpatient...I have advised that the patient follow up with the local burn center either [name of the hospitals] for outpatient follow up with the burn specialist...Will prescribe pain control..." A review of Patient 1's "Weekly wound Note," dated April 14, 2025, ( 4 days after the incident) indicated, "...RT [right] breast - 3rd degree burn [full thickness burn - destroys all layers of the skin] RT anterior forearm - 3rd degree burn RT posterior forearm - 3rd degree burn...Site of Wound and current measurement: RT Breast - 20.0x [by]10.0x0.1cm [centimeters] RT anterior forearm - 6x5x0.1 RT posterior forearm - 11x12xUTD [unable to determine]...Patient was assessed today by (name of doctor) during clinical wound rounds…The following information above was obtained…" A review of Patient 1’s physician’s order dated April 22, 2025, indicated, - “Silvadene External Cream 1% (Silver Sulfadiazine – topical antibiotic medication used to prevent and treat wound infection in patients with second- and third-degree burn) Apply to Right Breast topically [medication directly applied to a specific area of the skin] everyday shift for burn.” - “Silvadene Eternal Cream 1% (Silver Sulfadiazine) Apply to Right elbow topically everyday shift for burn.” On May 7, 2025, 1:37 p.m. an interview was conducted with CNA 1. CNA 1 stated the following: a. She was assigned to Patient 1 on April 10, 2025, morning shift. b. Patient 1 asked for a cup of tea while eating breakfast. c. She placed a tea bag in a cup and placed the cup in a microwave to heat the water up to a warmer temperature. d. She did not check the temperature of the hot tea prior to serving it to Patient 1. e. She was not aware the temperature of the hot beverage needed to be checked prior to serving it to the patient. f. She should have checked the temperature of the hot tea before serving it to Patient 1 as there was a risk of burn injury while serving hot beverages. On May 7, 2025, at 2:11 p.m., an interview was conducted with CNA 2, CNA 2 stated the following: a. She assisted CNA 1 on the morning of April 10, 2025, when Patient 1 was heard to be screaming. b. She noticed a cup of hot water had spilled on the right breast and right shoulder of Patient 1 and that she was in pain. c. She and CNA 1 immediately changed the soiled clothes and Patient 1 stated "I am sorry I spilled on me." d. Patient 1 did not appear to be confused at that time. e. She was instructed upon hire that hot food and beverages should not be served by reheating unless the temperature was checked to be within a specified range. f. She would not serve hot food or beverages to residents without having the kitchen to verify it first as there was a risk for burn injuries. On May 7, 2025, at 3:45 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated it was the policy of the facility that nursing staff including CNA's and nurses should check for safe serving temperature before serving it to the patient. The DON stated this was not done by CNA 1 when she served the hot tea to Patient 1 on April 10, 2025, and the hot liquid was accidentally spilled on Patient 1 which resulted in Patient 1 sustaining second degree burns on her right breast and right shoulder. On May 8, 2025, at 10:40 a.m. a concurrent observation and interview were conducted with Patient 1 in the resident's room. Patient 1 was observed to be alert and up in her wheelchair. Patient 1 had a clean white bandage on her right upper arm and right chest area. Patient 1 stated, she recalled the incident on April 10, 2025. Patient 1 stated, she asked a CNA for tea. Patient 1 stated that she was not fully awake when CNA 1 served tea and was awakened by the hot beverage spilled on her. Patient 1 stated she screamed in pain and the staff responded. Patient 1 stated that she was experiencing pain, and she was provided with pain medication. Patient 1 stated she did not recall being warned by CNA 1 before being served the hot beverage. Patient 1 stated the hot beverage was brought to her and was placed on the bedside table within her reach. A review of the facility policy and procedure titled, "Food Service Temperature Control," dated, 2024, indicated, "...Beverages...brewed coffee and hot water...will be portioned in small batches to retain the temperature...served at or below 155 degrees F (Fahrenheit) to prevent burns..." A review of the facility policy and procedure titled, "Hot Beverage Preparation and Service," undated, indicated, "...Hot Beverages will be prepared following food safety standards and served at a safe temperature to prevent burns or injury...Measure beverage temperatures prior to service using a calibrated food thermometer to ensure compliance with the safe serving temperature..." Based on interview and record review, the facility failed to provide an environment free of accident hazards when Patient 1 was served a hot beverage by a CNA 1 without checking the safe serving temperature on April 10, 2025. This failure resulted in the hot beverage spilling on Patient 1 causing second degree burn to third degree burn on her right breast and shoulder that required GACH transfer for medical intervention. 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.