Health inspection·May 6, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the environment remained free from accident hazards for one of three residents (Resident 1) when Certified Nurse Assistant 2 placed a hot cup of soup at Resident 1 bedside table without first ensuring the temperature of the soup would not burn. CNA 1 was aware of Resident 1's physical limit to reach safely and left the hot cup of soup on the bedside table. These failures resulted in Resident 1 reaching for the hot cup of soup in an unsafe manner, spilling the hot soup on his chest and stomach and suffering burns to the skin that required wound care. Findings: During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included but was not limited to hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), muscle weakness, pain in left shoulder and unspecified symptoms and signs involving the nervous system (referring to the brain and spinal cord). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive knowledge and understanding through thought, experience, senses and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During a review of Resident 1's Progress Notes, dated 4/14/24, Resident 1's Progress Note indicated .During rounds CNA brought to nurses' attention . [complaints of] pain and burning on [Resident 1's] chest and abdomen Resident is red across chest and abdomen. Blisters are present in the size of a quarter on the chest and the size of a dime on the abdomen . During a review of Resident 1's Initial Wound Evaluation & Management Summary, dated 4/19/24, the Initial Wound Evaluation & Management Summary, indicated, .Burn wound of the mid chest . mix between 1st and 2nd Degree (first degree burns affect outer layer of skin and second degree burns affect both the outer and underlying layer of skin) .per [physician] . Page 1 of 3 555892 555892 05/06/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0689 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1's Skin/Wound note, dated 4/19/24, the Skin/Wound note indicated . skin redness, burn wounds, (an injury to living tissue), blisters (bubbles on the skin filled with liquid) to the chest size: 15.0 x9.0 x 0.1 centimeter [cm: unit of measurement] . surface with open ulceration (break on the skin), light serous exudate (a clear or pale yellow, thin, and watery liquid), thick adherent necrotic tissue (dead skin) . left lower abdomen redness skin blister size 16.5 x 17.0 x 0 cm .with open ulceration light serous exudate . Surgical excisional debridement (surgical removal or cutting away of dead tissue) was performed . and abdomen . During a concurrent observation and interview on 5/6/24 at 4:16 p.m. with Resident 1 in his room, Resident 1 was observed with discolored spots on his chest and left side of stomach. Resident 1 stated he requested a hot cup of soup the early morning of 4/14/24. Resident 1 stated he has physical limits to his left hand. Resident 1 stated his hot cup of soup was left on his bedside table the early morning of 4/14/24, and when he reached for it he dropped the cup of soup on himself. Resident 1 stated he called for help so he could be cleaned up and have his linens changed. Resident 1 stated he needs assistance opening items during mealtimes but can feed himself. During an interview on 5/6/24 at 5 p.m., with the Certified Nursing Assistant (CNA) 1, CNA 1 stated when kitchen staff have left for the day during evening and night shift CNAs heat up food for the residents. CNA 1 stated they will heat up residents' personal food items in the microwave. CNA 1 stated she had not been trained to check the temperatures for food prior to serving the residents. During an interview on 6/3/24 at 12:38 p.m., with the Administrator (ADM), the ADM stated on 4/14/24 Resident 1 was provided with a cup of soup by staff. ADM stated Resident 1 spilled the cup of soup on himself causing Resident 1's burns to his chest and stomach. The ADM stated the facility did not have a procedure for staff to follow for reheating evening and nighttime snacks on 4/14/24. The ADM stated the night of 4/14/24 staff did not know to check temperatures of food items. During a phone interview on 6/3/24 at 3:45 p.m., with CNA 2, CNA 2 stated at approximately 3 a.m. on 4/14/24 Resident 1 requested a cup soup be prepared. CNA 2 stated she placed the water in the soup, microwaved the soup then placed it on his bedside table away from Resident 1. CNA 2 stated Resident 1 had fallen back asleep. CNA 2 stated she expected Resident 1 to call for assistance with the cup of soup when he woke up. CNA 2 stated CNA 3 let her know Resident 1 had dropped his soup on himself. CNA 2 stated there was no temperature guidelines for her to follow for heating up residents' food items. During a review of Investigation [for Resident 1] dated 4/14/24 completed by the Director of Staff Development (DSD) the Investigation [for Resident 1] indicated .both [CNA 2 and CNA 3] were counseled individually and educated on safety measures when providing hot liquid and food items. Temperatures regulations, thermometer use and appropriate temp no higher than 104 [Fahrenheit] . During an interview on 6/4/24 at 2:36 p.m., with DSD, the DSD stated the expectation was for staff to provide cold snacks outside of mealtimes, such as sandwiches, gelatin or cookies. DSD stated on 4/14/24 CNA 2 had not been trained on after hour food temperature guidelines. DSD stated his expectation is for staff to notify the nurse, check temperature of the food and reference the temperature log to provide food or liquid at the correct temperature. DSD stated on 4/14/24 CNA 2 did not check the temperature. During an interview on 6/10/24 at 8:50 a.m., with LVN 3, LVN 3 stated Resident 1 complained of pain from his burns during her morning rounds. LVN 3 stated she medicated Resident 1 and assessed his 555892 Page 2 of 3 555892 05/06/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0689 burns that were located on his upper chest and left side of his stomach. LVN 3 stated Resident 1 had blisters on his skin from where he was burned. Level of Harm - Actual harm Residents Affected - Few During a review of the facility's job description titled, Certified Nursing Assistant, not dated, the job description indicated, . Participate in meal service including serving, clearing, and cleaning the dining room; Assures that the residents are positioned appropriately for meals; Assures the appropriate utensils are within reach of residents; Serves food trays and assists with feedings as indicated; Delivers and documents all a.m., p.m., and bedtime snacks and supplements; Provides hydration to all residents according to center policy .Identifies and reports changes in condition to charge nurse, supervisor, ADON and/or DON .Assists with meal service, Identifies residents at risk for nutritional problems and implements preventative measures; Checks items and food that is brought in by family members to assure it complies with the resident's orders, dietary needs, and safety . During a review of the facility's policy and procedure (P&P) titled, Incidents and Accidents, dated 11/15/2023, the P&P indicated, .Accidents refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . An Incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member .The following incidents/accidents require an incident/accident report but are not limited to .Observed accidents/incidents .Pressure injuries/ulcers .Self-inflicted injuries .Unobserved injuries . 555892 Page 3 of 3