Health inspection·November 26, 2025

§483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. §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. §72311 Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. §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. On 10/16/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) burned himself and the staff at the facility knew about the burn but did not address it appropriately. On 10/17/2025, CDPH conducted an unannounced visit to the facility to investigate the allegation. Upon investigation CDPH determined Resident 1, who had diagnoses of paraplegia (loss of voluntary movement and sensation in the lower half of the body) and generalized muscle weakness, sustained a second-degree burn (a burn injury that damages the outer layers of the skin [epidermis] and/or part of the underlying layer of the skin [dermis] but does not penetrate deeper into the subcutaneous tissue (the deepest layer of the skin beneath the epidermis and dermis) to his left thigh while using an egg cooker in his room. The facility failed to: 1. Prevent Resident 1's use of an unauthorized egg cooker, thereby creating a condition in which Resident 1 independently handled eggs that rose to temperatures capable of causing a burn by putting the eggs in a bowl in his lap, resulting in a 5.0 cm x 5.0 cm second-degree burn to his left anterior (front/top of) thigh. 2. Develop, update, and implement an individual written plan of care for Resident 1 when multiple staff members knew he possessed an unauthorized egg cooker yet did not assess safety risk by determining specific hazards posed, incorporate interventions to address his resistance to room checks, plan to provide supervision or assistance to support Resident 1's use of the egg cooker, or remove the egg cooker from his room. 3. Implement their Policies and Procedures (P/P) titled "Electrical Appliances," that indicated only authorized electrical appliances would be permitted in residents living area. Residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.,), within their living area, unless approved, in writing, by the ADM [Administrator], or his/her designee, when Resident 1 continued to use the unauthorized egg cooker without written approval that indicated only authorized electrical appliances would be permitted in residents living area.. This deficient practice resulted in Resident 1 sustaining a second-degree burn to his left anterior (front or top of) thigh and had the potential for continued injuries if left in the resident's room/possession. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 40-year-old male, was initially admitted to the facility on 6/2/2025 and readmitted on 7/11/2025. Resident 1's diagnoses included paraplegia and generalized muscle weakness. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/5/2025 indicated Resident 1 was cognitively (mental action or process of acquiring knowledge and understanding ability) intact and required partial/moderate assistance with activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). A review of Resident 1's Change of Condition (COC) form, dated 10/7/2025 indicated Resident 1 reported, "I burned myself when I was cooking eggs." The COC form indicated Resident sustained a 5.0 centimeter ([cm] a unit of measurement) in length, by 5.0 cm in width, by 0.1 cm in thickness, partial thickness loss (a wound that affects the epidermis and/or the dermis but does not penetrate deeper into the subcutaneous tissue) from a burn. A review of Resident 1's Order Summary Report (Physician's Order) dated 10/7/2025 indicated to apply Silver Sulfadiazine cream 1% (an antibiotic medicated cream used to prevent and treat infection in severe burn wounds) to Resident 1's left anterior thigh, topically (the surface of the skin) daily during the day shift, for 30 days, for a second degree burn. During an interview on 10/17/2025, at 9:23 a.m., Resident 1 stated, on 10/4/2025 he was cooking eggs in his room using an egg cooker (the resident would not disclose where he obtained the egg cooker or eggs). Resident 1 stated when the eggs were done cooking, he took four of them out of the egg cooker, placed them in a large bowl and set it on his lap. Resident 1 stated, he went to the bathroom with the eggs in the bowl and did not feel the heat immediately. Resident 1 stated when he was in the bathroom, he observed his left thigh was red, and he knew it was burned. Resident 1 stated he waited a couple of days after burning himself, until he thought the burn needed to be treated, to tell staff about the burn on his leg. During an interview on 10/17/2025 at 12:06 p.m., Licensed Vocational Nurse (LVN) 1 stated on 10/7/2025 at 11:30 a.m., Resident 1 told her he burned his left leg while cooking eggs. LVN 1 stated, she told the ADM on 10/7/2025 about Resident 1 getting burned when he used the egg cooker. LVN 1 stated she knew Resident 1 had an egg cooker in his room, because when she went there daily to treat his other wounds, she observed the egg cooker on the floor but did not notify the director of nursing (DON) or ADM. LVN 1 stated residents were not allowed to have heating/cooking devices in their room because it could be dangerous, causing a fire and/or burns to the residents. During an interview on 10/17/2025 at 12:26 p.m., the DON stated he knew Resident 1 had an egg cooker in his room at one time, but he thought the egg cooker was finally gone but never checked Resident 1's room to verify if the egg cooker was gone. The DON stated if he knew the egg cooker was still in Resident 1's room, he would have checked to make sure it was functioning properly, educated Resident 1 on using the device safely and created a care plan. During an interview on 10/17/2025 at 12:41 p.m., the ADM stated, she believed Resident 1 came to the facility with the egg cooker, when she found out about it, she told him he could not have it in his room (date unknown). The ADM stated she did not check Resident 1's room to verify if the egg cooker was still there because of the resident's behavior of yelling, cursing, calling staff names and accusing staff of stealing his personal items. Resident 1 initially hid the egg cooker in a box that was in his room. Resident 1's egg cooker looked old and dirty, she purchased an egg cooker and eggs and kept them in the facility's kitchen for Resident 1's use, whenever he wanted eggs. The ADM stated she was notified by LVN 1 (10/7/2025) that Resident 1 had burned himself. She (ADM) could not remember if LVN 1 told her the burn was from an egg cooker. The ADM stated she did not go to Resident 1's room after the burn was reported to check on Resident 1. Residents were told they were not allowed to have heating devices in their room because of safety issues. The ADM stated she never gave approval for Resident 1 to have a cooking appliance in his room because it was not safe. A review of the facility's undated P&P titled, "Electrical Appliances" indicated only authorized electrical appliances will be permitted in residents living area. The P &P indicated residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.,) within their living area, unless approved, in writing, by the Administrator, or his/her designee. Should electrical appliances be permitted, each must be in good working order, free of frayed cords and UL (Underwriters Laboratories] a product that has been tested and certified by an independent safety science company, to meet specific safety, performance, or quality standards) approved. The facility failed to: 1. Prevent Resident 1's use of an unauthorized egg cooker, thereby creating a condition in which Resident 1 independently handled eggs that rose to temperatures capable of causing a burn by putting them in a bowl in his lap, resulting in a 5.0 cm x 5.0 cm second-degree burn to his left anterior (front/top of) thigh. 2. Develop, update, and implement an individual written plan of care for Resident 1 when multiple staff members knew he possessed an unauthorized egg cooker yet did not assess safety risk by determining specific hazards posed, incorporate interventions to address his resistance to room checks, plan to provide supervision or assistance to support Resident 1's use of the egg cooker, or remove the egg cooker from his room. 3. Implement their P/P titled "Electrical Appliances," that indicated only authorized electrical appliances would be permitted in residents living area. Residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.,), within their living area, unless approved, in writing, by the ADM, or his/her designee, when Resident 1 continued to use the unauthorized egg cooker without written approval that indicated only authorized electrical appliances would be permitted in residents living area. Residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.,), within their living area, unless approved, in writing, by the ADM, or his/her designee. This deficient practice resulted in Resident 1 sustaining a second-degree burn to his left anterior thigh and had the potential for continued injuries if left in the resident's room/possession. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probably that death or serious physical harm would result to Resident 1.