Health inspection·March 24, 2026

42 CFR §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 42 CFR §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §72523 Patient Care Policies and Procedure (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/27/2026 and 1/30/2026, the California Department of Public Health (CDPH) received complaints alleging a resident (Resident 1) sustained a second and third degree burns ([2nd] damage to the epidermis [top layer of the skin] and part of the dermis [underlying layer] causing painful, red, blistered, and swollen skin [3rd] severe injury that destroys both the epidermis and the dermis skin layers, potentially affecting fatty tissue, nerves, and muscle) on his right leg when a facility staff spilled boiling hot water on Resident 1's right leg on 12/28/2025 resulting in one big scar on Resident 1's entire lower leg. The complaints alleged Resident 1's Responsible party (RP) was not notified about the burn until 1/5/2026 (eight days after the burn had occurred). On 2/10/2026, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. During the investigation, CDPH determined Resident 1, who was diagnosed with Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) sustained a second degree burn when Certified Nursing Assistant (CNA 1) placed a lunch tray containing a cup of hot water on Resident 1's overbed table (a mobile, height-adjustable table with a narrow, rectangular top designed to slide over a bed or chair) and the cup of hot water fell onto Resident 1's right leg. The facility failed to: 1. Ensure CNA 1 considered Resident 1's risk factors related to his diagnosis of Parkinson's disease including tremors, poor coordination and impaired mobility before placing a cup of hot water in close proximity to him. 2. Ensure hot liquids were not placed within reach of Resident 1 and left unattended, when Resident 1 had known tremors and impaired mobility related to his Parkinson's diagnosis. 3. Follow its Policy and Procedure (P/P) titled "Accidents and Supervision," that indicated staff were required to observe and identify potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. These deficient practices resulted in Resident 1 sustaining a second degree burn to his right leg and created substantial probability of a more severe burn. The facility's actions reflected inadequate adherence to reasonable safety precautions, facility's policy and procedure, and patients' rights. Resident 1, a 68-year-old male, was admitted to the facility on 10/14/2021 with a diagnosis of Parkinson's disease. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/21/2026 indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired (a stage between normal age-related cognitive decline and dementia [progressive loss of memory], characterized by noticeable, measurable memory or thinking problems). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 1 required supervision or touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident complete activity) with eating. A review of Resident 1's Nursing Note dated 12/28/2025 indicated Resident 1 sustained a thermal burn (an injury caused by exposure to heat sources such as hot liquids, steam, fire, or hot objects) to his right forearm (this documentation was found to be incorrect, and this injury described a burn to Resident 1's right leg not his right forearm) after an accidental spill of hot tea. The Nursing Note indicated the burned area was noted with erythema (redness) and superficial skin peeling that was consistent with a partial thickness burn (a skin injury that damages both the epidermis and dermis). A review of Resident 1's Change of Condition (COC) Note dated 1/13/2026 (created after the family discovered the resident had a thermal burn) indicated Resident 1 sustained a thermal burn to his right lateral (outer area) leg after an accidental spill of hot tea. The COC indicated the affected area was red with superficial skin peeling consistent with a partial-thickness burn. There was no active bleeding or drainage noted. Resident 1 complained of pain and discomfort to the affected area. A review of Resident 1's Physician's Order dated 12/28/2025 indicated to cleanse Resident 1's thermal burn injury to his right lateral lower leg with normal saline (a sterile solution used to cleanse wounds), pat dry, apply triple antibiotic ointment (a medicated ointment used to prevent and treat skin infections cause by small cuts, scrapes, or burns), and to leave open to air every day for one month. A review of Resident 1's Podiatrist note dated 12/31/2025 indicated the dermal layer (the skin layer underneath the outer layer) of Resident 1's right lateral leg had sloughed (peeling of larger sheets of skin due to damage) off with no active drainage. The Podiatrist note indicated the burn on Resident 1's leg was classified as a second-degree burn. During an interview on 2/10/2026 at 1:25 p.m., Licensed Vocational Nurse (LVN) 1 stated CNA 1 reported to him (12/28/2025) that hot tea spilled on Resident 1, he (LVN 1) went to see what happened and noted a blanket covering Resident 1's legs, a cup on top of the blanket and when he touched the blanket it was wet and warm. LVN 1 stated Resident 1's right leg had a fresh red wound with peeling skin. During a telephone interview on 2/10/2026 at 2:08 p.m., and a subsequent telephone interview on 2/11/2026 at 1:36 p.m., CNA 1 stated Resident 1 experienced frequent shaking in his upper extremities (arms) and required a lot of assistance when eating, and Resident 1 could not bring a utensil or a cup to his mouth by himself. CNA 1 stated she placed Resident 1's lunch tray on his overbed table and placed the overbed table halfway over the resident's legs, close to his knees (12/28/2025), then proceeded to assist Resident 5 (Resident 1's roommate) with his lunch tray. She put Resident 5's lunch tray down, saw the cup of hot water falling from Resident 1's lunch tray and tried to grab the cup, but she could not catch the cup before it fell on Resident 1. CNA 1 stated she should not have placed Resident 1's lunch tray with hot water so close to Resident 1 because he could have grabbed the cup and caused it to fall. During an interview on 2/11/2026 at 11:39 a.m., the Podiatrist ([PD] a medical specialist focused on diagnosing, treating, and operating on disorders of the foot, ankle, and lower leg) stated it was obvious the burn to Resident 1's right lateral leg was caused by hot water because the epidermis and dermal layers were affected. During an interview on 2/11/2026 at 2:12 p.m., the Director of Nursing (DON) stated the use of Resident 1's fine motor skills (the coordination of small muscles, typically in the hands and fingers, with the eyes [hand-eye coordination) to perform precise, small-scale movements) were limited and his lunch tray should have been placed on his overbed table next to him just before CNA 1 fed him and not left unattended because there were hot items on the tray. A review of the facility's undated P/P titled "Accidents and Supervision," indicated staff were required to observe and identify potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. The facility failed to ensure: 1. CNA 1 considered Resident 1's risk factors related to Parkinson's disease including tremors, poor coordination and impaired mobility before placing a cup of hot water in close proximity to him. 2. Hot liquids were not placed within reach of Resident 1 and left unattended, when Resident 1 had known tremors and impaired mobility related to his Parkinson's diagnosis. 3. The facility followed its P/P titled "Accidents and Supervision," that indicated staff were required to observe and identify potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. This deficient practice resulted in Resident 1 sustaining a second degree burn to his right leg and had the potential for a more serious injury to occur. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.