Health inspection·August 20, 2025

42 CFR §483.25(d) Accidents. The facility must ensure that – CFR §483.25(d) (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. CFR §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.71. (a) Sufficient Staff. (1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. (3) The facility must ensure that licensed nurses have the specific competencies, and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. (4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. 22 CCR § 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. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. CCR § 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 7/10/2025, the California Department of Public Health (CDPH), received a facility reported incident (FRI) regarding an accident involving a resident (Resident 1). On 7/11/2025, CDPH conducted an unannounced visit at the facility to investigate the FRI. Upon investigation, CDPH has determined the facility failed to ensure Resident 1, who had diagnosis of self-harm, did not inflict self-injury by spraying oven-cleaner (degreaser) over his arms. The facility failed to: 1. Provide Resident 1 with one-on-one (1:1) sitter due to Resident 1’s ideations of self-harm, after the resident was readmitted back to the facility on 7/7/2025 from a general acute care hospital (GACH) 1, as indicated in the resident’s untitled Care Plan dated 7/8/2025. 2. Implement the facility’s policy and procedure (P&P) titled, “Resident Safety,” dated 04/15/2021, which indicated the facility would provide a safe and hazard free environment where residents would be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the residents. 3. Develop and implement a comprehensive person-centered care plan for Resident 1 according to the facility’s P&P titled, “Person-Centered Care Planning,” dated 5/22/2025. 4. Ensure staff followed the facility’s P&P titled, “Resident Initial Admission Assessment,” dated 3/23/2023, which indicated “upon admission to the facility, licensed nursing staff will complete an initial admission assessment to identify the resident’s needs and develop plans of care... The assessment will be documented in the medical record.” As a result, on 7/8/2025 Resident 1 sprayed oven cleaner over both of his arms causing second degree (damage to both the outer and underlying layer of skin) chemical burns and getting transferred to GACH 2 on 7/8/2025 and then to a burn center (GACH 3) on 7/10/2025 for surgical interventions. On 7/15/2025, at GACH 3 Resident 1 underwent surgical debridement of areas that were chemically injured on both arms. A review of Resident 1’s Admission Record indicated Resident 1 was admitted to the facility on 5/17/2025 and readmitted on 7/7/2025 with diagnoses including schizoaffective disorder, suicidal/self-harm ideations, depression), hypertension and morbid obesity. A review of Resident 1’s Psychology Note dated 5/27/2025, indicated Resident 1 complained of feeling depressed, and verbalized frustration with being physically impaired due to morbid obesity, muscle weakness, abnormal gait and mobility. The Psychology Note indicated Resident 1 had a history of self-harm behaviors. The Psychology Note indicated Resident 1 reported he would self-harm by burning himself to relieve his feelings of depression. A review of Resident 1’s History and Physical (H&P) dated 7/7/2025, indicated Resident 1 had the mental capacity to understand and make medical decisions. A review of Resident 1’s Minimum Data Set ([MDS], a resident assessment tool), dated 5/24/2025, indicated Resident 1 had moderately impaired cognitive skills for daily decision making and required set up assistance with self-care abilities such as eating, and supervision with oral hygiene, upper body dressing and personal hygiene, moderate assistance with lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1’s mood severity score was 10, which indicated moderate depression. A review of Resident 1’s untitled Care Plan dated 7/8/2025, indicated Resident 1 was having ideations of self-harm. The Care Plan indicated Resident 1 felt frustrated with being physically impaired because of morbid obesity. The Care Plan goal was for Resident 1 to remain safe, evaluate the risk of depression and manage undesirable behaviors (such as thoughts of self-harm). The Care Plan interventions included asking directly if there was any chance of harming himself, frequent visual checks, provide one-on-one sitter, engaging Resident 1 in conversations to distract him from thoughts of self-harm and ensure the safety of Resident 1 and others. A review of Resident 1’s medical records including Nursing Progress Notes for July 2025, Admission Notes dated 7/7/2025, and Social Services Assessment dated 7/8/2025, did not indicate the facility staff assessed Resident 1 regarding thoughts of self-harm or harm to others when he was admitted back to the facility on 7/7/2025. A review of Resident 1’s Change of Condition form dated 7/8/2025, indicated Resident 1 told Registered Nurse Supervisor (RNS) 1 that he wanted to go to a psychiatric hospital for further evaluation. The Change of Condition form indicated Resident 1 stated he had sprayed oven cleaner on his forearms to cause him pain. The Change of Condition form indicated Resident 1 showed RNS 1 both of his forearms that had scattered pinpoint redness. The Change of Condition form indicated the back of Resident 1’s right hand had a brown patch measuring 8.0 by 9.0 centimeters (cm) and the back of his left hand had scattered brown patches. The Change of Condition form indicated Resident 1 stated he needed to go to a psychiatric hospital that has therapy to stabilize him and to help him stop hurting himself. The Change of Condition form indicated 911 was called and Resident 1 was brought to GACH 2 for further evaluation and management due to the appearance of his forearms. A review of Resident 1’s Physician’s Orders Summary Report indicated an order dated 7/8/2025 to transfer the resident to GACH 2 via 911 for evaluation and treatment due to threatening to hurt self. A review of Resident 1’s Skilled Nursing Facility (SNF) to GACH 2 Transfer Form dated 7/8/2025, indicated Resident 1 was transferred out to GACH 2 at 7:12 p.m., with flat, tan to brownish discoloration on the back of his right hand, and left arm with flat brownish scattered discoloration. The SNF to GACH 2 Transfer Form indicated Resident 1 had symptoms of agitation with risk to harm self or others. A review of Resident 1’s GACH 2 Records dated 7/8/2025 at 7:22 p.m., indicated Resident 1 was admitted to GACH 2 with diagnoses including second-degree chemical burns to both forearms. The GACH 2 records indicated GACH 2 staff called the poison control center due to Resident 1 spraying himself with oven cleaner. The GACH 2 Records indicated Resident 1 had a surgical consultation for the burns on both forearms. The GACH 2 records indicated Resident 2 was in distress (emotional or psychological difficulty that is noticeable and impactful). A review of Resident 1’s GACH 2 records dated 7/9/2025 at 8:55 a.m., indicated Resident 1 had a pain level of 9 out of 10 on a pain rating scale from zero to ten (where a zero represents no pain and 10 is the worst pain possible) due to the chemical burns on both of his arms. A review of Resident 1’s GACH 2 records dated 7/9/2025 at 11:17 a.m., indicated physician's orders for: 1. Hydrocodone-Acetaminophen, with a not specified dosage, one tablet every six hours for pain (severity of pain not specified). 2. Morphine Sulfate intravenously (IV) 2.0 milligram (mg)/1.0 milliliter (mL) every six hours for pain (severity of pain not specified). A review of Resident 1’s GACH 2 records dated 7/9/2025 at 9:05 p.m., indicated Resident 1 had a surgical consultation. A review of Surgical Consultation note dated 7/9/2025, indicated both of Resident 1 arms were necrotic and the resident would need a debridement and possible skin grafting to an area on the back of the left hand. The Surgical Consultation Note indicated Resident 1 would need a transfer to a higher level of care/burn center for treatment. A review of Resident 1’s GACH 3 Records, indicated Resident 1 had a history of self-harm and was admitted to GACH 2 and then on 7/10/2025 was transferred to GACH 3 for management of burns to both arms. The GACH 3 records indicated Resident 1 was on one-on-one sitter for self-harm precautions and psychiatric evaluation. During a telephone interview on 7/11/2025 at 10:15 a.m., RNS 1 stated Resident 1 was admitted back to the facility on 7/7/2025 around 12:40 p.m., with a diagnosis of ideations of harm to self or others. Resident 1 did not have a one-on-one sitter to keep him safe. RNS 1 stated Resident 1 should have had a one-on-one sitter to keep him safe from self-harm and should have had a psychiatrist’s consultation regarding his ideations of self-harm when admitted back to the facility on 7/7/2025. During an interview on 7/11/2025 at 1:37 p.m., the Administrator (ADM) stated the facility does not have a screening and assessment process for residents that are admitted to their facility with diagnoses of thoughts of self-harm. The ADM stated the facility did not screen Resident 1 for thoughts of self-harm, but the facility should have implemented a screening assessment for residents who had diagnoses of ideation of harm to self or others. During an interview on 7/11/2025 at 2:20 p.m., the Director of Nursing (DON) stated there was no screening assessment done for Resident 1 who was admitted to their facility after the discharge from GACH 1 on 7/7/2025, with diagnoses of ideations of harm to self or others. The DON stated there was no specific screening assessment implemented for residents (in general) with diagnoses of harm to self or others but there should have been a screening done for Resident 1 to screen for thoughts of harm to self or others. During an interview and concurrent record review on 7/11/2025 at 3:26 p.m., with the Director of Nursing (DON), the untitled Care Plan initiated on 7/8/2025 and Nurse Progress Note dated 7/7/2025 were reviewed. Resident 1’s care plan interventions such as one-on-one sitter were not implemented when Resident 1 was readmitted back to the facility on 7/7/2025. Resident 1 was not with a one-to-one sitter because Resident 1 did not express he had any thoughts or feelings of harming self or others. The DON stated there was no documentation of any assessment or screening done upon admission. Resident 1 was on visual and verbal hourly monitoring/rounding where staff would check on the resident every hour. The DON stated Resident 1 would have benefitted from the one-on-one sitter because there would be continuous monitoring with “eyes on the resident.” During a telephone interview on 7/11/2025 at 4:01 p.m., Resident 1 stated he had thoughts of self-harm when he was admitted back to the facility on 7/7/2025. The facility staff did not ask him if he had any thoughts of hurting himself when he was admitted back to the facility on 7/7/2025. Resident 1 stated he ordered the oven-cleaner online and had it delivered to him on 7/8/2025 at the facility. Resident 1 stated he did not tell anyone he wanted to hurt himself but wished the staff had asked him if he had thoughts of self-harm. Resident 1 stated he wished he received help from the facility staff about his thoughts of self-harm. During a telephone interview on 7/14/2025 at 10:27 a.m., the RN that took care of Resident 1 at the GACH 3 burn center (RNGACH 3) stated Resident 1 was transferred to their facility on 7/10/2025. RNGACH 3 stated Resident 1 had a one-to-one sitter for self-harm precautions because Resident 1 had wounds from the self-harm he inflicted on himself while at the facility. Resident 1 needed treatment for second degree chemical burn injuries and surgery was planned for 7/15/2025. Resident 1 was scheduled for surgery for debridement on both his arms for the second-degree burns. During an interview on 7/14/2025 at 1:25 p.m. RNS 1 stated Resident 1 had a one-on-one sitter before he was transferred out on 6/24/2025 but he did not have a one-on-one sitter when he was readmitted back on 7/7/2025 from GACH 1. Resident 1 was on hourly rounding where a Certified Nursing Assistant (CNA) had a visual on him every hour, but Resident 1 would have benefitted from one-on-one sitter to prevent him from harming himself. RNS 1 stated “a one-on-one sitter would always keep eyes on the residents.” A review of the facility’s P&P titled, “Resident Safety,” dated 4/14/2021, indicated the purpose was to provide a safe and hazard free environment...residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident....during the comprehensive assessment period, the interdisciplinary team ([IDT], a collaborative meeting where professionals from various healthcare disciplines come together to discuss and coordinate patient care) members will assess the resident’s safety risk as well as any other resident specific safety risks...the IDT will establish a person centered observation or monitoring systems for residents to address the identified risk factors identified.....the person centered care plan may require more frequent checks. A review of the facility’s P&P titled, “Resident Initial Admission Assessment,” dated 3/23/2023, indicated upon admission to the facility, licensed nursing staff will complete an initial admission assessment to identify the resident’s needs and develop plans of care... the assessment will be documented in the medical records. A review of the facility’s P&P titled, Person-Centered Care Planning, dated 5/22/2025, indicated the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, 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. The comprehensive care plan must describe the following: the services that are to be furnished to attain or maintain the resident’s highest practical physical, mental, and psychosocial wellbeing...comprehensive care plans must be reviewed and revised by the inter