Other·May 15, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: CA00624660. Representing the Department of Public Health: HFEN # 33638. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00624660.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 04/24/2019 §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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident was free of accident for one of two sample residents (Resident 1). Certified Nursing LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 01LE11 Facility ID: CA950000105 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055104 (X3) DATE SURVEY COMPLETED 04/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNSET MANOR CONVALESCENT HOSPITAL 2720 Nevada Ave El Monte, CA 91733 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assistant 1 (CNA 1) gave a hot shower to Resident 1, who was unable to communicate verbally or by gestures and was dependent on staff for care, without checking the water temperature was tolerable for Resident 1. As a result, on 12/31/18, Resident 1 sustained blisters (second degree burns - skin damage that extend beyond the top layer of the skin) to the left hand and the right and left inner thighs, and scrotum (testicles) from exposure to scalding (burn from hot liquid) water temperature for unknown length of time during the shower. Resident 1 required indwelling urinary catheter for wound management and transfer to General Acute Care Hospital 1 (GACH 1) where the thigh burned injuries were found infected. Findings: A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on 4/20/17 and readmitted on 5/23/17 with diagnoses including chronic respiratory failure with a tracheostomy (is a surgically created hole [stoma] in the windpipe [trachea] that provides an alternative airway for breathing. A tracheostomy tube is inserted through the hole and secured in place with a strap around your neck) and stroke (a medical condition in which reduced blood flow to the brain results in cell death) with hemiparesis (unable to move or feel one side of the body). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and careplanning tool) dated 11/27/18, indicated Resident 1 did not speak and was dependent of two-staff assist with bed mobility, personal hygiene, dressing, and bathing. Resident 1 was incontinent (unable to control urination or bowel movement) and was dependent on a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 01LE11 Facility ID: CA950000105 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055104 (X3) DATE SURVEY COMPLETED 04/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNSET MANOR CONVALESCENT HOSPITAL 2720 Nevada Ave El Monte, CA 91733 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE gastrostomy tube (GT - a soft tube surgically inserted on the stomach through the abdominal wall to administer medications and food). A review of the Resident 1's Licensed Nurses Notes dated 12/31/18, timed at 10:20 a.m., indicated CNA 1 notified Treatment Nurse 1 (TN 1) of an open blister to the left and right inner thighs and left hand after showering. Licensed Vocational Nurse 1 (LVN 1) assisted CNA 1 to bring Resident 1 to the shower room (Tub Room 2) and noted Resident did not have skin problems. CNA 1 checked the water temperature after turning the shower head on to shower Resident 1's thigh areas and adjusted it after noticing it was a little hot and continued to shower Resident 1. CNA 1 could not recall the length of time she showered Resident 1. Resident 1 received first aid treatment and did not show signs of pain. A review of the Non-Pressure Sore Skin Problem Report dated 12/31/18, indicated Resident 1 had a right and left inner thigh open blisters, with no measurement. The report did not include the size of the burns. A review of the Resident 1' Physician's Orders dated 12/31/18, included: - Tylenol (acetaminophen - pain medication) administration to Resident 1 through the GT every six hours, for pain management; - Cleansing Resident 1's left hand, right and left inner thighs with normal saline solution (salt solution), apply Silvadene cream (antibiotic used in burns to prevent infection), cover wounds with xeroform gauze (an absorbent wound dressing), and then wrap with Kerlix gauze (woven bandage) daily for 14 days; and, - Inserting an indwelling urinary catheter (a tubing that drains urine from the bladder into a bag outside the body) attached to a drainage bag for wound management for 14 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 01LE11 Facility ID: CA950000105 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055104 (X3) DATE SURVEY COMPLETED 04/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNSET MANOR CONVALESCENT HOSPITAL 2720 Nevada Ave El Monte, CA 91733 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Non-Pressure Sore Skin Problem Report dated 1/3/19, indicated Resident 1's left thigh burn area measured 14 centimeters (cm) in length by 14 cm in width. The right thigh burn area measured 11 cm in length by 12 cm in, and the blisters to the left hand remained intact. A review of the Licensed Nurses Notes dated 1/5/19, timed at 7 p.m., indicated Family Member 1 (FM 1) visited Resident 1 and requested a transfer to GACH 1. A Physician's Order dated 1/5/19, timed at 9:10 p.m., indicated to transfer Resident 1 to GACH 1 for evaluation and treatment of scalded skin lesions. A review of the Licensed Nurses Notes dated 1/5/19, timed at 10:10 p.m., indicated the facility transferred Resident 1 to GACH 1 Emergency Room. A review of Resident 1's GACH 1 Emergency Documentation dated 1/5/19, indicated: a. Left hand with blisters in digits (fingers) one, two, three, and four, full thickness burn, no drainage or foul odor. b. Bilateral inner thighs with pink and white desquamation (the shedding of the outer layers of the skin), surrounding area pink in color. c. Right inner thigh with approximately 9 cm by 8 cm burn with purulent (pus) drainage. d. Left inner thigh with approximate 14 cm by12 cm burn with purulent drainage. e. Mid scrotum area skin tear of approximately 0.5 cm by 12 cm with no drainage. A review of the facility's Investigation Report dated 12/31/18 and conducted by the Director of Nursing (DON) indicated CNA 1 and LVN 1 transferred Resident 1 to Tub Room 2. LVN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 01LE11 Facility ID: CA950000105 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055104 (X3) DATE SURVEY COMPLETED 04/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNSET MANOR CONVALESCENT HOSPITAL 2720 Nevada Ave El Monte, CA 91733 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE left CNA 1 with Resident 1 in Tub Room 2 after assisting her with transferring Resident 1 in the tub. CNA 1 turned on the water faucet and did not check the water temperature first. CNA 1 pointed the shower head directly onto Resident 1's thighs. CNA 1 adjusted the water temperature when she felt it was a little hot and continued showering Resident 1. The report indicated LVN 1 stated that Resident 1 did not have blisters or skin issues when she assisted CNA 1 in transferring Resident 1 in the tub. A review of the Summary/Intervention/Conclusion of the Investigation dated 1/4/19, indicated CNA 1 might have left the water running on Resident 1's thighs for a time which resulted in scalding and blister. A review of the facility policy and procedure titled, "Shower/Tub" revised on October 2010, indicated staff should test the water temperature is heating to 105 degrees Fahrenheit using a bath thermometer or by using the staff's elbow. If using a shower, the facility staff should regulate the temperature and the flow of the water, then roll the bath chair next to the tub or shower. A review of the facility policy titled, "Building Systems Water Systems and Temperature Control," dated 3/1/16, indicated staff should check water temperatures periodically in rooms used by residents such as bathrooms and showers to ensure that hot water used by residents was heating to 105 - 115 degrees Fahrenheit (or applicable requirement). During an observation and interview, on 2/15/19 at 1:15 p.m., Maintenance Supervisor 1 (MS 1) stated he checked the water temperature in showers and tub rooms daily. During the observation, the temperature of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 01LE11 Facility ID: CA950000105 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055104 (X3) DATE SURVEY COMPLETED 04/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNSET MANOR CONVALESCENT HOSPITAL 2720 Nevada Ave El Monte, CA 91733 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE water from the shower head in Tub Room 2 was 116 degrees Fahrenheit after one minute. A sign was posted on the wall indicating to all nursing staff to check water temperature before giving a shower/bath. When asked how nursing staff checks the water temperature before bathing the residents, MS 1 stated the staff used their hands because he had the bath thermometer kept in his office. MS 1 added the Shower/Tub Rooms did not have available bath thermometers for nurses to use. During an interview with CNA 1, on 2/15/19 at 2:10 p.m., in the presence of CNA 2 (assisting with English translation), stated that after turning on the water she washed Resident 1's head first and then the body. CNA 1 stated during that time, "everything was okay." CNAs 1 and 2 stated they were not sure if there was a bath thermometer available to check water temperature before showering residents. CNAs 1 and 2 reported they tested the water temperature by feeling the water against the back of their hands. CNA 1 stated she could not remember if she checked the temperature before showering Resident 1. CNA 1 stated she noticed Resident 1's thighs turned red when she was about to rinse Resident 1. CNA 1 stated she immediately turned off the water and called LVN 1. CNA 1 reported the inner thighs looked like a "map" of four closed waterfilled blisters. During an interview, on 2/15/19 at 2:50 p.m., the Director of Nursing (DON) stated CNA 1 might have left the water running for a time causing Resident 1's skin to scald and blister. The DON stated staff should feel the water temperature through their skin and if the temperature was comfortable for staff, it should be comfortable for the residents too. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 01LE11 Facility ID: CA950000105 If continuation sheet 6 of 6