**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 4) reviewed for safety was free from accident/hazards. * The facility failed to ensure Residents 4 was evaluated to handle and consume hot beverages as per the facility's P&P. In addition, Residents 8 and 9 were also not evaluated to handle and consume hot beverages. * RNAs 1 and 2 failed to notify a licensed nurse immediately after Resident 4 spilled hot tea onto her lap. * The facility failed to ensure Resident 4 was provided the immediate and appropriate interventions when Resident 4 spilled hot tea to her left upper thigh. In addition, the facility failed to obtain a physician's order to properly treat a burn for Resident 4's left thigh. Theses failures resulted in Resident 4 sustaining a blisters to her left thigh and delay in the provision of the necessary and appropriate care/interventions which could potentially affect the resident's well-being.Findings: Review of the facility's P&P titled Accidents and Incidents Investigating and Reporting Procedure revised 2/2022 showed:1. Regardless of how minor an accident or incident may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned, and2. The nurse supervisor/charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the residents attending physician or physician on call when there has been a(an) accident or incident involving the resident,2. The nurse will record in the resident's medical record information relative to the changes in the resident's medical/mental condition or status,3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant information for the provider, including (for example) information prompted by the Interact SBAR Communication Form, and4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. According to the United States Product Safety Commission, Avoiding Tap Water Scalds (undated), showed most adults will suffer a third-degree burns if exposed to 150 degree Fahrenheit water for two seconds. Burns will also occur with a six-second exposure to 140 degree Fahrenheit water or with a thirty second exposure to 130 degree Fahrenheit water. Even if the temperature is 120 degrees Fahrenheit, a five minute exposure could result in third-degree burns. According to the National Library of Medicine dated 8/2023 showed the older adults are particularly susceptible to burn injuries due to increasing dementing illness, sensory impairment, poor mobility, slow reaction times, and medication side effects. Review of the facility's letter to CDPH L&C Program dated 9/5/25, showed on 9/4/25, during routine care, CNA observed blisters to Resident 4's left upper thigh. The charge nurse and RN supervisor evaluated the resident and observed three blisters to the left upper thigh. Further investigation was conducted, and it was noted that on 9/3/24, during lunchtime in the main dining room, Resident 4 spilled warm tea on her lap. Medical record review for Resident 4 was initiated on 9/9/25. Resident 4 was admitted to the facility on [DATE]. Resident 4 has a diagnosis of hemiplegia (one side paralysis) and hemiparesis (one sided muscle weakness) affecting the right side, aphasia (impaired ability to understand or form speech) following a cerebral infarction (condition where blood flow to brain was interrupted, causing tissue damage), and generalized muscle weakness. Review of Resident 4's H&P examination dated 11/22/24, showed Resident 4 had no capacity to understand and make medical decisions. Review of Resident 4's Plan of Care initiated on 11/22/24, and revised on 1/24/25, for the OT care plan showed Resident 4 demonstrated a decreased in ADL care function due to deficits in strength aphasia, right sided weakness, deficits in gross motor, and fine motor coordination, aerobic capacity, and balance deficits status post cerebral vascular accident (stroke). Review of Resident 4's MDS assessment dated [DATE], under Section GG-Functional Abilities showed the following:- for Functional Limitation in Range of Motion, showed Resident 4 had impairments on one side for the upper extremities (shoulder, elbow, wrist and hands), and - for Self-Care - Eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food/or liquid once the meal is placed before the resident), showed Resident 4 required supervision or touching assistance (the helper provides verbal cues and /or touching/steadying and/or contact guard assistance as the resident complete the activity). On 9/10/25 at 1216 hours, an observation was conducted for Resident 4. Resident 4 was observed removing her tea bag out of her mug and using both right and left hands to grab the mug and taking sips of her tea. 1. a. Review of the facility's P&P titled Safety of Hot Liquids dated 10/2014 showed the residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission, and on change of condition. The residents who prefer how beverages with meals (i.e. coffee, tea, soups, etc.) will not be restricted from these options. Instead, the staff will conduct regular hot liquids safety evaluations as indicated and document the risk factors for scalding and burns in the care plan. Review of the facility's document titled Beverage Preference by Resident dated 9/3/25, showed Resident 1 preferred hot tea for lunch and dinner. Review of Resident 4's medical records did not show Resident 4 was evaluated to handle hot liquids. A brief review of Residents 8 and 9's medical records showed the residents were not evaluated to handle hot liquids. On 9/12/25 at 1615 hours, an interview was conducted with the Administrator and Administrator Trainee. When asked if an assessment to handle hot beverages should be conducted for all the residents in the facility as per the facility's P&P, the Administrator stated yes. When asked if the facility conducted the assessment for any residents in the facility, the Administrator stated no. On 9/16/25 at 1332 hours, an interview and concurrent medical record review was conducted with the MDS Nurse. When asked if Residents 4, 8, and 9 were assessed to handle hot beverages, the MDS Nurse stated no. When asked if the assessment to handle hot beverages should have been conducted for all the residents based on the facility's P&P, the MDS Nurse stated yes. b. Review of Resident 4's Progress Note dated 9/4/25, showed at approximately 1830 hours, a CNA alerted charge nurse and RN supervisor of the redness on Resident 4's left upper thigh while providing care to the resident. The note further showed Resident 4 had blisters on her left thigh. Two blisters noted to the proximal left thigh, one located medially, measuring 4.5 cm by 1 cm; one located distally, measuring 2 cm by 2 cm; and a third blister noted laterally to mid-thigh, intact with no redness, and measuring 3 cm by 1 cm. On 9/9/25 at 1547 hours, an interview was conducted with RNA 1. RNA 1 stated on 9/3/25, when Resident 4 was eating lunch in Dining room [ROOM NUMBER], she heard a glass fell and was then informed by RNA 2 the tea had spilled onto Resident 4. RNA 1 stated they patted Resident 4 dry, then allowed Resident 4 to finish eating her dessert. RNA 1 stated after Resident 4 consumed her dessert, she was brought back to her room approximately five to 10 minutes later and then she informed CNA 4. When asked if she informed any licensed nurse or supervisor, RNA 1 stated no. On 9/9/25 at 1559 hours, an interview was conducted with RNA 2. RNA 2 stated on 9/3/25, while Resident 4 was holding her cup of tea, the cup tipped over and everything (tea) went into her lap, floor, and table. RNA 2 stated they patted Resident 4 dry. When asked how she knew it was a tea, RNA 1 stated it had the tea bag. When asked if she notified anyone, RNA 2 stated not me, RNA 1 told CNA 4. On 9/10/25 at 0933 hours, a telephone interview was conducted with CNA 3. CNA 3 stated on 9/4/25, she noticed blisters on Resident 4's skin while providing perineal care. CNA 3 stated she immediately notified LVN 2 and RN 1 to see if anyone had reported the blisters on her skin. CNA 3 stated she was not comfortable continuing the perineal care without notifying the licensed nurses as Resident 4's blisters were huge. On 9/10/25 at 1008 hours, a follow up interview was conducted with RNA 1. When asked what time lunch was served, RNA 1 stated approximately at 1200 hours. When asked the process was when an incident occurred, RNA 1 stated to report it right away. When asked if it was reported right away, RNA 1 stated no, it was not. On 9/10/25 at 1019 hours, an interview was conducted with CNA 4. CNA 4 stated on 9/3/25, when Resident 4 returned to her room from Dining room [ROOM NUMBER], she removed the resident's pants, saw redness on her left thigh, and reported it to RN 2 and Treatment Nurse 1. When asked what time she reported it to the licensed nurses, CNA 4 stated sometime between 1230-1345 hours. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2. RN 2 stated she was notified on 9/3/25, by CNA 4 when Resident 4 spilled hot water on her thigh. However, RN 2 further stated she was not notified at the time the incident had occurred. c. According to the National Library of Medicine titled First Aid for Burns, the Blister Controversy and Acute Washing of the Burn Wound dated 9/2020 showed cooling the burn with cool running tap water has been shown to decrease cellular damage and edema (swelling), reduce the inflammatory reaction with increased healing and decreased need for skin grafting. Although the ideal temperature of water is unknown, the duration shows maximum benefit when done for 20 min and is useful when done up to three hour/s post burn. Cooling the burn with ice is detrimental and can lead to prolonged vasoconstriction (constrict the blood vessels). Other first aid components include immediate removal of clothing and jewelry, but any clothing melted or firmly adherent to the wound should be left to experienced personnel. * Review of Resident 4's Interdisciplinary Progress Note dated 9/5/25, showed during the routine care on 9/4/25, the assigned CNA observed blisters to Resident 4's left upper thigh. The charge nurse and RN supervisor evaluated the resident and observed 3 blisters to the resident's left upper thigh and the surrounding skin was intact. The note further showed on 9/3/25, during lunchtime in the main dining room, Resident 4 spilled warm tea on her lap and upon returning to the resident's room, Resident 4 was evaluated by the nursing staff and noted slight redness to her left upper thigh to which ice was applied to the area. On 9/9/25 at 1603 hours, an interview was conducted with LVN 2. When asked if you would pat the resident dry after the hot liquid was spilled, LVN 2 stated no, we would remove the clothing and apply cold compress. When asked what can happen if you let hot liquid sit on the resident's clothing for five minutes LVN 2 stated blisters and pain. LVN 2 stated the licensed nurses should have been notified right away rather than waiting until Resident 4 finished eating her dessert. On 9/10/25 at 1019 hours, an interview was conducted with CNA 4. CNA 4 stated on 9/3/25, she was informed by RNA 1 that Resident 4's pants were wet because she spilled hot tea on her lap. CNA 4 stated she proceeded to take Resident 4 to the restroom and noticed redness on her left thigh. When asked if Resident 4 complained of pain, CNA 4 stated she's a little bit burnt that is why I put ice. On 9/11/25 at 1248 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified on 9/4/25, Resident 4 had three blisters on her left upper thigh. When asked if it is an appropriate treatment to apply ice to a burned skin, RN 1 stated no, because it can cause vasoconstriction and damage the tissue. On 9/12/25 at 0950 hours, an interview and concurrent medical record review was conducted with MDS Nurse. The MDS Nurse verified the progress notes dated 9/5/25, showed an ice was applied to Resident 4's burn to her left upper thigh. * Review of Resident 4's medical record for the incident on 9/3/25, failed show documented evidence Resident 4's left thigh was assessed, the physician was notified, treatment was obtained and provided, and the resident was monitored. The documentation was not initiated until 9/4/25 at 1830 hours, approximately 30 hours later. On 9/10/25 at 1119 hours, an interview was conducted with Treatment Nurse 1. Treatment Nurse 1 stated CNA 4 had notified her on 9/3/25, close to 1300 hours, of the incident when Resident 4 had spilled hot tea onto her lap and her clothes were warm. When asked if that would be considered a change in condition, Treatment Nurse 1 stated yes. When asked what the process for a change of condition, Treatment Nurse 1 stated to inform the physician and the resident's family, document, provide the treatment as ordered by the physician, and monitor the resident. Treatment Nurse 1 verified there were no documentation to show a change of condition was initiated on 9/3/25, for Resident 4. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2. RN 2 stated on 9/3/25, when she was notified of Resident 4 spilling hot tea on her thigh. RN 2 stated she assessed her skin, noticed slight redness, and was informed by Treatment Nurse 1 that she applied ice to the area. When asked what Resident 4's leg looked like on the second day, RN 2 stated she developed blisters. When asked what type of burn Resident 4 had, RN 2 stated on the first day it was redness, on the second day it was second to third degree burns. RN 2 verified the physician should have been notified on 9/3/25.