**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 95's admission Record, dated 12/18/2024, the admission record indicated Resident 95 was admitted on [DATE] and readmitted on [DATE] with the following diagnoses which included chronic kidney disease (CKD - a longstanding disease in which the kidneys are damaged and cannot filter blood as well as they should leading to renal failure), acute kidney failure (the sudden and rapid loss of the kidney's ability to filter waste and balance fluid in blood), hydronephrosis (a condition where one or both kidneys swell due to a buildup of urine), malignant neoplasm of the bladder (bladder cancer), and retention of urine definition (a condition that makes it difficult to empty the bladder). During a review of Resident 95's History and Physical (H&P), dated 8/9/2024, the H&P indicated Resident 95 had the capacity to understand and make decisions. During a review of Resident 95's MDS, dated [DATE], the MDS indicated Resident 95's cognition was intact. The MDS indicated Resident 95 had an indwelling catheter and required supervision with eating, toileting and personal hygiene, and toileting. During a review of Resident 95's Order Summary Report, dated 10/10/2024, the order summary report indicated and active order to monitor Resident 95's nephrostomy bag for signs and symptoms of infection, noting cloudiness, sediment, blood, and odor and notify if any signs and symptoms were present every shift. During a review of Resident 95's MAR, dated 12/1/2024 through 12/16/2024. The MAR indicated to monitor Resident 95's nephrostomy bag for signs and symptoms of infection, noting cloudiness, sediment, blood, and odor and notify if any signs and symptoms were present every shift. The MAR indicated there were no signs of cloudiness, sediment, blood, or odor from 12/1/2024 through 12/16/2024 for all shifts. During a review of Resident 95's Care Plan titled Nephrostomy Placement Bilateral (both sides) Surgery, initiated on 10/10/2024 and revised on 11/13/2024, the care plan indicated Resident 95's bladder would be adequately emptied without complication as evidenced by no bladder distention, pain/discomfort and no signs and symptoms UTI The care plan interventions indicated to monitor nephrostomy bag for signs and symptoms of infection and notify physician if an signs and symptoms present and provide nephrostomy care per protocol daily and as needed. During a review of Resident 95's Care Plan titled UTI, initiated on 12/8/2024, the care plan indicated Resident 95's would have no complaints of pain or bladder discomfort and would resolve after treatment interventions. The care plan indicated interventions to monitor urine for sediment, cloudiness, odor, blood tinge and amount and report any signs and symptoms to the physician. m bladder would be adequately emptied without complication as evidenced by no bladder distention, pain/discomfort and no signs and symptoms of UTI. The care plan interventions indicated to monitor nephrostomy bag for signs and symptoms of infection and notify physician if an signs and symptoms present and provide nephrostomy care per protocol daily and as needed. During a review of Resident 95's Nursing Progress Notes, dated 2/9/2024, the progress note indicated Resident 95 was started on Rocephin (a medication to treat infections) until 12/15/2024 due to UTI. During an observation on 12/16/2024 at 2:44 p.m., in Resident 95's room, Resident 95 was sitting in a wheelchair with both left and right nephrostomy bags lying on his bed which was positioned higher than his wheelchair. The right nephrostomy tubing contained an off-white, thick milky sediment. During an observation on 12/17/2024 at 1:44 p.m., in Resident 95's room, Resident 95 was sitting in his wheelchair with both left and right nephrostomy bags rolled up into his pants pocket. Resident 95's pocket on the right side was wet from urine leaking from the nephrostomy bag. Resident 95's nephrostomy tubing on the right side showed an off-white, thick, milky sediment. During a concurrent observation, interview, and record review on 12/17/2024 at 1:47 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 observed Resident 95's nephrostomy bag and nephrostomy tubing. LVN 2 also reviewed Resident 95's monitoring log on the MAR, and the nursing progress notes. LVN 2 noted that there was sediment in Resident 95's nephrostomy tubing on the right side and the nephrostomy bags on the left and right side were rolled up and placed inside of Resident 95's pants pockets as he sat in his wheelchair. LVN 2 also noted Resident 95's right pants pocket was saturated with urine leaking from the right nephrostomy bag. LVN 2 stated Resident 95 was recently treated for a UTI and the sediment in the tubing was due to the recent UTI. LVN 2 stated it was her responsibility to monitor the tubing for signs of infection, which included cloudiness, sediment, or blood and document the findings on Resident 95's nephrostomy monitoring log and nursing progress notes during her shift. LVN 2 admitted she had not monitored Resident 95's nephrostomy for sediment in the tubing on 12/16/2024 and this observation was her first time seeing the sedimentation in the right tubing. LVN 2 stated she would notify the doctor immediately since she had been made aware of the sedimentation. LVN 2 reviewed Resident 95's nephrostomy monitoring log. LVN 2 acknowledged that she had been marking N for no sedimentation on Resident 95's nephrostomy monitoring log even though she had not been checking it daily. LVN 2 acknowledged she placed an N for no sediment on Resident 95's nephrostomy monitoring log on 12/16/2024 although she had not checked for sedimentation on that day. LVN 2 stated it was important to monitor Resident 95's nephrostomy tubing and urine output every shift and to call the doctor if sediment was observed in the tubing so that the doctor would be aware of Resident 95's status and write orders if needed. LVN 2 stated it was also important to document the finding in the nursing progress notes and the nephrostomy monitoring log. LVN 2 acknowledged she had not made any notes regarding Resident 95's nephrostomy bags or tubing in the nursing progress notes. LVN 2 also admitted it was inappropriate for Resident 95 to keep his nephrostomy bags and tubing rolled up inside of his pockets. LVN 2 stated the nephrostomy bags should have been positioned to gravity so the urine in the tubing could flow freely into the bags and not back flow into the kidneys. LVN 2 stated if urine flowed backwards into the kidneys, it could lead to further urinary tract infections. During a concurrent interview and record review with LVN 1, Resident 95's nursing progress notes and nephrostomy care plan were reviewed for the month of November and December. LVN 1 stated that Resident 95's primary care physician informed the nurses that it was normal for Resident 95 to have sediment in the tubing because he had bladder cancer. LVN 1 viewed the nursing progress notes and stated he could not find the notes regarding sediment in the nephrostomy tubing to be normal for Resident 95. LVN 1 reviewed Resident 95's nephrostomy care plan and acknowledged the care plan indicated to notify the physician if there was sedimentation in the nephrostomy tubing. LVN 1 stated the physician should have been notified if sedimentation was present in the tubing. During a concurrent interview and record review on 12/17/2024 at 3:09 p.m., with TXN 1, Resident 95's nursing care plan and nephrostomy monitoring log on the MAR was reviewed. TXN 1 stated she was responsible for Resident 95's daily nephrostomy dressings change. TXN 1 stated she had observed sedimentation in Resident 95's tubing every day for the month of December 2024 when performing nephrostomy dressing changes. TXN 1 stated she did not document the sedimentation or call the physician because she had heard from nurses that it was okay for Resident 95 to have sedimentation in his nephrostomy tubing. TXN 1 acknowledged there was no documentation in the nursing progress notes to indicate it was okay for resident to have sedimentation in his tubing. TXN 1 stated Resident 95's nephrostomy instructions should have been documented in the nursing progress notes when the resident returned from his nephrology appointment so that the nursing staff would have something to follow regarding the nephrostomy tubing. TXN 1 reviewed Resident 95's nephrostomy care plan and stated she was not following the care plan interventions for monitoring the nephrostomy bags for signs and symptoms of infection, including monitoring for sediment as indicated because Resident 95 was already on antibiotics for a UTI. TXN 1 admitted she should have followed Resident 95's nephrostomy care plan to ensure Resident 95 did not continue to develop UTIs. During a concurrent observation and interview on 12/19/2024 at 8:04 a.m., with TXN 1 and Resident 95, the nephrostomy dressing changes were observed by TXN 1. Resident 95 was sitting on the edge of his bed with both nephrostomy bags lying on his bed. TXN 1 stated she put Resident 95's nephrostomy bags on the bed to prepare for his nephrostomy dressing changes. Resident 95 stated wanted his nephrostomy bags lying out on the bed or in his pockets because it was easier to get to the bags when he needed to urinate. TXN 1 stated Resident 95 needed more education regarding the care of his nephrostomy bags because he should not have to bother the bags when he needed to urinate. TXN 1 stated, since Resident 95 could also urinate from his penis, he only needed to use the bedside urinal when he had the urge to urinate. TXN 1 stated there was a urinal at his bedside. TXN 1 proceeded to educate Resident 95 in Spanish regarding the care of his nephrostomy bags. TXN 1 stated that she educated Resident 95 that he should not touch the nephrostomy bags when he had an urge to urinate. TXN 1 stated she also explained to Resident 95 the importance of keeping the bags to gravity and not in his pocket to prevent infection. TXN 1 explained that the dignity bag was for his protection and privacy. TXN 1 showed the dignity bag to Resident 95 and how they were to be placed inside of the dignity bag. Resident 95 shook his head in agreement and did not refuse the dignity bags. During a telephone interview on 12/19/2024 at 10:17 a.m., with Physician 1, Physician 1 stated that the white slimy sedimentation noted in Resident 95's nephrostomy tubing was normal for Resident 95, however the sedimentation should have been documented and monitored by the nurse to ensure any changes could be noted for comparisons. Physician 1 stated he would educate the nurses on the proper care of Resident 95's nephrostomies because the nurses are not familiar with the caring for nephrostomies. Physician 1 state he would also educate the nurses on Resident 95's nephrostomy baseline (an initial measurement of a resident's condition and used for comparison over time to look for changes) and inform the nurses that the baseline should be documented. Physician 1 stated the nurses must then notify him (Physician 1) if there were any changes from the baseline. During an interview on 12/19/2024 at 10:42 a.m. with the DON, the DON stated it was important to ensure Resident 95's nephrostomy tubing was at gravity level and not rolled up in his pockets to prevent back flow to the kidneys which would cause an infection. The DON stated Resident 95 was preparing for surgery and could not afford to keep getting UTIs. The DON stated once Resident 95's immune system was compromised, and frequent infections would delay his radiation treatments and upcoming surgery. During review of the facility's policy and procedure (P&P) titled, Catheter - Care of, revised on 6/10/2021, the P&P indicated the purpose of the policy was to prevent catheter associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. The P&P also indicated the following: 1. Nursing staff would assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine. 2. Licensed nurse would notify the attending physician of any signs and symptoms of infection for clinical interventions. 3. Anyone manipulating the catheter site or apparatus must wash their hands thoroughly immediately before and after touching the site or apparatus. 4. The catheter and collecting tube would be kept free from kinking and the collection bag would be kept below the level of the bladder. 5. The catheter will be anchored to prevent excessive tension on the catheter. 6. Documentation of catheter care will be maintained in the resident's medical record. 7. The resident's privacy and dignity will be protected by placing a cover over the drainage bag when the resident is out of bed. Based on observation, interview, and record review, the facility failed to: 1. Provide services to prevent the development of septic shock for one out of six sampled residents (Resident 259), who had long-term usage of an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) by failing to ensure the following: 1a. Ensure Resident 259's the urinary drainage was monitored for the presence of sediment (a buildup of particles within the catheter tubing, often caused by factors like dehydration, urinary tract infection [UTI- an infection in the bladder/urinary tract], improper catheter care, or the presence of certain bacteria that promote crystal formation), abnormal color, and foul odor, per the facility's P&P and Resident 259's care plan, for a total of six months. 1b. Ensure a urine culture (a lab test that checks for bacteria in a urine sample) was performed after Resident 259's urine analysis (a lab test that provides information about the appearance, chemical composition, and microscopic contents of a urine sample) results indicated Resident 259 had a urinary tract infection on 10/7/2024. These deficient practices led to the delay in UTI identification, delayed treatment, and a three-day admission to the intensive care unit for a diagnosis of septic shock secondary to a UTI for Resident 259. 2. Provide adequate nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) care for one of six sampled residents (Resident 95) when: 2a. The nephrostomy bags (a bag that collects urine that drains from a nephrostomy tube) were not placed to gravity (where the urine flows downhill from the nephrostomy tube [inserted in the kidneys] and into the nephrostomy bag and must be positioned below the resident's bladder to allow urine to drain properly) by nursing staff. 2b. Sediment (crystals, bacteria, or blood exited through the urine) was present in the right nephrostomy tubing was not documented by the licensed nurses and the physician was not notified of the sediment as ordered. This failure had the potential to cause avoidable urinary tract infections (UTI - an infection in the bladder/urinary tract) and delay in treatment for Resident 95. Findings: 1. During a review of Resident 259's admission Record, the admission Record indicated Resident 259 was originally admitted to the facility on [DATE]. Resident 259's diagnoses included UTI, sepsis, extended spectrum beta lactamase resistance ([ESBL]- a bacterial infection that can occur in the blood, skin and other parts of the body, which can cause frequent urination, burning when urinating, and reddened skin) , hydronephrosis (kidney swelling) with ureteropelvic junction (the area where the ureter [urine tube] connects to the renal pelvis [inner curve of the kidney]) obstruction (a blockage preventing urine from draining properly and causing the kidney to enlarge), renal and ureteral calculus obstruction (a condition where the kidneys swell due to a blockage in the urinary tract caused by kidney stones and ureteral stones), and neuromuscular dysfunction of the bladder (lack of bladder control). During a review of Resident 259's Minimum Data Set ([MDS], a resident assessment tool), dated 9/26/2024, the MDS indicated Resident 259's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 259 was entirely dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 259's care plan titled, Urinary Catheter Care Plan, initiated 6/4/2024, the Care Plan indicated the facility was to monitor Resident 259's urine for color, sediments, amount, and hematuria (blood in the urine), and order laboratory tests, if indicated. During a review of Resident 259's Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/4/2024, the SBAR indicated Resident 259 exhibited generalized weakness, an elevated heart rate of 147 beats per minutes (bpm, normal range 60 -100 bpm), and rapid breathing with the use of accessory muscles (additional muscles used when a resident exhibits difficulty breathing). The SBAR indicated an unspecified licensed nurse elevated Resident 259's head of the bed and administered oxygen via nasal cannula (tubing used to deliver oxygen) at three liters per minute (LPM). The SBAR indicated Resident 259's oxygen saturation (the percentage of oxygen in a person's blood) increased from 88 percent (%) to 98%, (normal range 93-100%). The SBAR indicated Resident 259 was provided cooling measures and administered acetaminophen (fever-reducing medication). The SBAR indicated Resident 259's indwelling urinary catheter drainage bag had large amounts of sediments present. The SBAR indicated Resident 259's physician was notified and the resident was transferred to the general acute care hospital (GACH). The SBAR indicated Resident 259 had the following vital signs (measurements of the body's most basic functions): 1. Respiratory (breathing) Rate of 25 breaths per minute (RR, normal RR 12 to 20 breaths per minute). 2. Blood Pressure was 100/64 millimeters of mercury ([MM HG]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120-129 [top number] and 80-84 [bottom number]). 3. Temperature of 101.1 Fahrenheit (normal range 97 to 99 degrees Fahrenheit [a unit of measurement]). During a review of Resident 259's Urine Analysis (UA), dated 10/7/2024, the UA indicated Resident 259's urine appearance was cloudy, positive for nitrites (byproducts found in urine when bacteria like Escherichia coli [[E. Coli] - a type of bacteria] are present), and positive for the presence of leukocytes (white blood cells that help your body fight an infection). The UA also indicated Resident 259's physician did not order a urine culture. During a review of Resident 259's GACH Emergency Department (ED) Medical Doctor (MD) Progress Notes, dated 12/4/2024, the notes indicated Resident 259 was brought into the emergency department, on 12/4/2024 at 10:54 a.m. with the following vital signs: blood pressure of 78/54 MM HG, temperature of 102.4 F, heart rate of 145 bpm, respiratory rate of 42 (RR, breaths per minute), and oxygen saturation of 84 percent (%) and was placed on 15 liters per minute via non-rebreather mask (oxygen mask that delivers high concentrations of oxygen). The notes indicated Resident 259 was disoriented and repeatedly asked about the reason for his visit. The notes indicated Resident 259's computed tomography ([CT]- a noninvasive imaging procedure that uses X-rays to create cross-sectional images of the body) scan indicated Resident 259 had a 2.5 centimeter ([CM]- a unit of measurement) left ureter stone (a crystal-like hard stone that gets lodged into ureter [the tube that connects your kidneys to your bladder]) with hydronephrosis and perinephric stranding (a sign of inflammation or obstruction in the kidney or collecting system). The notes indicated Resident 259 was given intravenous (IV, through the veins) fluid, placed on a Levophed (a medication used to maintain blood pressure) and Amiodarone (a medication used to stabilize and control the heart rate) drip, and admitted to the Intensive Care Unit (ICU, a specialized hospital ward that provides critical care and life support to patients who are very ill or injured), on 12/4/2024, for stabilization. The note indicated Resident 259 was diagnosed with sepsis (a life-threatening medical emergency that occurs when the body's immune system has an extreme response to an infection or injury) due to UTI with hypotension (low blood pressure). During a review of Resident 259's GACH UA Laboratory Results, dated 12/4/2024, the results indicated Resident 259's urine appearance was turbid (not clear or transparent because of stirred-up sediment). During a review of Resident 259's GACH Blood Laboratory Results, dated 12/4/2024, the results indicated Resident 259's lactic acid level (a blood test that is used to help diagnose sepsis) was critically high at a value of 4.1 (normal: 0.7-1.9) millimoles per liter ([MMOL/L]- a unit of measurement). The results indicated Resident 259's white blood cell count ([WBC]-a blood test used to indicate the presence of inflammation or an infection) was abnormally high at a value of 15.5 (normal WBC count: 4.5 and 11.0 microliters) microliter ([X10^3/Ul]- a unit of measurement used to report WBC counts). During a review of Resident 259's GACH Urine Culture Laboratory Results, dated 12/4/2024, the results indicated Resident 259 had greater than 100,000 colony forming units per milliliter ([CFU/ML]- a unit of measurement) of E. Coli and Proteus Mirabilis (a type of bacteria). During a review of Resident 259's GACH Progress Notes, dated 12/5/2024, the notes indicated Resident 259 was treated with a Levophed drip 4 milligram (mg, unit of measurement) per 250 milliliters (ML]- a unit of measurement, Amiodarone drip 900 MG /18 ML, and Ceftriaxone (an antibiotic) 1 gram ([GM]- a unit of measurement) IV every 24 hours. During a review of Resident 259's GACH MD Progress Notes, dated 12/10/2024, the notes indicated Resident 259 was downgraded from the ICU to the telemetry unit (a unit that enables continuous tracking of the resident's heartbeat). During a review of Resident 259's GACH Discharge Summary Note, dated 12/11/2024, the note indicated Resident 259 was diagnosed with septic shock secondary to pyelonephritis (kidney infection) and bacteremia (bacteria in the blood) with ESBL E. coli. During an interview on 12/18/2024, at 9:35 a.m., with the facility's Treatment Nurse (TXN) 1, TXN 1 stated she was familiar with Resident 259 and noticed Resident 259's indwelling urinary catheter always had sediments since his initial admission into the facility. TXN 1 stated she did not notify the charge nurse or Resident 259's physician because Resident 259 always had sediments in his urine. During a concurrent record review and interview, on 12/18/2024, at 10:30 a.m., with Registered Nurse (RN) 2, Resident 259's Physician Orders, dated 6/2024 to 12/4/2024, and Medication Administration Record (MAR), dated 6/2024 to 12/4/2024, were reviewed. RN 2 stated the Physician Orders indicated Resident 259 was ordered to have an indwelling urinary catheter from 6/3/2024 to 12/4/2024. RN 2 stated the Physician Orders did not indicate any orders to monitor Resident 259's urine output appearance (presence of sediment, color, foul odor) from 6/3/2024 to 12/4/2024. RN 2 stated the MAR indicated Resident 259's urine output appearance was not documented from 6/3/2024 to 12/4/2024. RN 2 stated it was important for the licensed nursing staff to monitor the appearance of Resident 259's urine output to prevent Resident 259 from developing an infection and sepsis. RN 2 stated the order to monitor the indwelling urinary catheter's urine output was missed, and all licensed nurses were responsible with ensuring the order was inputted and carried out. RN 2 stated the facility may have delayed the treatment of Resident 259's UTI because the licensed nurses did not effectively monitor Resident 259's urine output appearance. During a concurrent record review and interview, on 12/18/2024 2:00 p.m., with RN 2, Resident 259's UA, dated 10/7/2024, was reviewed. RN 2 stated it was important to order a urine culture if a UA was positive so the resident could receive the proper antibiotics for treatment of the UTI. RN 2 stated MD 1 was made aware of the positive UA. RN 2 stated MD 1 did not order a urine culture because MD 1 was conservative when it came to prescribing antibiotics for Resident 259. RN 2 stated because Resident 259 did not present with any other signs and symptoms of a UTI antibiotics were not prescribed. During an interview, on 12/18/2024, at 3:31 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 259's urine output appeared foggy at various times (CNA 1 could not recall the dates). CNA 1 stated she did not notify the charge nurses because she believed the charge nurses already knew Resident 259's urine output normally appeared that way. During an interview, on 12/19/2024, at 10:06 a.m., with Physician 1, Physician 1 stated that he was Resident 259's attending physician, a urologist (a medical doctor who specializes in the diagnosis and treatment of diseases and conditions of the urinary tract system) and the facility's Medical Director. Physician 1 stated that the expectation of the licensed nurses regarding the care of a resident with an indwelling urinary catheter was to monitor for the signs and symptoms of an infection. Physician 1 stated that it was important to monitor the urine output appearance to identify the signs of an active urinary infection and to avoid sepsis. Physician 1 stated that the order to assess the qualities of the urine output was a part of the order set for all residents who had an indwelling foley catheter. Physician 1 stated that he met with the nursing staff to educate them on the importance of monitoring the appearance of the urine output and always reminded the staff not to underestimate the presence of precipitate (a buildup of particles), and cloudiness of the urine. Physician 1 expected that he would have been notified of these kinds of changes for Resident 259. During an interview, on 12/19/2024, at 11:53 a.m., with the Director of Nursing (DON), the DON stated it was important that the licensed nurses assessed the qualities and characteristics of a resident's urine output for cloudiness, presence of sediment and odor every shift so that the care of the resident was not delayed and to decrease the potential for sepsis. The DON stated Resident 259's order to assess the urine output was missed and there was no documentation of a baseline assessment to verify that Resident 259's urinary output improved or worsened over time. The DON stated a urine culture should have been ordered so that Resident 259 could have received treatment in a timely manner even if Resident 259 was asymptomatic (exhibiting no signs and symptoms of a medical condition). The DON stated the lack of assessment of Resident 259's urinary output and advocacy for a urine culture led to a delay in treatment, diagnosis of septic shock, and harm for Resident 259.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision (oversight, encouragement, or cueing) from staff for one of four sampled residents (Residents 4). Resident 4 was given a hot cup of noodle soup and left unsupervised. This deficient practice resulted in Resident 4 spilling hot noodle soup on herself and sustained third (3rd), ([full thickness], a burn that cause damage to the top layer, middle layer, and layer of fat underneath the skin) ) to fourth (4th) degree ([full thickness] burns, that affect all layers of the skin and also structures below the skin, such as the bone, and muscles) to the left inner arm and left breast. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Parkinson's disease (a brain disorder that affects movement, often including tremors.), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), hemiplegia (paralysis of one side of the body) and hemiparesis (partial paralysis) affecting left dominant side, muscle weakness and dysphagia (difficulty swallowing). During a review of Resident 4's history and physical (H/P) dated 11/12/2022, the H/P indicated Resident 4 had the capacity to understand and make decisions. During a review of Residents 4's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 2/7/2023, the MDS indicated Resident 4 was able to understand, and be understood by others. The MDS indicated Resident 4 required a one-person physical assist and supervision by staff when eating. The MDS also indicated Resident 4 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility, dressing and personal hygiene, and was totally dependent on staff for transfer and toileting. During a review of Resident 4's Care Plan titled, Resident requires assistance with bed mobility, transfer and eating initiated on 11/11/2022. The care plan was related to lack of upper body coordination and control, limitation of joint mobility, presence of mood/behavioral issues and lack of safety awareness and judgment. The interventions included nursing staff will assist Resident 4 with activities of daily living (ADLs, essential tasks that each person needs to perform, on a regular basis, to sustain basic survival and well-being, such as bathing, eating, toileting, dressing). During a review of Resident 4's Care Plan titled Potential for injury from tremors and individual movements due to Parkinson's disease initiated on 11/11/2022, the interventions indicated staff should invite Resident 4 to activities which do not depend on dexterity (skill in performing tasks, especially with the hands), listen to resident when verbalizing concerns over disease symptoms and address issues raised, monitor the environment for possible padding of side rails and special chair needs if involuntary movements put resident at risk for injury. During a review of Resident 4's Investigation Summary for Change of Condition (COC) dated 4/28/2023, the Investigation Summary indicated on 4/27/2023 at approximately 10:20 p.m., Certified Nurse Assistant (CNA) 3, heated up a cup of noodle soup and left it on Resident 4's bedside table for the resident to eat. The Investigation Summary indicated CNA 3 informed Resident 4 to allow the noodle soup to cool down before eating and CNA 3 left the resident unattended. The Summary also indicated Resident 3 spilled the soup on her gown onto her left chest and left arm when she tried to grab the cup of noodle soup to feed herself. The Investigation Summary indicated Resident 4 was found to have open blisters on her left chest and left arm. During a review of Resident 4's COC Evaluation dated 4/28/2023, the COC indicated Resident 4 complained of itchiness and burning sensation to the left chest and left arm. The COC indicated Resident 4 was assessed to have redness and blisters to the left chest and left arm. During a review of Resident 4's Physician Orders dated 4/28/2023, the orders indicated the following: 1. Left chest open blister: cleanse with Normal Saline ([NS], solution with salt and water), pat dry, apply Silvadene cream (medication to prevent and treat wound infections in residents with serious burns) and leave open to air daily for 21 days. 2. Left upper arm open blister: cleanse with NS, pat dry, apply Silvadene cream and cover with a dry dressing daily for 21 days. During a review of Resident 4's Wound Assessment and Plan dated 5/4/2023, the Wound Assessment and Plan indicated Resident 4 had the following 3rd degree burns: 1. Left inner arm full thickness with fat layer exposed; wound measured at 8 centimeters ([cm], unit of measurement) length x 13 cm. width x 0.2 cm. depth with large amount of exudate (drainage). 2. Left breast full thickness with fat layer exposed; Wound measured at 8 cm. length x 17 cm. width x 0.2 cm. depth with large amount of exudate. The Wound Assessment and Plan also indicated treatment orders included xeroform (mesh occlusive dressing), cleanse wound with NS or sterile water, cover with dry clean dressing, abdominal pad and gauze wrap and change as indicated and as needed. Additional treatment included Silvadene to wound bed daily. During a review of Resident 4's GACH emergency room (ER) Records dated 5/9/2023 and 5/10/2023, the Records indicated Resident 4 had increased tremors and presented to the ER with left upper arm and left breast burns that occurred as a result of spilling a hot cup of noodles onto the left upper body. During a review of Resident 4's GACH Physician Progress notes dated 5/10/2023, the progress notes indicated Resident 4 had a left axillary 3rd degree burn, due to scalding water two weeks ago from instant noodle soup. During a review of Resident 4's Nursing Narrative Note dated 5/9/2023, at 10:19 p.m., the notes indicated Resident 4 had a left upper arm and left breast thermal burns that occurred as a result of spilling a hot cup of noodles onto the left upper body. During a review of Resident 4's Nursing Narrative Note (GACH) dated 5/10/2023 at 6:18 pm, the notes indicated Resident 4 was observed with two large burn wounds located at left breast and left upper arm (medial presentation), and the wounds appeared to have slough (dead tissue that needs to be removed from the wound for healing to take place) on both areas suggesting 3rd to 4th degree burns , with the left breast leaning towards 4th degree and possibly higher. The notes also indicated Resident 4 had weakness and tremors in both hands which may be contributory to spillage of the soup. During an interview on 5/11/2023 at 12:55 p.m., with CNA 1, in the facility, CNA 1 stated, Resident 4 needed supervision such as observing how the resident ate, and not leave the resident unattended, while eating. Resident 4 was on aspiration (when food or liquid enters resident's airway and lungs) precautions and Resident 4's hands would shake while eating. CNA 1 stated she observed Resident 4 with redness to the left chest area and blister on the left arm on 4/28/2023 in the morning while she was repositioning the resident. CNA 1 stated Resident 4 informed CNA 1 that she spilled soup on herself. During a concurrent interview and record review on 5/11/2023 at 4:00 p.m., with Registered Nurse (RN) 1, Resident 4's Progress Notes (PN) dated 4/2023 were reviewed. RN 1 stated, Resident 4's PN indicated Resident 4 required visual monitoring during mealtimes, and the resident should not be left unattended for safety. RN 1 stated it was the nurses' responsibility to prevent Resident 4 from accidents and injuries including choking, aspirating, and spilling food on herself which could cause hospitalization and health deterioration for Resident 4. During a telephone interview on 5/19/2023 at 10:45 a.m. with CNA 3, CNA 3 stated on 4/27/2023 at approximately 10 p.m., Resident 4 asked her (CNA 3) for a cup of noddle soup. CNA 3 stated after preparing the noodle soup, she (CNA 3) elevated Resident 4's head of the bed and put the soup at the resident's bedside table. Resident 4 was instructed to throw the empty noddle cup in the trash, after the resident finished eating. CNA 3 stated she was not aware Resident 4 was on precautions for aspirations and it did not occur to her that Resident 4 would get burned because there was only a little amount of liquid in the noodle soup. CNA 3 stated she left Resident 4's room and when she returned 15 minutes later, Resident 4 was asleep and CNA 3, did not see the cup of noodles on the resident's table. CNA 3 stated she did not see any wetness, or noodles on Resident 4's gown. During a telephone interview on 5/19/2023 at 11 a.m. with CNA 4, CNA 4 stated on 4/28/2023, at approximately 4:30 a.m., during care, Resident 4 stated she felt a burning sensation on her left arm and left breast. CNA 4 stated she observed the resident's left breast and left arm were very red and looked like a big blister popped out. CNA 4 stated Resident 4 did not complain of pain. CNA 4 stated she notified the charge nurse (LVN 1) of the blisters on Resident 4's left breast and arm. During a review of the facility's policy and procedure (P/P) titled, Assistance with ADL Care undated, the P/P indicated it was the policy of the facility to provide assistance to residents with performance of their ADLs, taking into consideration each resident's needs. During a review of the facility's P/P titled, Resident Safety dated 4/15/2021, the P/P indicated the purpose was to provide a safe and hazard free environment. The P/P indicated any facility staff member who identified an unsafe situation, practice or environmental risk factors should immediately notify the supervisor or charge nurse.