**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one of six sampled residents (Resident 1) when: 1. Resident 1 was admitted to the facility with diagnoses of Type 2 Diabetes Mellitus (Type 2 DM- a disorder in which blood sugar or glucose levels are abnormally high) and licensed nursing staff did not develop an individualized care plan intervention to monitor Resident 1's blood glucose levels, from 5/4/25 to 5/18/25. This failure resulted in Resident 1 experiencing significant change in condition. On 5/18/25, Resident 1 was found with altered mental status (AMS- change in person's level of awareness, thinking, or behavior, a medical emergency requiring prompt evaluation and treatment), with a blood glucose level of 53 mg/dl (milligram per deciliters- unit of measurement), and requiring emergency transport to a higher level of care. Resident 1 was admitted to the hospital from [DATE] to 6/3/25. 2. Resident 1 was admitted to the facility with diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing) and licensed nursing staff failed to implement the nursing care plan interventions to monitor Resident 1's oxygen level according to the physician's order. This failure resulted in Resident 1 experiencing significant change in condition. On 5/18/25, Resident 1 was found with AMS, with an oxygen level of 86% (percent- unit of measurement), and requiring emergency transport to a higher level of care. Resident 1 was admitted to the hospital from [DATE] to 6/3/25. Findings: 1. During a review of Resident 1 ' s admission Record, dated 6/6/25, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Muscle Weakness, Hypertension (high blood pressure), Cervicalgia (neck pain) and Congestive Heart Failure (CHF- heart is unable to pump blood efficiently). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], the MDS indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS- assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a concurrent interview and record review on 6/6/25, at 2:30 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. RN 1 confirmed she worked on 5/17/25 PM shift (afternoon shift, from 2:00 p.m. to 10:30 p.m.) and was the charge nurse for Resident 1. Resident 1's Nursing Note, dated 5/17/25 at 6:39 p.m. was reviewed. The note indicated, . Vital signs . BP (blood pressure) 139/60 - 5/17/25 15:57 (3:57 p.m.) . O2 (oxygen saturation- measure of how well oxygen is being transported throughout the body) 93% - 5/17/25 9:06 a.m . Oxygen via nasal cannula (NC-medical device that provides oxygen through a thin flexible tube with two prongs that fit into the nostrils) . Signed [RN 1] . RN 1 stated there was no documentation related to obtaining Resident 1's blood glucose levels every shift or daily, from admission [DATE]) to discharge (5/18/25). During a concurrent interview and record review on 6/6/25, at 2:33 p.m. with RN 1, Resident 1's Order Summary Report (OSR), dated 6/6/25 was reviewed. The OSR indicated, . Glipizide ER (medication to control Type 2 DM, use to lower blood glucose levels) Oral Tablet Extended Release 24 Hour 5MG (milligrams - unit of measurement). Give 1 tablet by mouth two times a day for DM type 2 . RN 1 stated Resident 1's record indicated he took the prescribed Glipizide from 5/4/25 to 5/17/25 twice a day. During a concurrent interview and record review on 6/6/25, at 2:37 p.m. with RN 1, Resident 1's Food Intake, dated 5/17/25 was reviewed. The Food Intake indicated, . 5/16/25 Breakfast - 51% to 75%, Lunch - Refused, Dinner - 51% to 75% . 5/17/25 Breakfast - Refused, Lunch - Refused, Dinner 51% to 75% . RN 1 stated Resident 1's intake from 5/16/25 to 5/17/25 were reduced compared to 5/15/25 (75% to 100%). During a concurrent interview and record review on 6/6/25, at 2:39 p.m. with RN 1, Resident 1's Diabetes Mellitus care plan dated 5/5/25 was reviewed. The care plan indicated, . Focus . [Resident 1] has Diabetes Mellitus, Glipizide ER Oral Tablet Extended Release 24 hour 5 MG . Interventions . Diabetes medication as ordered by doctor. Monitor/document effectiveness . Educate regarding medications and importance of compliance . RN 1 stated the careplan interventions should have been individualized to meet Resident 1's needs and it was not. RN 1 stated the care plan did not include a blood glucose check and hold glipizide administration during meal refusals. RN 1 stated taking glipizide without food intake could result to severe hypoglycemia (low blood sugar) and avoidable hospitalization. During a concurrent phone interview and record review on 6/12/25, at 8:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. LVN 1 confirmed she worked on 5/18/25 NOC (evening shift, from 10:00 p.m. to 6:30 a.m.) and was the charge nurse for Resident 1. Resident 1's Nursing Note, dated 5/18/25 at 3:15 a.m. was reviewed. The note indicated, . CN (Charge Nurse) was informed by the CNA (Certified Nurse Assistant) that resident was coughing and was having difficulty expelling mucus (phlegm) to clear throat. CN immediately assess resident . CN noticed that resident was not responding verbally to any commands. Multiple attempts for verbal response were ineffective. VS (Vital Signs) 154/63 (blood pressure), O2 (oxygen) sat [saturation] 86-88% via NC (nasal cannula) at 3L (liters- unit of measurement) . [Ambulance] was call[ed] at 03:55 a.m. left resident via gurney at 04:15 a.m. LVN 1 stated several paramedics came to the facility and checked Resident 1's vital signs, including oxygen level and blood glucose levels. LVN 1 stated she was informed by one paramedics who responded to the emergency call that Resident 1's initial blood glucose level was 53 mg/dl and was given D5W (dextrose, a liquid solution containing 5% dextrose [a type of sugar]). During a concurrent phone interview and record review on 6/12/25, at 8:49 a.m. with LVN 1, Resident 1's Order Summary Report, dated 6/6/25 was reviewed. LVN 1 stated there was no order to check Resident 1's BS (blood sugar) every shift or daily. Resident 1's Food Intake, dated 5/17/25 was reviewed. LVN 1 stated she was not aware of Resident 1's refusing meals while taking his Glipizide. Resident 1 ' s Diabetes Mellitus care plan dated 5/5/25 was reviewed. LVN 1 stated the careplan interventions should be resident specific and it was not. LVN 1 stated the care plan did not include monitoring of meal intake and blood glucose check. LVN 1 stated Resident 1's low level of blood glucose resulted to altered mental status and subsequent hospitalization. During a concurrent interview and record review on 6/12/25 at 2:21 p.m. with the Director of Nursing (DON), the DON stated Resident 1 has a diagnosis of COPD, CHF, Cervicalgia and Type 2 DM. The DON stated Resident 1 was transferred to an acute care hospital (ACH) on 5/18/25 due to AMS, and did not return to their facility. The DON stated Resident 1 was previously admitted (4/20/23) to the facility and was on blood glucose monitoring and she was unsure why it was discontinued on his most recent readmission [DATE]). The DON reviewed Resident 1 ' s Type 2 DM care plan dated 5/5/25 and stated the care plan intervention column was incomplete. The DON stated the purpose of a care plan was to guide staff for a resident's plan of care and the interventions in place to meet the resident goals. The DON stated Resident 1's care plan should be individualized and specific, without specific interventions, Resident 1 could experience a negative outcome, including hypoglycemia or hyperglycemia. During a review of Resident 1's Acute Hospital History and Physical, dated 4/28/25, the record indicated, . [Resident 1] . male with PMHx (Patient's past medical history) sig (significant) for COPD, CHF . DM . who presented to the ER with complaint of mild SOB (shortness of breath) . Recent Labs [laboratory] . Glucose 189 ml/dl . Plan: Admit . Insulin regimen, hypoglycemic precautions . During a review of Resident 1's Ambulance Service Record, dated 5/18/25, the record indicated, . 04:00 [4:00 a.m.] . Chief Complaint . not acting like his usual self . Vital Signs BP [blood pressure] 166/67 . Oxygen Saturation 92% (percent- unit of measurement) . Blood Glucose 53 mg/dl . Comments: low blood sugar . Narrative: Pt found semi-Fowlers in bed at [Facility Name]. Family at scene. Staff states that pt (patient) is not his usual self. Usually converses more but this morning he just yells. Pt has history of COPD and is on 2 LPM (liters per minute - unit of measurement) via nasal cannula. Pt has an oxygen saturation of 88 %, EMS [Emergency Medical Staff] increased oxygen to 3 LPM this improved his oxygen saturation to 93%. Glucose check showed 53 mg/dl. Pt moved to gurney to unit . During a review of Resident 1's Acute Hospital ED [Emergency Department] Physician Notes, dated 5/18/25 at 7:26 a.m., the note indicated, . Patient presenting from the [Facility Name] for altered mental status male history of COPD, diabetes, hypertension presents for altered mental status. Vital signs with borderline tachycardia (faster heart rate) hypoxemia (low oxygen level) to the low 90s and high 80s on supplemental oxygenation. Exam with diffuse wheezing (sound heard throughout the chest) as well as significant weakness in bilateral upper and lower extremities (arms and legs). Considered a broad differential (symptoms could be attributed to a large number of potential conditions) for this patient who present for altered mental status found to be hypoglycemic . Final Diagnosis this visit: COPD with acute exacerbation (worsening of condition) . Acute hypoxemic respiratory failure . Altered mental status . Hypoglycemia . Disposition: transfer to other hospital [Hospital name] . Condition: Guarded (patient's condition is uncertain) . During a review of the facility ' s policy and procedure (P&P) titled Comprehensive Care Plans, dated 11/2017, the P&P indicated, . provide each resident with a person-centered, comprehensive care plan to address the resident ' s medical, nursing, physical, mental and psychosocial needs . facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-center care plan for each resident that includes measurable objectives and timeframes that meet a resident ' s medical, nursing, physical, mental, and psychosocial needs . It will drive the type of care and services that a resident receives and will describe the resident ' s medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting these needs and preferences . During a review of the professional reference titled, Lippincott procedures-Care plan preparation, long-term care, dated 5/19/22, the professional reference indicated, .The care plan for each resident must include: . resident goals, expressed in measurable objectives with timetables to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment, interventions that describe the services the interdisciplinary team employs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, evaluation of the fulfillment of goals .The care plan should reflect elements of person-centered are, make every effort to understand what each resident is communicating verbally and non-verbally, and identify what daily routines are important each resident . During a review of a professional reference retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-a-care-plan-in-skilled-nursing-facilities#:~:text=This%20helps%20keep%20you%20aware,kind%20of%20services%20you%20need titled What ' s a care plan in skilled nursing facilities, undated, the reference indicated, . When your health condition is assessed, skilled nursing facility (SNF) staff prepare or update your care plan . This helps keep you aware of how the care you get will help you reach your health care goals . may include . what kind of services you need . How often you'll need the services . What kind of equipment or supplies you need . Your health goal (or goals), and how your care plan will help you reach your goal . 2. During a review of Resident 1 ' s admission Record, dated 6/6/25, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis that included COPD, Type 2 Diabetes Mellitus, Muscle Weakness, Hypertension, Cervicalgia and CHF. During a review of Residents 1's MDS assessment dated [DATE], indicated Resident 1's BIMS scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a concurrent interview and record review on 6/6/25, at 2:42 p.m. with RN 1, RN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. RN 1 confirmed she worked on 5/17/25 PM shift (afternoon shift, from 2:00 p.m. to 10:30 p.m.) and was the charge nurse for Resident 1. Resident 1's Nursing Note, dated 5/17/25 at 6:39 p.m. was reviewed. The note indicated, . O2 93% - 5/17/25 9:06 a.m. Oxygen via nasal cannula . Signed [RN 1] . RN 1 stated there was no record of Resident 1's oxygen level taken during her shift (from 2:00 p.m. to 10:30 p.m.). During a concurrent interview and record review on 6/6/25, at 2:46 p.m. with RN 1, Resident 1's OSR dated 6/6/25 was reviewed. The OSR indicated, . Administer oxygen @2-3Lmin (Liter per minute - unit of measurement) via nasal cannula . Order Date 5/5/25 . Check oxygen saturation PRN (as needed) every 8 (eight) hours as needed for Dyspnea (shortness of breath) /Cyanosis (discoloration of the skin due to a lack of oxygen in the blood) . Order Date 5/5/25 . RN 1 stated Resident 1's physician's order to check oxygen saturation was not followed. RN 1 stated Resident 1's oxygen saturation level was not checked for 17 hours (from 9:07 a.m. to 2:20 am). RN 1 stated Resident 1's changed in condition could have been discovered sooner if his oxygen saturation level was checked once a shift. Resident 1 ' s COPD and CHF care plan dated 5/5/25 was reviewed. The care plan indicated, . Focus . [Resident 1] has oxygen therapy r/t [related to] CHF. Administer oxygen @2-3L/min via nasal cannula, Continuous for Chronic COPD . Interventions/Tasks . Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (physician): increased respirations (breathing) . decreased pulse oximetry . cough . RN 1 stated the careplan interventions was not followed. RN 1 stated Resident 1's oxygen saturation level was not checked according to the care plan and physician's order. RN 1 stated Resident 1's changed in condition could have been discovered sooner if his oxygen saturation level was checked during her shift. During a concurrent phone interview and record review on 6/12/25, at 8:45 a.m. with LVN 1, LVN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. LVN 1 confirmed she worked on 5/18/25 NOC (evening shift, from 10:00 p.m. to 6:30 a.m.) and was the charge nurse for Resident 1. Resident 1's Nursing Note, dated 5/18/25 at 3:15 a.m. was reviewed. The note indicated, . CN (Charge Nurse) was informed by the CNA (Certified Nurse Assistant) that resident was coughing and was having difficulty expelling mucus (phlegm) to clear throat. CN immediately assess resident . CN noticed that resident was not responding verbally to any commands. Multiple attempts for verbal response were ineffective. VS (Vital Signs) 154/63 (blood pressure), O2 (oxygen) sat [saturation] 86-88% via NC (nasal cannula) at 3L (liters- unit of measurement) . [Ambulance] was call[ed] at 03:55 a.m. left resident via gurney at 04:15 a.m. LVN 1 stated several paramedics came to the facility and checked Resident 1's vital signs, including oxygen level and blood glucose levels. During a concurrent phone interview and record review on 6/12/25, at 8:55 a.m. with LVN 1, Resident 1's OSR dated 6/6/25 was reviewed. The OSR indicated, . Check oxygen saturation PRN every 8 hours as needed for Dyspnea/Cyanosis . Order Date 5/5/25 . LVN 1 stated Resident 1's physician's order to check oxygen saturation was not followed by the previous shift. LVN 1 stated Resident 1's oxygen saturation level was not checked for more than 12 hours (from 9:07 a.m. to 2:20 am). LVN 1 stated Resident 1 was on continuous oxygen and checking the oxygen saturation level was part of the vital signs, and it was not done. During a concurrent phone interview and record review on 6/12/25, at 9:00 a.m. with LVN 1, Resident 1 ' s COPD and CHF care plan dated 5/5/25 was reviewed. The care plan indicated, . Focus . [Resident 1] has oxygen therapy r/t CHF. Administer oxygen @2-3L/min via nasal cannula, Continuous for Chronic COPD . Interventions/Tasks . Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD: increased respirations (breathing) . decreased pulse oximetry . cough . LVN 1 stated the careplan interventions should be implemented and it was not. LVN 1 stated the facility failed to follow Resident 1's care plan interventions and physician's order to monitor oxygen saturation level every shift, and resulted to altered mental status and subsequent hospitalization. During a concurrent interview and record review on 6/12/25 at 2:21 p.m. with the DON, the DON stated Resident 1 has a diagnosis of COPD, CHF, Cervicalgia and Type 2 DM. The DON stated Resident 1 was transferred to an acute care hospital (ACH) on 5/18/25 due to AMS, and did not return to their facility. The DON reviewed Resident 1's COPD and CHF care plan dated 5/5/25 and stated the care plan intervention to monitor oxygen saturation level every shift was not followed on 5/17/25. The DON stated the purpose of a care plan was to guide staff for a resident's plan of care and the interventions in place to meet the resident goals. The DON stated failure to follow the nursing care plan interventions could lead to a negative outcome, including low oxygen level and respiratory distress. During a review of Resident 1's Acute Hospital History and Physical, dated 4/28/25, the record indicated, . [Resident 1] is a [AGE] year old, male with PMHx (Patient's past medical history) sig (significant) for COPD, CHF . DM . who presented to the ER with complaint of mild SOB (shortness of breath) . Recent Labs [laboratory] . Glucose 189 ml/dl . Plan: Admit . Insulin regimen, hypoglycemic precautions . During a review of Resident 1's Ambulance Service Record, dated 5/18/25, the record indicated, . 04:00 [4:00 a.m.] . Chief Complaint . not acting like his usual self . Vital Signs BP 166/67 . Oxygen Saturation 92% . Blood Glucose 53 mg/dl . Comments: low blood sugar . Narrative: Pt found semi-Fowlers in bed at [Facility Name] . Family at scene. Staff states that pt (patient) is not his usual self. Usually converses more but this morning he just yells. Pt has history of COPD and is on 2 LPM (liters per minute - unit of measurement) via nasal cannula. Pt has an oxygen saturation of 88 %, EMS increased oxygen to 3 LPM this improved his oxygen saturation to 93%. Glucose check showed 53 mg/dl. Pt moved to gurney to unit . During a review of Resident 1's Acute Hospital ED Physician Notes, dated 5/18/25 at 7:26 a.m., the note indicated, . Patient presenting from the [Facility Name] for altered mental status . 74 y.o. male history of COPD, diabetes, hypertension presents for altered mental status. Vital signs with borderline tachycardia, hypoxemia to the low 90s and high 80s on supplemental oxygenation. Exam with diffuse wheezing as well as significant weakness in bilateral upper and lower extremities. Considered a broad differential for this patient who present for altered mental status found to be hypoglycemic . Final Diagnosis this visit: COPD with acute exacerbation . Acute hypoxemic respiratory failure . Altered mental status . Hypoglycemia . Disposition: transfer to other hospital [Hospital name] . Condition: Guarded . During a review of the facility's P&P titled Comprehensive Care Plans, dated 11/2017, the P&P indicated, . provide each resident with a person-centered, comprehensive care plan to address the resident ' s medical, nursing, physical, mental and psychosocial needs . facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-center care plan for each resident that includes measurable objectives and timeframes that meet a resident ' s medical, nursing, physical, mental, and psychosocial needs . It will drive the type of care and services that a resident receives and will describe the resident ' s medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting these needs and preferences . During a review of the professional reference titled, Lippincott procedures-Care plan preparation, long-term care, dated 5/19/22, the professional reference indicated, .The care plan for each resident must include: . resident goals, expressed in measurable objectives with timetables to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment, interventions that describe the services the interdisciplinary team employs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, evaluation of the fulfillment of goals .The care plan should reflect elements of person-centered are, make every effort to understand what each resident is communicating verbally and non-verbally, and identify what daily routines are important each resident . During a review of a professional reference retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-a-care-plan-in-skilled-nursing-facilities#:~:text=This%20helps%20keep%20you%20aware,kind%20of%20services%20you%20need titled What ' s a care plan in skilled nursing facilities, undated, the reference indicated, . When your health condition is assessed, skilled nursing facility (SNF) staff prepare or update your care plan . This helps keep you aware of how the care you get will help you reach your health care goals . may include . what kind of services you need . How often you'll need the services . What kind of equipment or supplies you need . Your health goal (or goals), and how your care plan will help you reach your goal .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to address the risk of fire while smoking for one of three sampled residents (Resident 1), when staff were aware of Resident 1's need for oxygen (a colorless, odorless gas that is essential for life), history of smoking and bringing in cigarettes and lighters into the facility and did not implement effective measures to ensure Resident 1's safety from fire. These failures resulted in Resident 1 smoking unnoticed while wearing oxygen on 2/4/25, catching fire and suffered avoidable second-degree burns (injury that damages both the outer layer of skin and part of the underlying layer) to the face and right forearm, swelling and severe pain, requiring emergency transport to a higher level of care and hospital with a Burn Unit (a hospital ward that treats patients with burns). Resident 1 was admitted to the acute care hospital (ACH) Burn Unit for two days and may suffer pain and scarring (a mark remaining after injured tissue has healed) as a result of the burns and possible reduced mobility. Findings: During an interview on 2/5/25 at 9:23 a.m. with the Administrator (ADM), the ADM stated on 2/4/25 around 1:00 a.m., a Certified Nursing Assistant (CNA) heard a loud noise coming from Resident 1 ' s room. The CNA went into the room, and the oxygen tubing and nasal cannula (NC-medical device that provides oxygen through a thin flexible tube with two prongs that fit into the nostrils) were on fire. The ADM stated it was reported Resident 1 had blood on his nose, soot (black powder that forms when something is burned) on his face and his beard was burned off. The ADM stated Resident 1, and his roommate Resident 2, were removed from the room and Resident 1 was transported by ambulance to the ACH Burn Unit for treatment. The ADM stated they did not know where the lighter came from. The ADM stated facility staff was aware Resident 1 was a smoker and would smoke when he was at hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). During a review of Resident 1 ' s admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), end stage renal disease (ESRD-irreversible kidney failure), shortness of breath and dyspnea (difficulty breathing). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 2/5/25 at 9:38 a.m. with the Maintenance Supervisor (MS), the MS stated he received a call on 2/4/25 around 1:00 a.m. from facility staff and was told there was a fire at the facility. The MS stated when he arrived, the fire department was already at the facility and had reset the fire alarm. The MS stated he walked into Resident 1 ' s room, saw burnt areas on the floor next to the bed and holes burnt into Resident 1 ' s mattress. During a concurrent observation and interview on 2/5/25 at 9:43 a.m. with the Maintenance Supervisor (MS) in Resident 1 ' s room, Resident 1 ' s bedframe was in the room, but the mattress was gone. The MS stated he had removed the mattress and replaced the burnt tiles on the floor. Resident 1 ' s mattress was observed lying on the ground outside and there were three floor tiles next to the mattress. The MS pointed to the blackened areas on the floor tiles and stated they were caused by the nasal cannula landing on the floor when it was on fire. The mattress had five holes in it, the MS pointed to the largest hole which had discolored areas on the foam with an irregular surface and appeared to have melted a small area. The MS stated it was a fire retardant (substance used to slow down or stop the spread of fire) mattress which prevented to mattress from continuing to burn. During an interview on 2/5/25 at 10:10 a.m. with Resident 2 ' s Paid Caregiver (PCG) in Resident 1 and 2 ' s room, the PCG stated she visited Resident 2 over the weekend and saw Resident 1 with a cigarette in the room. The PCG stated Resident 1 had wheeled over to the sliding glass door and opened it part way. The PCG stated she saw the cigarette and asked what Resident 1 was doing and he replied he was going to smoke. The PCG stated, I told him you are not going to smoke that in here. The PCG stated she mentioned Resident 1 ' s cigarette to a staff member, but did not know if anything was done about it. During an interview on 2/5/25 at 10:13 a.m. with CNA 1, CNA 1 stated she normally worked day shift and was responsible to get Resident 1 ready for HD. CNA 1 stated the staff had been notified to watch Resident 1 ' s belongings for cigarettes or lighters because he had previously been caught with them in his room. During an interview on 2/5/25 at 10:27 a.m. with CNA 2, CNA 2 stated Resident 1 was a known smoker and had been caught smoking at the facility even though the facility was smoke-free. CNA 2 stated the staff was told to make sure Resident 1 was not smoking, have cigarettes or a lighter. CNA 2 stated Resident 1 would go to HD and bring cigarettes and lighters back with him. During a review of Resident 1 ' s Nursing Note, dated 2/4/25 at 5:07 a.m., the note indicated, . 0100am [1:00 a.m.] CNA heard a noise coming from [Resident 1 ' s room], Upon entering CNA noted smock [smoke] and fired flames on the floor with nasal cannel [cannula] burning on the floor, CNA immediately put out the fired [sic], Code RED [emergency indicating fire or smoke] was activated . Resident stated I just wanted smoked a cigarette, Resident led [lit] a lighter for a cigarette, Resident was on contentious [continuous] oxygen nasal Cannula, the lighter blew up on his face, CN [charge nurse] noted blood on his mouth and nose and soot all over face, noted soot stains in bed matters [mattress], Noted resident in a sitting position . took resident to hospital for eval and TX [treatment] . During a review of Resident 1 ' s Nursing Note, dated 2/4/25 at 5:30 a.m. indicated, . resident was admitted to Burn Unit [name of hospital] . During a review of Resident 1 ' s Nursing Note, dated 2/4/25 at 10:26 a.m., the note indicated, . CN called [name of ACH] for an update . resident is currently in the ER [emergency room] trauma unit [hospital department which treats patients with severe injuries], he will be admitted to the burn center . has superficial partial thickness burns [burn that damages the top two layers of skin] to his face, over his nose, left eye, and mouth area. He also has swelling to the left eye and lips . During a concurrent interview and record review on 2/5/25 at 10:37 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a history of bringing cigarettes and lighters into the facility. Resident 1 ' s Nursing Note, dated 10/31/24 at 9:05 a.m. was reviewed. The note indicated, . Resident noted to have 8 Norco ' s [medication used to treat severe pain] in his bag, a pocketknife, and a lighter. Educated resident that he cannot have medications, knife, or lighter at bedside. Resident stated that he needs his lighter for when he goes to dialysis. Informed resident that he can take the lighter while he goes out for dialysis, but he needs to give it back to the nurse to put in the narcotic box after he comes back . Resident 1 ' s Nursing Note, dated 10/31/24 at 2:06 p.m. was reviewed, the note indicated, . Resident returned . Lighter put in narcotic [substance used to treat severe pain] box . LVN 1 stated facility was smoke-free but the notes indicated the nurse had given Resident 1 his lighter when he left for dialysis. LVN 1 stated the nurses kept Resident 1 ' s cigarettes and lighter locked in the medication cart if they were aware he had them, but he was found with them in his room, so it was not always effective. Resident 1 ' s Order Summary Report, dated 2/2025 was reviewed, the orders indicated, . Administer oxygen @ [at] [SPECIFY] 3_L/min [liters (unit of measurement) per minute] via nasal cannula, For SOB every shift for Dyspnea . LVN 1 stated Resident 1 had been on oxygen continuously since admission. The medication cart narcotic drawer was observed, there were two lighters in the cart, but neither belonged to Resident 1. During an interview on 2/5/25 at 12:44 p.m. with the Admissions Coordinator (AC), the AC stated it was her responsibility to review the admission documents with the residents and have the signed. The AC stated when Resident 1 was admitted , she reviewed the facility ' s smoking policy and procedures (P&P) with him and had notified him it was a smoke-free facility. The AC stated when she gave Resident 1 resident a copy of the P&P, the resident became upset, crumpled up the P&P and threw it on the bed. During a concurrent interview and record review on 2/5/25 at 1:10 p.m. with the Director of Nursing (DON), Resident 1 ' s Nursing Note, dated 12/4/24 at 1:04 p.m. was reviewed. The note indicated, . [Name of Resident 1 ' s responsible party] said that she did not give him cigarettes. He is asking a driver to buy him cigarette . Per Resident daughter [name] he had accident in the past while smoking with oxygen on . The DON stated she contacted Resident 1 ' s daughter because the facility staff was concerned, he was smoking at dialysis with his oxygen on. The DON stated Resident 1 ' s daughter told her about the resident smoking with oxygen on was nothing new and he would not stop because he was stubborn. The DON stated the nurses would check Resident 1 for cigarettes and lighter when he returned from dialysis and would lock them up. The DON was aware the staff gave Resident 1 his cigarettes when he left for dialysis with oxygen on. The DON stated Resident 1 would smell like smoke when he returned from dialysis. The DON stated on 11/10/24, Resident 1 was caught smoking in his room with oxygen on. Resident 1 ' s IDT (Interdisciplinary team-involves team members from different disciplines working collaboratively, with a common purpose to set goals, make decisions and share resources for the best interest of the resident) note dated 11/11/24 was reviewed, the note indicated, . spoke with [Resident 1] on 11/8/24 about being a nonsmoking facility. [Resident 1] was subsequently found to be smoking outside of his sliding door on 11/10/24 . spoke with him againg [sic] today and reminded him that there is no smoking allowed in this facility. Writer offered to refer him to another facility or to get an order for a nicotine patch. [Resident 1] declined both options . The DON stated on 1/10/25 the transportation company had notified her he tried to smoke in the van, and they threatened to stop transporting him. The DON stated the facility did not investigate why the nurses were giving Resident 1 his cigarettes and lighter when he left for dialysis and stated they should not have. The DON stated Resident 1 was admitted to the burn unit at the ACH on 2/4/25. Resident 1 ' s care plan dated 11/10/24 was reviewed, the care plan indicated, . Focus . [Resident 1] is a smoker . Goal . will not smoke in the facility premises . Interventions . The facilities [sic] smoking policy was reviewed and accepted by the resident and/or resident family . The resident requires a cigarette holder while smoking . the resident requires a smoking apron while smoking . The DON stated the campus was smoke-free and she did not know why the interventions included the smoking apron and cigarette holder because the resident was not supposed to smoke onsite. The DON stated the care plan was not accurate. The DON stated the purpose of care plans were to guide staff on the plan of care and interventions to meet the resident goals. The DON stated they should be individualized and specific to each resident. Resident 1 ' s care plan dated 12/6/24 was reviewed and indicated, . behavior issue risk and benefit of smoking explained. Per patient he smokes outside the dialysis and not in post acute care center premises . Goal resident will have fewer episodes . education on risk of smoking with oxygen use provided to patient. Non compliant behavior noted during dialysis days . The DON stated Resident 1 was provided education to not smoke while on oxygen. The DON stated Resident 1 was known to be non-compliant and the intervention of providing education was not effective. During an interview on 2/5/25 at 2:16 p.m. with the ADM, the ADM stated Resident 1 had a history of smoking in the facility. The ADM stated on 11/8/24 Resident 1 had gone outside his room to smoke. The ADM stated the IDT met to discuss interventions for the resident ' s care. The ADM stated the facility had Resident 1 sign a risk versus benefit form regarding smoking while on oxygen. Resident 1 ' s nurse ' s notes dated 10/31/24 indicated, Resident 1 left for dialysis and the nurse had given him the lighter while wearing oxygen. The ADM stated he was aware Resident 1 ' s cigarettes were kept in the medication cart and given to him when he left for dialysis, but did not know the nurses had provided him the lighter while he wore oxygen. The ADM stated, We cannot control what he does when he is out of the facility. The ADM stated, He is going to do what he is going to do. The ADM stated Resident 1 had a right to not be searched when he returned from dialysis. During a telephone interview on 2/5/25 at 5:08 p.m. with CNA 3, CNA 3 stated Resident 1 was rebellious. CNA 3 stated the staff frequently caught Resident 1 returning from HD with cigarettes and a lighter and he would smell like smoke when he returned. CNA 3 stated he worked the evening shift on 2/3/25 when Resident 1 returned from dialysis and checked his fanny pack. CNA 3 stated he did not find any cigarettes or a lighter which was unusual because Resident 1 normally had them when he returned. During a telephone interview on 2/5/25 at 5:23 p.m. with LVN 2, LVN 2 stated she was the charge nurse on duty during Resident 1 ' s incident on 2/4/25. LVN 2 stated she heard a CNA yell for her and went into Resident 1 ' s room. LVN 2 stated there was smoke coming out of the room and there was a fire on the ground that the CNA was trying to put out. LVN 2 stated they took the residents out of the room and pulled the fire alarm. LVN 2 stated she assessed Resident 1, and he had blood coming out of his nose and mouth and his face was black with soot. LVN 2 stated Resident 1 ' s face was smoking where his beard had been burned. LVN 2 stated the resident told her he just wanted a cigarette and when he lit the lighter, the nasal cannula caught on fire, and he threw it on the ground. LVN 2 stated Resident 1 had a lighter and cigarette with him, but she did not know where he had gotten them from. LVN 2 stated the CNAs searched Resident 1 ' s belongings and found more cigarettes. LVN 2 stated Resident 1 was on oxygen continuously and should not have been smoking. During a telephone interview on 2/6/25 at 7:21 a.m. with CNA 4, CNA 4 stated he was on duty at the time of Resident 1 ' s accident. CNA 4 stated he was in a room nearby and heard a loud noise coming from Resident 1 ' s room so he went in there. CNA 4 stated there was smoke everywhere and he saw the nasal cannula on fire on the ground. CNA 4 stated he turned off the oxygen concentrator (medical device that gives you extra oxygen) and put the fire on the ground out by stomping on it. CNA 4 stated Resident 1 ' s face was black, and his beard was burnt, and smoking and he had blood coming out of his mouth. CNA 4 stated, He looked shocked and wasn ' t saying anything, just quiet then said, ' the thing blew up ' and he ' wanted to go for a puff ' . During a review of Resident 1 ' s Acute Care Hospital ED [emergency department] Provider Notes, dated 2/4/25, indicated, . Chief Complaint . Burn . 2nd degree burns to face and right forearm from lighting cigarette while on oxygen . Face . Partial thickness burns to the left cheek. Superficial burns to the left eyelid. Burns to the lip. Soot noted in the nose. Singed hair to the face . During a review of Resident 1 ' s ACH document titled History and Physical (H&P) dated 2/4/25, the H&P indicated, . He went to hemodialysis yesterday . he decided to have a cigarette while wearing his oxygen. He accidently ignited the oxygen and suffered facial burns . Patient reports smoking about 4 cigarettes a day on days he goes to dialysis . burns are second degree . burn wounds with left eye swollen shut, lip and cheek swelling . A: [assessment] 1st and 2nd degree burn of face from contact with fire . Anticipate facial swelling, recommend nasal cannula in place at all times to stent [maintain pressure to promote healing] open the nostrils . During a review of Resident 1 ' s ACH document titled Burn Surgical Service, dated 2/4/25, the note indicated, . sustaining facial burns from smoking while using O2 [oxygen] . P: [plan] . Admit to Burn service . MMPC [multimodal pain control-treatment plan using multiple medications and therapies to control pain] . wound care . nothing by mouth for now . During a review of Resident 1 ' s ACH document titled Discharge Summary, dated 2/6/25, the DC summary indicated, . Patient c/o [complains of] nasal dryness with scab [protective crust that forms over a wound] formation making it difficult to breath[e] through his nose. He has some dyspnea [difficulty breathing] . 02/06 . Reports feeling better today but still reports pain in his face . Patient can be discharged today back to his skilled nursing facility . During a review of the facility ' s policy and procedure (P&P) titled Quality of Care Accident Hazards/Supervision/Devices, dated 7/2018, the P&P indicated, . provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents . facility recognizes the high-risk nature of the facility population and setting . Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment. Interventions will be modified when necessary . Identification of potential hazards in the resident environment and the risk of a resident having an avoidable accident . Identification of or development of interventions based on the severity of the hazard and immediacy of risk . Care plan intervention will be monitored for effectiveness and modified as necessary to increase effectiveness . During a review of the facility ' s P&P titled Physical Environment Smoke Free Facility, dated 3/2019, the P&P indicated, . provide a safe environment for residents . facility shall be designated smoke free . residents, visitors, contractors and staff are not permitted to smoke on the property at any time . non-smoking policy will be included in the admission packet . Residents will be informed that violation of the facility smoking policy could place the resident at risk for a facility initiated discharge due to endangerment of residents and individuals in the facility . Oxygen Therapy . resident with oxygen delivery systems will be informed of safety precautions and prohibitions for oxygen. Staff will monitor resident for compliance with the safety rules . During a review of a professional reference found at https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/oxygen-therapy/using-oxygen-safely#:~:text=Oxygen%20Therapy,-Oxygen%20survey&text=Oxygen%20is%20a%20safe%20gas,from%20what%20your%20doctor%20prescribedtitled Oxygen Therapy: Using Oxygen Safely, dated 12/15/23, the reference indicated, . Materials burn more readily in an oxygen-enriched environment . Oxygen Safety Guidelines . Keep Away from Heat and Flame . [NAME] ' t smoke and don ' t allow others to smoke near you . Keep sources of heat and flame at least five feet away . Always have a fire extinguisher [a portable devices that extinguishes a fire] nearby .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of nine sampled residents (Resident 1), when Resident 1 was diagnosed with dementia (a chronic or persistent disorder of the mental processes marked by memory disorder, personality changes, and impaired reasoning), and a known history of poor safety awareness and muscle weakness and contracture (shortening of muscular or connective tissue that results in deformity) of left hand; and was not supervised while she drank hot tea on 2/16/22, in accordance with comprehensive care plan which indicated Resident 1 was totally dependent on staff to eat and drink. This failure resulted in Resident 1 spilling hot tea onto her chest, suffering avoidable second-degree burns (a burn to the skin characterized by injury to the outer and middle layers of the skin), causing pain and required routine acetaminophen (pain medication) twice daily for pain management, an assessment by the Would Consultant Physician (WCP), and daily dressing changes. Findings: During a review of Resident 1 ' s admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain), clostridium difficile (a germ that causes diarrhea and inflammation of the colon [large intestine]), protein-calorie malnutrition (inadequate intake of food), dementia, transient ischemic attack (TIA- a brief episode of weakness, vision problems, slurred speech resulting from an interruption in the blood supply to the brain), hemiplegia (weakness or partial paralysis on one side of the body) and contracture of muscle left upper arm (fixed tightening of a joint preventing normal movement of the body part). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [pertaining to memory and judgement] and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental Status assessment (BIMS – assessment of cognitive status for memory and judgement) scored 04 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had severe cognitive impairment. The MDS assessment section G (functional status) dated 1/23/22 indicated Resident 1 required the support of one-person physical assistance for eating. During a review of Resident 1 ' s progress notes written by the WCP, dated 2/16/22, the notes indicated, . 2° [second degree] burn chest . consistent with hot water . Wound Location . Chest . Type . Trauma . Burn . L x W x D [length by width by depth-measurements] 18 [cm-unit of measurement] x 40 [cm] x 0.2 [cm] . Wound cleanser . silvasorb [wound dressing for partial thickness (outer and middle layer of skin) burns]/alg [alginate-treatment for wound healing] . D [daily] . During a review of Resident 1 ' s Order Summary Report, (OSR-physician orders) dated 2/2022, the OSR indicated, . Cleanse chest with wound cleanser pat dry apply silvasorb gel and leave open to air one time a day related to BURN OF SECOND DEGREE . [brand name] Tablet 325 MG [milligrams-unit of measurement] (Acetaminophen) Give 2 tablet[s] by mouth two times a day related to BURN OF SECOND DEGREE . During a review of Resident 1 ' s IDT Note (Interdisciplinary Team-a group of different healthcare disciplines to plan, coordinate and deliver personalized care) dated 2/17/24 at 2:21 p.m., the IDT note indicated, . IDT met to review redness noted to [Resident 1 ' s] chest on 2/16/22 . Chest injury measurement is 18 [cm] x 40 [cm] x 0.2 [cm] with scant [small amount] drainage . Wound doctor, [WCP ' s name] notified and came in to evaluate [Resident 1] . [WCP] stated the site is a 2nd degree superficial [situated on the skin or immediately beneath it] burn . [Resident 1] stated she spilled tea on her chest . [Resident 1] is also at risk due to fragile skin and a contracture to her left hand . [physician (PHY) 1 ' s name] notified of event and ordered routine pain medication [brand name for acetaminophen] 325 mg 2 tabs PO [by mouth] BID [twice daily] for pain management . During a concurrent interview and record review on 4/2/24 at 1:29 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s medical diagnoses were reviewed. LVN 1 stated Resident 1 ' s diagnoses included cerebral infarction with hemiplegia, weakness and dementia which could affect Resident 1 ' s ability to safely feed herself. Resident 1 ' s ADL [activities of daily living- includes eating, dressing, bathing] care plan dated 1/21/22 was reviewed, the care plan indicated, . [Resident 1] has an ADL self-care performance deficit . Eating: [Resident 1] is totally dependent on (1) staff for eating . The resident has contractures of the left hand . LVN 1 stated the care plan indicated Resident 1 needed a staff member to physically feed her, which would include holding a cup. LVN 1 stated, probably nobody assisted her that day [when Resident 1 was burned]. A color photo of Resident 1 ' s chest dated 2/16/22 at 1:54 p.m., was reviewed. The photo revealed multiple reddened areas on the right upper chest, right breast, mid-chest, and the left inner breast with a few scattered darkened areas. LVN 1 stated the darkened areas in the photo appeared to be scabs (dry protective crust that forms over wounds) which were deeper burns to the skin. During a telephone interview on 4/11/24 at 6:31 a.m. with LVN 2, LVN 2 stated she was the day shift charge nurse on 2/16/22. LVN 2 stated at approximately 1:00 p.m., the Director of Nursing (DON) had called for her to Resident 1 ' s room. LVN 2 stated when she entered Resident 1 ' s room, she observed redness across Resident 1 ' s chest area. LVN 2 stated Resident 1 reported she had spilled hot tea on herself. LVN 2 stated Resident 1 complained she had a burning pain of eight out of 10 on the numeric pain scale (1-3 no pain to mild pain, 4-6 moderate pain, 7-10 severe pain). LVN 2 stated Resident 1 was assessed by the WCP who was in the facility at the time of the incident. LVN 2 stated the WCP indicated Resident 1 had 2nd degree burns to her chest and ordered wound care. LVN 2 stated Resident 1 ' s PHY 1 ordered acetaminophen 325 mg two tablets twice daily for pain management. Resident 1 ' s ADL care plan was reviewed, LVN 1 stated the care plan indicated Resident 1 was totally dependent on one staff member for eating. LVN 2 stated totally dependent meant Resident 1 required a staff member to provide physical assistance to eat and drink. During an interview on 4/17/24 at 10:15 a.m. with CNA 5, CNA 5 stated if a resident required assistance to eat, they were not safe to handle a hot beverage without assistance. CNA 5 stated, they could burn themselves. During a concurrent interview and record review on 4/17/24 at 10:42 a.m. with LVN 3, Resident 1 ' s NSG [nursing] Hot Beverage Safety Evaluation (HBSE- an assessment to determine the level of supervision needed for safe consumption of hot beverages) dated 1/21/22 was reviewed. The HBSE indicated, . score 3 [out of 5] . May require set up assistance . A. Resident demonstrates impaired orientation . yes . B. Resident has a diagnosis of Neuropathy [disease of the peripheral nerves causing numbness or weakness] or other neurological impairment . yes . C. Resident demonstrated one or more of the following cognitive impairments: Poor safety awareness, Impaired short term memory, Impulsiveness . Yes . score . 1-3 points: Resident may require set up assistance while consuming hot beverages . 4-5 points . Resident is unable to consume hot beverages safely independently. Resident requires supervision while consuming hot beverages . LVN 3 stated the HBSE indicated Resident 1 may require set up assistance with hot beverages but did not indicate she needed supervision. LVN 3 stated Resident 1 ' s diagnoses of cerebral infarction, dementia and weakness should be considered when evaluating if Resident 1 was safe to drink hot beverages independently. LVN 3 stated, I would question the results [of the HBSE]. LVN 3 stated Resident 1 ' s diagnoses placed her at a higher risk of burning herself if left unsupervised with a hot beverage. During a concurrent interview and record review on 4/17/24 at 11:23 a.m. with the DOR (Director of Rehabilitation), Resident 1 ' s Occupational Therapy OT Evaluation & Plan of Treatment, dated 1/24/22 was reviewed. The evaluation indicated, . Musculoskeletal System [bones, muscles and joints] Assessment . RUE [right upper extremity (arm)] Strength = Impaired [weakened or damaged] . LUE [left upper extremity] Strength = Impaired . General RUE Strength = 3/5; Shoulder = Impaired . Elbow/Forearm = Impaired . Wrist = Impaired . LUE Strength = 2+/5; Shoulder = Impaired . Elbow/Forearm = Impaired . Wrist = Impaired . Self Feeding=Patient requires assistance . Evaluation Summary . Physical/Cognitive/Psychosocial [evaluation of mental health and social well-being] Performance . presents with impairments in balance, dexterity [performing tasks with hands], fine motor coordination [small exact movements], gross motor coordination [large movements], mobility [movement], strength . limitations and/or participation restrictions in the areas of general tasks and demands . The DOR stated the evaluation indicated Resident 1 had an impairment in the strength and mobility to both arms. The DOR stated the evaluation indicated Resident 1 ' s daughter assisted with all care and mobility needs before facility admission. During a concurrent interview and record review on 4/17/24 at 12:14 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1 ' s MDS Section G dated 1/23/22, was reviewed. The MDS indicated, . H. Eating-how resident eats and drinks, regardless of skill . ADL Support Provided . code 2 [One-person physical assistance] . The MDSC stated the MDS indicated Resident 1 needed one person to physically assist her to eat. The MDSC reviewed Resident 1 ' s ADL care plan and stated the care plan indicated she was totally dependent on staff to eat. The MDSC stated it was unsafe for Resident 1 to drink a hot beverage without assistance. During a concurrent interview and record review on 4/17/24 at 12:45 p.m. with the Director of Staff Development (DSD), the DSD stated she remembered Resident 1. The DSD stated she was not working the day Resident 1 had a burn incident but had seen Resident 1 ' s wound after the incident. The DSD stated an HBSE was done for all residents on admission, quarterly and if there was an incident. The DSD reviewed Resident 1 ' s HBSE dated 2/16/22 and stated it indicated there was a cognitive impairment, poor safety awareness, impaired short-term memory, and impulsiveness. The DSD reviewed Resident 1 ' s ADL care plan and stated one person should have stayed with her the entire time she was drinking the hot beverage. The DSD stated Resident 1 was not safe to drink hot tea unsupervised. During a concurrent interview and record review on 4/17/24 at 1:10 p.m. with the DON, the DON stated on 2/16/22 at approximately 1:00 p.m. she answered Resident 1 ' s call light. The DON stated she noticed Resident 1 ' s neck was wet and there was redness across her chest. The DON stated called for the charge nurse. The DON stated she asked Resident 1 what had happened, and Resident 1 told her she spilled tea on herself. The DON stated the WCP was in the facility and assessed Resident 1. The DON stated the WCP diagnosed Resident 1 with 2nd degree burns to her chest. Resident 1 ' s ADL care plan dated 1/21/22 was reviewed, and the DON stated the care plan indicated Resident 1 was totally dependent on staff for eating. The DON stated totally dependent meant staff would set up meals, cut the food and feed the resident. The DON stated care plans were important because they provided individualized care for the residents. The DON stated Resident 1 ' s MDS Section G dated 1/23/22 indicated Resident 1 was assessed as needing one-person physical assistance to eat. The DON stated somebody should have stayed with Resident 1 while drinking hot tea. The facility ' s policy and procedure (P&P) titled Quality of Care, dated 7/2018 was reviewed. The P&P indicated, . provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents . Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment . The DON stated Resident 1 ' s individualized care plan was not followed according to P&P, and it may have prevented the accident from occurring. During a review of Resident 1 ' s NSG [nursing] Admission/readmission Evaluation, dated 1/21/22, at 5:24 p.m., the evaluation indicated, .ADLs . Eating . The resident has an ADL self-care performance deficit . [box checked] Eating: the resident is dependent on (1) staff for eating . Impairments . [box checked] cognitive . Forgetfulness and confusion noted . During a review of Resident 1 ' s History and Physical, (H&P-complete assessment), dated 1/23/22, at 6:13 p.m., written by Physician (PHY) 1, the H&P indicated, . past medical history significant for generalized weakness, Dementia, CVA [Cerebrovascular Accident-loss of blood flow to part of the brain] with left sided weakness and left hand contracture . Dementia; Monitor behavior and help with ADL . During a review of the facility ' s policy and procedure (P&P), titled Quality of Care, dated 7/2018, the P&P indicated, . provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents . Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment. Interventions will be modified when necessary . Individualized interventions will be developed to reduce the potential for accidents .Interventions will be consistent with professional standards . Resident specific interventions will be reflected in the resident ' s person-centered, individualized care plan . Monitoring and modification process may include . verifying that interventions are implemented . evaluating the effectiveness of interventions . The facility may use supervision as an intervention to mitigate accident risk . Risks and Environmental Hazards . In order to be considered hazardous, a potentially hazardous item or situation must be accessible to a vulnerable resident . Hot water may reach temperatures that are hazardous for residents, putting them at risk for burns caused by scalding [injury from hot liquid or steam] . During a review of a professional reference retrieved from https://nursinghomesabuse.org/nursing-home-injuries/burns/ titled Burn Injuries in Nursing Homes, dated 4/30/23, the reference indicated, . Burn injuries are a common occurrence in nursing homes, with elderly residents being at higher risk due to factors such as decreased mobility, sensory deficits [loss, absence, or marked impairment of vision, hearing taste, touch or smell] and cognitive impairment . Burn injuries can be cause by hot surfaces, scalding liquids . are often preventable with proper staff training and safety protocols . following factors make elderly individuals more vulnerable to scalds . Impaired sensation that prevents elders from reacting quickly to heat . Thinner skin, which burns to its full depth more readily . Nursing home residents could come into contract with hot liquids if the nursing home fails to take protective measures . Hot coffee and the steam from hot foods can cause painful and severe burns. Health conditions common to the elderly . can increase the risk of elders spilling coffee on themselves . Nursing homes should always ensure food and coffee are served at safe temperatures, and that coffee is served in cups with secured lids . older adults with the following characteristics face the highest risks of experiencing burns . limited mobility Slow reaction times . Sensory impairment . Decreased coordination . Cognitive decline . When nursing homes accept patients, they accept responsibility for any harm that comes to patients while under their care . has the duty to provide a safe, hospitable environment for residents . Their duties include . protect patients . supervise patients . Take proactive measures to prevent injuries .