**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a Finger Contracture Cushion (a fabric cushion made of breathable and absorbent material, with three large loops in the middle for: index, middle and third finger, and two tight rings on both ends. The cushion is used to separate the fingers and protect the palm), commonly known as a hand roll, was placed correctly on one of three sampled residents ' (Resident 1) left hand. Resident 1 was left unattended and unsupervised, when his pinky finger was tightly inserted in the last ring of the cushion, for over seven hours. This failure resulted in Resident 1 sustaining an injury to the left pinky finger, as evidenced by purplish discoloration, pain, bleeding, an open wound, and a transfer to the acute care hospital for further care. Findings: During a record review of Resident 1 ' s undated Face Sheet (a record with residents ' basic information), the record indicated Resident 1 was admitted to the facility on [DATE]. During a record review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 7/2/24, the assessment indicated Resident 1 had an active diagnosis of a left-hand contracture (a permanent tightening of the muscles, skin, or other tissues that limits a body part's normal movement). The assessment indicated Resident 1 rarely or never understood others and was rarely or never able to make his needs known. The assessment indicated Resident 1 was dependent for care and mobility; and was at high risk of developing skin injuries. During a record review of Resident 1 ' s physician ' s order dated 7/4/24, the record indicated to apply hand roll to Resident 1 ' s left hand for six (6) hours a day every day. During an observation and interview on 9/27/24 at 1:14 p.m., with Restorative Nursing Aide (RNA) 1, RNA 1 stated he placed a hand roll to Resident 1 ' s left hand whenever he was on duty, but he did not work on 9/9/24 when Resident 1 sustained injury to his pinky finger. RNA 1 brought a sample hand roll Finger Contracture Cushion the kind that Resident 1 was using for his left hand. RNA 1 demonstrated and explained the placement of three fingers on the rings: point finger, middle finger, and ring finger. RNA 1 stated the hand roll did not have a loop for pinky finger. During an interview on 9/27/24 at 12:00 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was the assigned morning shift (7 a.m. to 3 p.m.) assistant for Resident 1 on 9/9/24. CNA 1 stated Resident 1 used a hand roll with four (4) rings, wherein the point finger, middle finger, ring finger and pinky finger on the left hand were inserted for the hand contractures. During an observation and interview on 9/27/24 at 1:58 p.m. with CNA 1, the finger contracture cushion/hand roll sample was observed. CNA 1, at this time, stated she only placed the hand roll in the left hand of the Resident 1 to hold it and did not insert fingers in the loops of the cushion. CNA 1 stated somebody might have placed the left pinky finger in the small ring which should not be. During an interview and observation on 9/27/24 at 3:37 p.m., with CNA 2, CNA 2 stated she took care of Resident 1 in the evening shift (3 p.m. to 11 p.m.) on 9/9/24. CNA 2 stated on 9/9/24, around almost 10 p.m., she went to the Resident 1 ' s room and noticed something was wrong with Resident 1. CNA 2 stated she was about to give bed bath to Resident 1, but he resisted care at that time. CNA 2 stated she saw Resident 1's left hand pinky finger was inserted in one of the tight rings of hand roll causing purplish discoloration, and she went straight to Registered Nurse (RN) 1. CNA 2 stated she suggested RN 1 to cut the tight ring of the hand roll, because it was very tight. CNA 2 demonstrated the placement of the left pinky finger using the sample hand roll, and how the left pinky finger was inserted in the tight ring hole. CNA 2 stated her shift was from 3:00 p.m. to 11:15 p.m. but she did not pay attention and did not know Resident 1 was using the hand roll for his left hand the whole time. During an interview on 9/27/24 at 3:22 p.m. with RN 1, RN 1 stated during evening shift on 9/9/24, CNA 2 called her attention for Resident 1. RN 1 stated she saw Resident 1 ' s left pinky finger placed on the last ring of the hand roll and stated she was not sure if it was supposed to be there. RN 1 stated the left pinky finger was purplish in color and was bleeding. RN 1 stated Resident 1 was moaning at that time. RN 1 stated she rushed to get a scissor but was not sure how to cut it since Resident 1 ' s left pinky finger was tightly stuck in the ring of hand roll cushion. RN 1 demonstrated the placement of the left pinky finger using the sample hand roll, and the left pinky finger was placed all the way inside the tight ring. During an interview on 9/27/24 at 3:45 p.m., with RN 2, RN 2 stated he was Resident 1 ' s assigned charge nurse in evening shift (3 p.m. to 11:30 p.m.) on 9/9/24. RN 2 stated on 9/9/24 around 5:00 p.m., he saw Resident 1 lying in bed when he administered evening medications to him but did not remember seeing the Resident 1 ' s hands. RN 2 stated he did not know Resident 1 required a hand roll and had not seen him using one before. RN 2 stated he did not know who put on the hand roll in Resident 1 ' s left hand. RN 2 also stated somebody must have placed it on, since Resident 1 did not have the ability to do so. RN 2 stated he saw Resident 1 ' s left hand after RN 1 had already cut the hand roll cushion. RN 2 stated Resident 1 had a cut open wound about 1.0 cm. deep and, and it was bleeding. RN 2 stated the hand roll can be placed for a long period of time, but it depends. RN 2 stated hand rolls need to be taken off intermittently, otherwise they could impede the blood circulation in fingers. During a record review of Resident 1 ' s progress notes dated 9/9/24, documented by RN 1, the record indicated, Around 10:15p.m., [CNA 2] showed to [RN 1] [Resident 1 ' s] left pinky. [RN 1] assessed finger and finger was purple and noted to be wrapped with the ring part of a hand splint. [RN 1] cut the ring around the finger and the finger was almost falling off. Bone was visible. [RN 1] reported to on-call [Medical Doctor] and [Medical Doctor] gave an order to send out [Resident 1]. [RN 1] called 911 and ambulance came around 10:30 p.m. Ambulance left with [Resident 1] around 10:50 p.m. [RN 1] notified [Responsible Party] . During a record review of Resident 1 ' s Acute Care Hospital record dated 9/10/24, the record indicated, [Skilled Nursing Facility] found left pinky open wound this [morning] (9/10). Occurred after [one] day of application of a cushion to his left hand to prevent him from scratching himself. Subsequently, [Skilled Nursing Facility] suspected that the cushion was wrapped around his finger too tight and dug into his skin. Per [Emergency Medical Services], the vitals (blood pressure, temperature, respiration, pulse, pain) at the scene noted. [Resident 1] to be febrile [increased body temperature] and mildly tachypneic [abnormally labored breathing] . The record also indicated Resident 1 had . hypotensive [low blood pressure] episodes .could [likely] be from acute open [left] 5th digit infection at wound site and that Resident 1 received Cefazolin 1 grams (an antibiotic medication to manage infection) .

Based on observation, interview, and record review, the facility failed to maintain safe water temperature for facility residents when hot water temperature from faucets in 31 of 31 bathrooms in resident rooms, and one of one resident shower room measured between 134 to 151.5 degrees Fahrenheit (°F). The facility had 26 of 56 residents (Residents 1, 2, 3, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 36, 37, 38, 42, 43, 47, 50, 52, 53, 58, 313, and 365) who were mobile and able to access bathroom faucets. Facility's residents and direct care staff were unaware of water boiler (a tank that heats water) malfunction and unsafe water temperature, even after identifying the issue, for three days. This failure placed Residents 1, 2, 3, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 36, 37, 38, 42, 43, 47, 50, 52, 53, 58, 313, and 365 at risk for burns (injury to skin or other tissue caused by heat) up to and including third degree burns (when all three layers of skin are burned) within two (2) seconds of contact with hot water at 148°F. Through observations, interviews, and record reviews, the facility showed they initiated the plan of action by turning the hot water heater (a tank that holds and heats water) thermostat down to 120°F; posted signage on every bathroom door warning of the hot water temperature; instituted checks every 30 minutes for Residents 1, 2, 3, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 36, 37, 38, 42, 43, 47, 50, 52, 53, 58, 313, and 365 identified as mobile and being able to access a faucet; trained staff regarding safety of water temperatures to prevent scalding residents; and performed temperature checks every two hours on all faucets accessible to residents until water temperature was 120°F or below. Findings: During a concurrent observation and interview on 6/05/23, at 12:10 p.m., in the hallway outside Resident 53's room, Resident 53 stated, his bathroom didn't have soap in the soap dispenser. State Agency Surveyor (Surveyor 1) tested the soap dispenser in the shared bathroom of Resident 53 and 38 (Bathroom A) and found it to be working when soap dispensed onto Surveyor 1's left hand. Surveyor 1 turned the hot water faucet on and immediately placed left hand into the water stream. The water was immediately (within 1-2 seconds) too hot to keep Surveyor 1's hand in the water stream to rinse the soap. Surveyor 1 observed left hand palm to be stinging and red. Surveyor 1 turned on cold water and rinsed the soap off the left hand. Surveyor 1 requested maintenance come to Bathroom A to evaluate hot water temperature at 12:15 p.m. During a concurrent observation and interview on 6/05/23, at 12:55 p.m., with Environmental Services Supervisor (EVS) 1, in Bathroom A, EVS 1 put his hand under the running hot water and stated it got too hot too fast. EVS 1 called for a thermometer to test the water temperature. During a concurrent observation and interview on 6/05/23, at 1:02 p.m., with EVS 1 and FS1 in Bathroom A, FS1 tested the hot water temperature. FS1 stated, the hot water temperature was 151.5°F. FS1 then went to the room next door and tested the hot water temperature of Resident 58's bathroom (Bathroom B) faucet. FS1 stated Bathroom B's hot water temperature was 150.1°F. FS1 stated hot water temperature should be maintained at and no more than 120°F in facility residents' rooms. FS1 also stated the boilers were old and needed to be replaced. FS1 stated the hot water temperature would be the same in 31 of 31 bathrooms in resident rooms because the same water line fed all rooms assigned to 56 residents residing at the facility. During a concurrent observation and interview on 6/05/23, at 1:12 p.m., with Certified Nurse Assistant (CNA) 5, in the shower room, CNA 5 put her hand under the hot water and stated, the hot water felt very hot. CNA 5 stated, staff had to mix hot and cold water in the shower to ensure the water temperature was okay before she gave showers to residents. During a concurrent observation and interview on 6/05/23, at 2:00 p.m., with facility's vendor technician for environmental services, Service Technician (ST) 1, facility's water boilers were observed. ST1 stated, the temperature for the water heater that supplied water to resident rooms and shower room was 150°F while water heater thermostat was set to 160°F at that time. ST1 stated, he turned the thermostat down to 140°F and that should decrease water temperature of 1-2°F every hour. ST1 also stated he was at the facility also on 6/03/23 and 6/04/23 to make repairs because facility did not have supply for hot water. During a concurrent observation and interview on 6/05/23, at 2:10 p.m., with ST1, in Resident 41's bathroom faucet (Bathroom C), and resident Shower room, ST1 tested the hot water temperature. ST1 stated the hot water temperature was 134.2°F in Bathroom C and 141°F in resident shower room. During an interview on 6/05/23, at 2:10 p.m., Resident 53 stated there was no hot water on 6/3/23 and had to take a cold shower on 6/04/23. Resident 53 stated on 6/5/23, the water had been so hot that had to pull his hand out of the water stream quickly. Resident 53 stated he was not able to use hot water to wash his hands that day. During a concurrent observation and interview on 6/05/23, at 3:00 p.m., with EVS 1, in the basement boiler room, the water heater temperature was 159°F at that time. During a concurrent interview and record review, on 6/05/23, at 5:10 p.m., with ADM, Resident Census and Condition of Residents dated 6/05/23, and facility's untitled document with list of residents who were to ambulate with/without assistive devices were reviewed. ADM stated facility had a total of 26 residents who had access to sinks because they moved independently or with assistive devices. The ADM stated Residents 47 and 53 ambulated independently without assistive devices; Residents 3, 36, 38, 50, and 365 ambulated with assistive devices; and Residents 1, 2, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 37, 42, 43, 52, 58, 313 were able to self-propel in a wheelchair. During an interview on 6/09/23, at 9:40 a.m., the ADM stated she expected all outside vendors were escorted by facility's designated staff and vendors should not work without direct observation in the facility. The ADM stated she was unaware of water temperature issues for 6/3/23 till 6/5/23 until Surveyor 1 brought it to facility's attention. During a concurrent interview and record review on 6/09/23, at 10:04 a.m., with FS1, Logbook Report, dated 6/05/23 was reviewed. FS1 stated, facility had two hallways designated to resident rooms, and he completed the water temperature checks on a weekly basis. FS1 stated weekly water temperature checks were due on 6/3/23; however, he did not complete it until 6/5/23. The Report showed FS1 documented the hot water temperature was 150°F for resident rooms and 145°F for the shower room on 6/05/23. FS1 stated, he checked the resident rooms only at the end of both halls. FS1 stated, on 6/3/23, one of his coworkers, Maintenance Technician (MT) 1 told him that the water boiler was leaking and at noon he called the vendor company that they used for maintenance of facility's environmental services and left a voice message. FS1 stated, he did not tell anyone, including facility's administration, that he turned the boiler off and/or to check water temperatures to ensure safe water temperature for residents at the facility. During a concurrent observation and interview on 6/09/23, at 10:45 a.m., with FS1, in the boiler room, two large boiler units were positioned near center of one wall. FS1 pointed to a blue box on each unit and stated they must be the thermostat for the boilers. During a concurrent observation and interview on 6/09/23, at 10:52 a.m., with Executive Director (ED) and FS1, in the boiler room, ED stated the boilers constantly alternated to prevent wear on a single boiler so neither boiler is designated as back up. ED then pointed to the thermostat on the water heater opposite the boilers and stated the thermostat was replaced after the water temperature issue was identified on 6/5/23. During a review of Centers for Medicare and Medicaid Services State Operations Manual (SOM) - Appendix PP, revised 2/03/23, the SOM indicated many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding (a burn resulting from heated fluids). SOM Table 1 indicated safe bathing temperature was 100°F. The SOM also indicated two (2) seconds was the time required for a third degree burn at 148°F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify, monitor, and intervene for weight loss of seven (7) pounds (lbs.), 5.6% in one month, for one of two sampled resident (Resident 8) for more than one month. This failure resulted in Resident 8 to not receive an assessment and intervention to prevent further weight loss for one month and Resident 8 lost 1.8 more lbs. during that period. Resident 8 had a severe weight loss of 13.4 lbs. with a percentage of 10.31% within a period of three (3) months. Resident 8 was at risk for continued weight loss, weakness, malnutrition (not getting proper/enough nutrients for the body) such as protein calorie malnutrition, and decline in functional status. Findings: During a review of Resident 8's Profile face sheet, Resident 8 was recently readmitted on [DATE] with diagnosis of Epilepsy (seizures), Dysphagia (difficulty or discomfort in swallowing food or liquids), and Major Depressive Disorder (characterized by persistent feelings of sadness, hopelessness and worthlessness). During a review of Resident 8's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/14/23 indicated Resident 8's Brief Interview for Mental Status (BIMS- a mental status exam) was three (3) out of 15, indicating severely impaired mental status. The MDS assessment also indicated Resident 8 required one staff's extensive assist with eating. During observation on 6/6/23, at 12:51 p.m., with Certified Nursing Assistant (CNA) 2, in Resident 8's room, CNA 2 was feeding Resident 8 at her bedside. During an interview on 6/6/23, at 1:45 p.m., CNA 2 stated Resident 8 consumed 50% of her lunch. CNA 2 also stated Resident 8 ate 25% of breakfast that morning. During a concurrent interview and record review on 6/7/23, at 3:09 p.m., with Registered Dietician (RD) 1, Resident 8's electronic medical record for Resident Vital Stats was reviewed. The record showed Resident 8's weight on 4/3/23 and 5/7/23 was 125.4 lbs. and 118.4 lbs. respectively. RD 1 stated, Resident 8 lost a total of eight (8) lbs./5.6% in one month, which was a significant weight loss. RD 1 stated, she was not aware of Resident 8's significant weight loss as she only utilized a Weight Binder to track residents' weights. During a concurrent interview and record review on 6/7/23, at 3:15 p.m. with RD 1, at the nursing station, a Weight Binder with a document labeled Monthly Weight Grid-June 2022 through May 2023 was reviewed. The document indicated Resident 8's weight was not entered for the month of 5/2023 and 6/2023. RD 1 stated, Resident 8 could have been on weekly weight monitoring and a fortified diet (more nutrients added to the diet) with additional 600 calories to ensure no more further weight loss specially because Resident 8 had a history of weight fluctuations; however it was not done since 5/7/23. RD 1 also stated Resident 8's physician and the responsible party should have been made aware of Resident 8's significant loss. During a concurrent interview and record review on 6/7/23, at 3:20 p.m., Resident 8's Quarterly Nutritional Assessment dated 5/22/23 was reviewed. The assessment indicated Noted weight loss this month, recommended to reweigh, Goal to maintain 118 pounds. RD 1 stated however she did not recall if she asked Restorative Nursing Aide (RNA- staff responsible to weigh residents) to reweigh Resident 8 on or after 5/22/23. During a concurrent a record review on 6/8/23, at 10:15 a.m., with RD 1, Resident 8's electronic health record for weights was reviewed. The record indicated Resident 8 weighed 116 lbs. on 6/7/23, indicating Resident 8 lost 1.8 lbs. since 5/7/23. During an interview 6/08/23, at 2:03 p.m., RD 1 stated, Resident 8 was expected to stay in weight range of 120-130 lbs., it was alarming if it went down below 120 as she was not on a physician prescribed weight loss regimen. During a concurrent interview and record review on 6/8/23, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 8's electronic medical record including progress notes, weights, weekly summary from 5/1/2023 till 6/8/2023 reviewed. LVN 2 stated Resident 8 was more sleepy last week, and is eating more in her room as compared to before. LVN 2 stated, she notified Resident 8's physician about her increased sleepiness and decreased meal intake couple days ago but was unable to find any documentation regarding her communication and interventions. Resident 8's Licensed Nurse Weekly Summary dated 5/3/23 under Nutrition, showed stable weight, increasing weight and decreased weight on 5/10/23, 5/18/23, and 5/24/23 respectively while Resident 8 was being weighed only on a monthly basis. During an interview on 6/9/23, at 10:44 a.m., with Director of Nursing (DON), DON stated unaddressed weight loss for Resident 8 placed her at risk for continued weight loss, weakness, malnutrition (not getting proper/enough nutrients for the body) such as protein calorie malnutrition, and decline in functional status. During a concurrent interview and record review on 6/9/23, at 11:15 a.m., with RD 1, the facility's Policy and Procedure(P&P) titled Fortification of Food: Increasing Calories and/or Protein in the Diet, dated 2018, was reviewed. The P&P indicated, The enrichment of foods will be done on an individual basis for the residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. RD 1 stated facility used ½ a ladle scoop of margarine in two food items to meet the extra 600 calories per day for fortification of resident's meals. RD 1 stated each ½ ladle of margarine provided extra 300 calories. During a review of the facility's Policy and Procedures (P&P) titled, RDs For Health Care, INC. Weight Change Protocol dated 2018, the P&P indicated, Early identification of weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner. Residents will be weighed on a monthly basis and weekly for those newly admitted and those deemed to be at high risk for weight changes according to the facility's policies. Variances are calculated from monthly and weekly weights that are obtained by the facility staff. Residents who experience significant changes in weight or insidious weight loss will be assessed by RD. The following criteria define significant or insidious weight changes: Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights, pounds weight loss or gain in 1 week or as facility policy states, pounds weight loss or gain in 1 month, 5.0% weight loss or gain in 1 month, 7.5% weight loss or gain in 3 months, 10% weight loss or gain in 6 months. During a review of facility's Policy and Procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated 2017, the P&P showed, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with weight loss or gain, anorexia and significant risk for impaired nutrition. The staff will report to the physician significant weight losses or gains or any abrupt or persistent change from baseline appetite or food intake.