**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, physician interview, and facility policy review, the facility failed to protect residents right to be free from neglect, to ensure one Resident (#1) out of 17 residents who required one-person assistance with self-feeding, was provided care and assistance to prevent a burn injury during meal service time. The facility neglected to provide care and service during a meal to a vulnerable resident who had known physical limitations, tremors, and visual impairments. Resident #1 suffered second-degree burns resulting in pain and injury to her subcutaneous chest tissue, and permanent body disfigurement related to scarring as a result of the facility's neglect to ensure safety during meal service. These actions resulted in findings of Immediate Jeopardy on 09/18/23. The findings of Immediate Jeopardy were determined to be removed on 10/11/23 and the Scope and Severity was reduced to a D after verification of removal of Immediate Jeopardy. Findings included: On 10/10/23 at 3:09 p.m., an interview was conducted with Staff A, CNA, who reheated the coffee. She said she was not assigned to the resident, but the resident was in her hall the day before and her breakfast tray was on her cart. She said she delivered the resident her tray between 7:30 a.m. and 7:45 a.m. She stated she set the tray down and asked the resident if she needed help with set up and the resident said she was good. Staff A stated she was new to this job and had only worked 3 weeks. She stated she did not know the resident well. Staff A said, The resident said she wanted coffee. I went to get it. I gave her the coffee and she said, 'it was ice cold.' Staff A said when she was pouring the coffee she couldn't tell if it was warm or lukewarm. Staff A said she took the coffee to the microwave and heated it up for all of 30 seconds. She said by the time she got back to the resident's room the resident had spilled her milk in her tray. She said the resident told her she knocked it over. She said she got napkins and tried to clean up some of the spilled milk. Then she gave the resident her coffee and the resident said, Thank you. Staff A said, Then I left the room and went back to my hall. At 1:00 p.m. the CNA assigned to the resident [Staff B] came and told me the resident spilled her coffee and had suffered a burn. Staff A stated the supervisor came and told her what happened and asked for a statement. She said after the statement she went back to the hall and was called to HR [Human Resources] and had been on suspension ever since. Staff A stated she did not have the resident's Kardex [a documentation system that gives a brief overview of patient's care]. Staff A stated when she arrived on shift, she did not receive a report on her resident's status. She stated the expectation was for the CNAs to look up residents on the computer. She stated she did not know anything about this resident because Resident #1 was new. She stated she had not reviewed this resident's care plan and did not know the level of assistance she required. Staff A stated she was not aware the resident had vision issues and she did not notice if the resident's hands were shaky. Staff A stated she did not receive full orientation. Staff A confirmed she had not received any training about not heating up resident drinks or foods. On 10/10/23 at 12.42 p.m., an interview was conducted with Staff B, CNA. She stated she was assigned to Resident #1 the day she was burned. She stated she worked with the resident often. Staff B said, It was morning. I saw her between 7:30 a.m. and 8:00 a.m., probably closer to 8 a.m. I received report from [Staff A] who was helping pass trays in my assigned area because I was late. When I went to see [Resident #1], she said she had spilled coffee on herself. I observed coffee stains and wetness on her gown. This was in her mid-chest area. She said it was burning and it hurt. I went and got the nurse immediately. The nurse [Staff C, LPN] came and saw her. I then got linens and cleaned her up. Staff B said, She is dark, but you could see she had been burned between her breasts. I observed some blisters. She was talking. She was like, 'sit me up.' The rest of the day she slept a lot. She watched a TV show. I took care of her. Her behavior was normal, but her skin had blisters on her chest. Staff B said the resident said to her, 'Girl, you see what she did to me, she gave me blisters with that hot coffee.' Staff B stated the facility gave them education not to reheat anything after the incident occurred. She stated reheating food/drinks was the kitchen's job. She stated CNAs did not test temperatures. On 10/10/23 at 2:33 p.m., an interview was conducted with Staff C, LPN, assigned to Resident #1 the day she suffered coffee burns. Staff C stated she was notified by a CNA (Staff B) at approximately 8:00 a.m. that Resident #1 had spilled coffee on herself. She said Staff B had reported the resident burned herself. Staff C said, I went to look at it [the burn wound], it was red and then it bubbled up later . It was in the middle of her chest area and scattered to her lower chest areas. I asked her if she had pain. She said 'Yes.' The ARNP, who was already in the building, came to see her. I was not aware the coffee was warmed up. The ARNP reported her skin had bubbled up. She saw her within 20 minutes of being notified. The ARNP ordered Silvadene. I got some out of the cart and applied it on her chest. The MD/PCP came maybe another 20 minutes later. He said to continue Silvadene and apply clean dry gauze. I gave the resident Tylenol and notified the Unit Manager [UM] and the resident's family member. Staff C stated she found out the CNA had heated the coffee. Staff C said, She should not have. Staff C stated there was no education prior to the incident at this facility. She stated the expectation was to take the drink to the kitchen or acquire fresh coffee. Staff C stated Resident #1 needed assistance with meals. She stated, She had the shakes, kind of like someone with Parkinson's or dementia tremors. Whenever I gave her meds and gave her water cup, I would hand it to her to her right hand and hold on to it, so she would not spill it. Staff C stated staff would set up the resident's tray and let her know where everything was. She was a total care. She was weak, and she had vision issues. A review of a Resident Information Record dated 10/10/23 showed Resident #1 was admitted to the facility on [DATE] and was discharged to [local hospital] on 09/26/23. The resident was admitted with diagnoses to include unspecified pulmonary hypertension, persistent atrial fibrillation, fluid overload, non-pressure chronic ulcer of right ankle, breakdown of skin, muscle weakness, dependence on supplemental oxygen, and acute kidney failure. A review of a 5-day MDS (Minimum Data Set), dated 09/16/23, section G showed Resident #1 required supervision and one-person physical assist during eating. A review of a care plan dated 09/14/23, showed an ADL (Activities of Daily Living) focus showing Resident #1 had a self-care deficit related to muscle weakness. An intervention among others showed for eating the resident required mod (moderate) assistance of one staff member. A review of a document titled Visual/Bedside Kardex Report, initiated on 09/13/23, showed Resident #1 required moderate assistance by one staff to eat. On 10/10/23 at 1.24 p.m., a telephone interview was conducted with Resident #1's family member. She stated they had not received an official report from the facility on what happened to the resident on the day she was burned with coffee. The family member said, I don't know the details. She was weak, she went there for rehab and was given hot coffee, that in itself is poor judgement. I have been wondering how and why it happened. They called me four hours after the incident happened. [Resident #1] could not call me. Another family member went into the facility and saw her visually. She was in pain. She had blisters on her chest, and she was not able to talk on the phone. As a family, we have been frustrated. It was unacceptable how everything was handled. You do not treat a person her age that way. They gave her hot coffee that scalded her chest area. The family member confirmed Resident #1 suffered significant burns which caused her pain and complicated her recovery. A review of a social services progress note dated 09/18/23, showed SSD (Social Services Director) was notified that resident received a burn after spilling coffee on herself that was warmed by a staff member. Investigation initiated. SSD met with resident who was in her bed. She noted that the coffee was sitting on the left side of her bedside table, and she reached over with her right hand when she dropped the cup across her. She indicated that the liquid burned her, but she knew the cup was hot when she picked it up. She noted that she turned on the light and was addressed immediately by staff. When asked if she had any prior incidents of dropping items, she stated 'no'. Resident presented anxious and fidgety, but she expresses that she has pain on both the burn area and a headache. Nurse made aware. Resident reported visual impairments with better vison in left side. She has prior history of cataract removal, but vision continues to worsen (per her report). Resident seen by facility MD [Medical Director] and wound care [physician] per nursing report. Investigation reported to [State Abuse Agency] via online reporting system and call placed to [name of city] PD [Police Department]. We will continue to follow up with resident and offer supports as needed. A review of a nursing incident note signed by Staff B, Licensed Practical Nurse (LPN), dated 09/18/23 showed, Writer was notified by assigned CNA [Certified Nursing Assistant] that patient had spilled coffee on her chest. Writer assessed area and noted a fluid filled blister on midline area of chest. Writer asked patient what happened, and resident stated that her coffee was too cold, and she had asked CNA if they could warm up her coffee and make it hot. Writer assessed area and obtained vitals. ARNP [Advanced Registered Nurse Practitioner] was present in-house and ordered for patient to receive Silver Sulfadiazine Cream 1% apply to chest, topically every shift to blister for seven days writer administered first treatment as ordered. MD was present in house and assessed area and included to add ABD [abdominal] pad onto chest area without any tape. POA [Power of Attorney] was notified of incident. A review of a skin wound note dated 09/18/23 showed, MD was present in facility and assessed patient midline chest area with fluid filled blisters, MD ordered for patient to have silver sulfadiazine cream 1%. Apply to chest topically every shift for blister for 7 days. Patient stated pain 6/10 PRN [as needed] acetaminophen was given as ordered. A review of a document titled Skin Observation tool - Licensed Nurse, dated 09/18/23, showed Resident #1 had a chest blister. The notes indicated midline chest area with fluid filled blister. Review of a document titled Skin Observation tool - Licensed Nurse, dated 09/23/23, showed Resident #1 had a ruptured chest blister burn, Stage II, indicating Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. An interview was conducted on 10/11/23 at 9:32 a.m., with the Advanced Registered Nurse Practitioner (ARNP). She stated she saw the resident first. She said, I went in to see the patient that morning and she informed me she burned herself with the coffee. She said she spilled it on herself. She was on the list to be seen that day. The ARNP said staff did not come to find her or notify her when she got burned. She stated the resident was the one who told her she got burned when she entered her room. The ARNP stated Resident #1's chest area was red and looked like it was just starting to blister. She stated the resident said it was sensitive to touch. The ARNP ordered Silvadene. She stated she had not noticed any shakiness when she would see the resident, but she had weakness. She stated she could not recall what time she saw the resident and she doesn't know what time the incident had happened. An interview was conducted with the Medical Director/Primary Care Physician (MD/PCP) on 10/10/23 at 12:01 p.m. He confirmed he saw Resident #1 the day she was burned sometime around noon. The MD/PCP said. She was bed-bound and was in the hospital prior to admission to the facility. She was alert and oriented. She had debilitating chronic medical problems. She was always in bed. Her lower extremities were weak. She was burned with hot coffee and suffered second degree burns in her mid-chest area. The coffee had hit her chest, and some ran into her breasts area. It was not a large spill; it left a small line running to her left breast which remained closed. The coffee rolled approximately 8 inches from the mid-chest area. She suffered mild discomfort. She was apologizing, saying she made a mistake. The MD/PCP stated the problem was the staff person who put the coffee in the microwave. He stated no one should have reheated the coffee. The MD/PCP confirmed Resident #1 was treated due to multiple blisters. He said, There was no significant skin loss. Just blistered partial skin burn, to a second-degree burn. The burn was 1% of her body. The resident will definitely have some discoloration and hyper pigmentation. The bottom line is, they should not have reheated the coffee. The MD/PCP stated they had not discussed that incident since the day it happened. A review of a physician progress note, signed by Resident #1's PCP (also the Medical Director), dated 09/19/23 at 10:04 a.m. showed, Patient is an [AGE] year-old female seen today in [name of facility] SNF [Skilled Nursing Facility] for evaluation, treatment and management chest wall burn and other related chronic conditions. Patient reports wasting coffee on her chest this morning and reports soreness to chest. No open areas noted at this time. Patient states it was a mistake that she spilled it as she was trying to take a sip . patient reports mild pain to superficial chest burn. The assessment revealed the resident was seen for superficial partial thickness burn of chest wall disorder. Burn of second degree of chest wall, initial encounter. On 10/11/23 at 10:11 a.m., a telephone interview was conducted with the ADON (Assistant Director of Nursing)/acting DON (Director of Nursing) at the time of the incident. During the interview, the ADON stated she was no longer employed at the facility. The former ADON stated she was notified of the incident by the nurse (Staff C) sometime around noon. She stated staff had not mentioned it prior to that point. She said, Honestly, yes I would have expected to have been notified sooner. She stated she went down to see the resident. She said, You could see there was a burn. The ARNP and the MD had already seen the resident. She stated she had started an investigation and figured it happened around breakfast time, but she did not know the exact time. She stated breakfast was typically between 7:30 a.m. and 8:00 a.m. She thought the burn occurred at approximately 8:30 a.m. She stated the nurse conducted a pain assessment. She stated the resident was burned because [Staff A] heated up the coffee and served it to the resident. The former ADON said, I know she was on OT [Occupational Therapy] to help with tremors, weakness, and being able to feed herself. She did not require assistance for meals, the only thing needed was for set up. She confirmed prior to the incident she had not instructed staff not to reheat foods/drinks for residents. She stated after the incident staff were instructed to go to the kitchen if food/drinks needed to be reheated. The former ADON confirmed that not reheating food had not been part of any orientation or training prior to the incident with [Resident #1]. Review of progress note, communication with family dated 09/25/23, revealed, .Resident [#1] has tremors and was unable to feed herself. Resident baseline continues to be assist for meals and family member was informed by therapy director resident continues on case load for occupational therapy and the therapist is working with resident on self-feeing due to left side weakness. On 10/10/23 at 11:50 a.m., an interview was conducted with Staff D, Speech Therapist (ST). She stated she was not present when the resident was burned. She stated the resident was on her case load and saw her 5 times a week. She stated the resident reported having spilled coffee on herself as she ate breakfast from her bed. Staff D said, I was asked to write a statement to establish her history of requesting to have her coffee reheated. A week prior, she had asked me to reheat her coffee. I was with her in her room for swallowing therapy during breakfast. I got her a fresh cup. I did not reheat it. Staff D stated she did not raise alarm related to Resident #1 requesting to have a coffee reheated. She stated she did not think much of it and did not mention it until after the burn incident. A review of a document titled, Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 09/14/23, showed under cognition and communication assessment Resident #1 was impaired and lacked safety awareness. The assessment summary showed, Patient presents with impairments in balance, strength and mobility resulting in limitations and/or participation restrictions in the areas of self-care which requires skilled OT services . to facilitate independence with ADLs, facilitate sitting tolerance and postural control and increase functional activity tolerance in order to perform UB ADLs [Upper Body Activities of Daily Living] with increased independence and safety . Due to the documented physical impairments associated functional deficits, without skilled therapeutic intervention, the patient is at risk for falls and further decline in function. A review of a document titled Speech Therapy (SLP) Evaluation and Plan of Treatment, dated 09/14/23, showed Resident #1 received a bedside assessment of swallowing. Evaluation of position during eval revealed posture impacts function and is modifiable with intervention. Under supervision, the evaluation showed the patient [Resident #1] required supervision/assistance during mealtime due to swallowing/safety 50-75% of the time. The review showed identified barriers included identification of support systems were required for safe transition and multiple medication management. Patient characteristics that may impact treatment included, lacks insight into condition and risk factors, multiple conditions/history, multiple medications, and reduced numeracy skills for self-monitoring. A review of a progress note dated 09/21/23 showed, [Resident #1] ate 25% of breakfast, she did not want pancakes or sausage, only oatmeal with brown sugar. Patient ate 50% of lunch and is currently eating dinner. Dressing changes were done to chest burn, silver sulfadiazine applied, and bilateral lower leg wounds, xeroform and kerlix applied. Bilateral legs rubbed down with ammonium lactate and dry skin lotion provided by patient. Patient requested something stronger for pain than Tylenol. Request given to ARNP for refill of Tramadol. Patient informed that request was sent out. A review of a health status note dated 09/20/23 showed (late entry for 09/19/23 7:00 p.m. - 7:00 a.m. shift), Resident was given HS [Hours of Sleep] medication and took them without problems. Medicated with Tramadol for c/o [because of] pain. Blister on chest remains intact and Silvadene applied, and blister covered with ABD [abdominal] pad. A review of a Health Status Note dated 09/25/23, showed, Resident served lunch tray at this time. Pulled up in bed with CNA. Resident stated she was hurting. PRN [as needed] Tramadol administered. A review of a document titled, Mini nutritional Assessment, signed by the Registered Dietician (RD), dated 09/14/23, showed Resident #1's physical and mental functioning indicated she required assistance . due to motor agitation and tremors. The assessment further showed she required limited feeding assistance and required supervision during eating. On 10/10/23 at 12:27 p.m., an interview was conducted with the Certified Registered Dietician (CDM). She stated when coffee was brewed in the kitchen, the temperature would normally be 205 degrees Fahrenheit. She said, We brew the coffee before we start tray line and put it in the carafes [a small thermos]. It should be served at 150-160 degrees. The CDM stated they do not retest the coffee prior to service. The CDM stated this facility did not have policies and procedures related to hot liquids. She said, I learned the temperature parameters in a different building. The CDM confirmed she had not initiated temperature monitoring for hot liquids. She stated her expectation would be to take the temperatures before the coffee is taken out to the residents. It should be checked before you put it on the cart. The CDM stated she did not have records or temperature logs. She stated she did not have temperature parameters posted for staff to reference. She said, I don't have anything posted for the staff. I ran across an old log dated 2022. I will re-implement the temperature log. The CDM stated she had just looked up on the internet what the temperature range should be; she said, I just googled it. The temperature should be between 150 and 155 degrees. We will start monitoring effective today. On 10/10/23 at 9:48 a.m., an interview was conducted with Staff E, Cook. She stated she monitored food temperatures during tray line but not coffee temperatures. She stated the dietary aides were responsible for brewing and serving coffee. Staff E showed the dietary food logs. The logs did not include coffee temperature monitoring. Staff E stated she heard a resident was burned with hot coffee because a CNA reheated coffee in the microwave. She said, It was reheated on the floor. Not in the dining room or kitchen. Dietary did not have anything to do with it. Staff E confirmed the facility did not implement processes to prevent coffee burns following Resident #1's incident. She stated they were not checking coffee temperatures. On 10/10/23 at 9:54 a.m., an interview was conducted with Staff F, Dietary Aide. She stated the aides brewed the coffee. It was their assignment. She stated they used a coffee urn which had a water line already set. She stated the brewing temperature was preset. She stated they poured the coffee grounds and hit Start. She said, When the coffee is done brewing, it gets into a heating stage which takes about 3 minutes. The coffee then reaches a final temperature of 205 degrees F. We wait until the trays are ready to get the coffee out to the floor or to the dining room, which takes about 30 minutes. We then put it in the carafe. It is supposed to hold coffee hot for about 6 hours. She stated she could not speak of the incident when the resident was burned. She stated she heard a CNA reheated the coffee in a microwave and that was how the resident sustained burns. She stated nursing staff had microwaves in the nutrition rooms. At that time, Staff F brewed coffee and tested it. At the end of the brewing, the coffee in the urn tested 205 degrees F. Staff F waited 30 minutes and retested the coffee that was in the carafe ready to be served. It tested 175 degrees. Staff F did not know what a safe temperature range would be. Staff F confirmed they had not received education related to monitoring coffee temperatures, or reheating coffee. A telephone interview was conducted with the Registered Dietician (RD) on 10/11/23 at 10:33 a.m. She stated she heard a resident was burned with coffee. She stated she was not involved in the process of investigation or educating the staff. She stated her role was the clinical side. The RD stated the kitchen should make sure food is served at acceptable temperatures, which would be above 135 degrees and below 141 degrees. She stated she followed facility policies. The RD stated she could not answer if a reading of 178 degrees was too hot or not. She said, There is no regulation related to coffee temperatures when it is in the kitchen, but when it is in the unit being served, it should be between 130-150 degrees. The RD stated she did not know if the facility was monitoring hot liquid temperatures or not. She said, It is not a regulation to take coffee temperatures. The regulation requires food to be palatable and safe. The staff should serve food to the resident's palate and follow facility policies on safety if they had one. A review of the physician orders summary report dated 10/10/23, showed Resident #1 required Renal (Dialysis) diet, mechanical soft texture, thin consistency. The orders showed on 09/18/23 a telephone order was initiated, Silver Sulfadiazine cream 1%, apply to chest topically every shift for blisters for 7 days. Other orders included: -Acetaminophen 325mg 2 tab by mouth every 4 hours as needed for General discomfort not to exceed greater than 3000mg in 24 hours. -Tramadol HCL 50mg. Give 1 tab by mouth every 12 hours as needed for moderate pain. -Send to (Local hospital) via non-emergency transport with (name of) transport company per family request. 9/25/23 Review of Resident #1's Medication Administration Record (MAR), dated 09/01/23 to 09/31/23, revealed Resident #1 received new medications related to burn wounds. The resident received Silver Sulfadiazine cream 1%, apply topically every shift for blister for 7 days. The ointment was documented applied from 09/18/23 to 09/25/23 the day the resident was sent out to the hospital. The MAR review further showed Resident #1 continued to receive pain medications following the burn accident as follows: -9/18/23 at 3:39 p.m. Pain level 7. Given Acetaminophen 325mg (milligram) x 2 tablets. Effective -9/18/23 at 10:02 p.m. Pain level 4. Given Tramadol HCL (hydrochloride) 50mg x 1 tablets. Effective -9/19/23 at 9:30 p.m. Pain level 3. Given Acetaminophen 325mg x 2 tablets. Unknown effectiveness. -9/20/23 at 7:26 p.m. Given Acetaminophen 325mg x 2 tablets. Signed off under order for Fever. No pain level given. -9/21/23 5:12 a.m. Pain level 4. Given Acetaminophen 325 mg x 2 tablets. Effective. -9/21/23 1:59 p.m. Pain level 8. Given Acetaminophen 325 mg x 2 tablets. Effective. -9/22/23 No pain meds given. -9/24/23 2:30 a.m. Pain level 6. Given Acetaminophen 325 mg x 2 tablets. Effective. -9/24/23 12:50 p.m. Pain level 8. Given Tramadol 50 mg x 1 tablet. Effective. -9/25/23 12:31 p.m. Pain level 4. Given Tramadol 50 mg x 1 tablet. Effective. A review of a document titled, Wound Evaluation & Management Summary, dated 09/18/23, showed on wound site #5, Burn Wound chest, Wound size: 7.5 cm (centimeters) length, 4.2 cm width, depth not measurable. Surface Area: 31.50 cm2 , Exudate, None. Blister, fluid filled. Expanded evaluation performed, The development of this wound and the context surrounding the development were considered in greater depth today. Counseling offered to optimize wound healing and relevant conditions were addressed through management changes or investigations regarding conditions including Peripheral Artery Disease, Anemia, Congestive Heart Failure, impaired nutritional status discussed with patient, family, and nursing staff and/or dietician. Recommend consult/reconsult with dietitian to review current nutritional status. A review of a document titled, Wound Evaluation & Management Summary, dated 09/25/23, showed on wound site #5, Burn Wound chest full thickness, Wound size: 8 cm (centimeters) length, 13.6 cm width, 0.1 cm depth. Surface Area: 108.80 cm2, Cluster Wound: open ulceration area of 92.48 cm2, Exudate light serous, Granulation tissue: 85%, Skin 15%, Wound progress: Not at goal, Additional Wound Detail: Open Blister, Primary dressing: silver sulfadiazine apply once daily and as needed for 20 days. Xeroform gauze, apply once daily and as needed for 20 days. Site 5, procedure: this wound has previously undergone autolytic debridement. Factors complicating wound healing, anemia unspecified. During a facility tour 10/10/23 at 11:53 a.m., an observation was made of CNAs starting to pass lunch trays. The CDM was asked to verify the temperature of the coffee which was being served. The coffee temperature was 178 degrees Fahrenheit. The CDM stated she thought coffee temperature should be between 150-155 F and when the coffee was recorded to be 178 F, the CDM said, Is that too hot? She then said, I don't want anyone to get burned. She took the pot back to the kitchen. She stated they try to pour the coffee up a little in advance, so it can cool down before coming out to the residents for service. She said that carafe must have just come out. She stated she would be monitoring that. On 10/10/23 at 12:01 p.m., a family member was observed in the same hall pouring a cup of coffee from a black carafe placed on top of the cart. The family member stated she did not know the temperature of the coffee and if it was safe to serve. The family member said, It's hot, you just got to sip it. On 10/10/23 at 3:01 p.m., an interview was conducted with the facility's interim DON and the Nursing Home Administrator (NHA). The Interim DON stated she was in the building and heard a resident had gotten burned. She said, I went down to the unit. It was in the afternoon, probably early afternoon. The MD/PCP was in the building. I asked him to look at the burn and address. I asked the wound doctor to look at it. They both ensured treatment was in place. Interim DON stated she observed areas in Resident #1's mid-chest with fluid filled blisters. The interim DON stated the resident said to her, 'I need Silvadene' [and] I told the nurse. The interim DON stated the previous NHA and ADON conducted the investigation. She stated she could review the file. She stated the following: On 9/18/23 at 1p.m. the (previous) NHA was notified, and he did the initial report. The previous ADON initiated the investigation. She talked to the staff who were involved and obtained statements from employees. Review of the statements with the Interim DON and the NHA revealed the following: Staff A, CNA's statement, I gave [Resident #1] her breakfast tray this morning. She said her coffee was cold. I warmed it for 30-45 seconds. I gave it to her and left the room. Staff B, CNA's statement, When I walked into my assignment the CNA [Staff A] said resident requested coffee to be warmed up. She said she heated it and gave it to the resident. I walked into the room and resident said she got burned. I reported it to the nurse [Staff C]. Staff C, LPN's statement, assigned CNA [Staff A] reported resident had wasted coffee on her chest. Writer notified ARNP who was in the building and ordered Silvadene. Writer saw the resident. She had a 10 x 4 burn area on her chest, skin was intact just blistered. Applied Silvadene. (Family member) was made aware of situation. The interim DON stated they immediately provided education for [Staff A] regarding, Food should be reheated by kitchen staff. Floor staff should not reheat any food/drink. She stated they followed the same education for all other staff and educated the entire facility. The interim ADON stated they reported to the State Abuse Agency on 9/18/23 at 3:20 p.m. and the report was not accepted. They contacted law enforcement on 9[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, physician interview, and facility policy review, the facility failed to ensure one Resident (#1), out of 17 residents who required one-person assistance with self-feeding, were free from hazards during meal service. The facility's failure to ensure this resident's safety during meal service, and failure to monitor hot beverages to prevent burns, and failure to educate staff on safe food re-heating practices, and failure to ensure vulnerable residents were assessed and supervised during meals, resulted in injury to Resident #1. On 09/18/23 Resident #1, who required one-person physical assistance and supervision for eating, was served hot coffee that had been reheated in a microwave and not tested for safe serving temperature. The facility failed to ensure the resident who had a known visual impairment and was known to have tremors and would shake while drinking, received supervision to prevent the hot coffee from spilling. Resident #1 suffered painful blisters and second degree burns to her chest area, causing pain and permanent body disfigurement related to scarring and discoloration of the skin. The facility's failure to monitor coffee temperatures and failure to provide supervision and assistance to a vulnerable resident with physical limitations, and the likelihood of similar harm to other residents, resulted in the determination of Immediate Jeopardy on 9/18/2023 The findings of Immediate Jeopardy were determined to be removed on 10/11/23 and the severity and scope was reduced to a D after verification of removal of Immediate Jeopardy. Findings included: A review of a Resident Information Record dated 10/10/23 showed Resident #1 was admitted to the facility on [DATE] and was discharged on 09/26/23. The resident was admitted with diagnoses to include unspecified pulmonary hypertension, persistent atrial fibrillation, fluid overload, non-pressure chronic ulcer of right ankle, breakdown of skin, muscle weakness, dependence on supplemental oxygen, and acute kidney failure. A review of a 5-day MDS (Minimum Data Set), dated 09/16/23, section G showed Resident #1 required supervision and one-person physical assist during eating. A review of a care plan dated 09/14/23, showed an ADL (Activities of Daily Living) focus showing Resident #1 had a self-care deficit related to muscle weakness. An intervention among others showed for eating the resident required mod (moderate) assistance of one staff member. A review of a document titled Visual/Bedside Kardex Report, initiated on 09/13/23, showed Resident #1 required mod assistance by one staff to eat. On 10/10/23 at 1.24 p.m., a telephone interview was conducted with Resident #1's family member. She stated they had not received an official report from the facility on what happened to the resident on the day she was burned with coffee. The family member said, I don't know the details. She was weak, she went there for rehab and was given hot coffee, that in itself is poor judgement. I have been wondering how and why it happened. They called me four hours after the incident happened. [Resident #1] could not call me. Another family member went into the facility and saw her visually. She was in pain. She had blisters on her chest, and she was not able to talk on the phone. As a family, we have been frustrated. It was unacceptable how everything was handled. You do not treat a person her age that way. They gave her hot coffee that scalded her chest area. The family member confirmed Resident #1 suffered significant burns which caused her pain and complicated her recovery. A review of a social services progress note dated 09/18/23, showed SSD (Social Services Director) was notified that resident received a burn after spilling coffee on herself that was warmed by a staff member. Investigation initiated. SSD met with resident who was in her bed. She noted that the coffee was sitting on the left side of her bedside table, and she reached over with her right hand when she dropped the cup across her. She indicated that the liquid burned her, but she knew the cup was hot when she picked it up. She noted that she turned on the light and was addressed immediately by staff. When asked if she had any prior incidents of dropping items, she stated 'no'. Resident presented anxious and fidgety, but she expresses that she has pain on both the burn area and a headache. Nurse made aware. Resident reported visual impairments with better vison in left side. She has prior history of cataract removal, but vision continues to worsen (per her report). Resident seen by facility MD [Medical Director] and wound care [physician] per nursing report. Investigation reported to [State Abuse Agency] via online reporting system and call placed to [name of city] PD [Police Department]. We will continue to follow up with resident and offer supports as needed. A review of a nursing incident note signed by Staff B, Licensed Practical Nurse (LPN), dated 09/18/23 showed, Writer was notified by assigned CNA [Certified Nursing Assistant] that patient had spilled coffee on her chest. Writer assessed area and noted a fluid filled blister on midline area of chest. Writer asked patient what happened, and resident stated that her coffee was too cold, and she had asked CNA if they could warm up her coffee and make it hot. Writer assessed area and obtained vitals. ARNP [Advanced Registered Nurse Practitioner] was present in-house and ordered for patient to receive Silver Sulfadiazine Cream 1% apply to chest, topically every shift to blister for seven days writer administered first treatment as ordered. MD was present in house and assessed area and included to add ABD [abdominal] pad onto chest area without any tape. POA [Power of Attorney] was notified of incident. A review of a skin wound note dated 09/18/23 showed, MD was present in facility and assessed patient midline chest area with fluid filled blisters, MD ordered for patient to have silver sulfadiazine cream 1%. Apply to chest topically every shift for blister for 7 days. Patient stated pain 6/10 PRN [as needed] acetaminophen was given as ordered. A review of a document titled Skin Observation tool - Licensed Nurse, dated 09/18/23, showed Resident #1 had a chest blister. The notes indicated midline chest area with fluid filled blister. Review of a document titled Skin Observation tool - Licensed Nurse, dated 09/23/23, showed Resident #1 had a ruptured chest blister burn, Stage II, indicating Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. An interview was conducted with the Medical Director/Primary Care Physician (MD/PCP) on 10/10/23 at 12:01 p.m. He confirmed he saw Resident #1 the day she was burned sometime around noon. The MD/PCP said. She was bed-bound and was in the hospital prior to admission to the facility. She was alert and oriented. She had debilitating chronic medical problems. She was always in bed. Her lower extremities were weak. She was burned with hot coffee and suffered second degree burns in her mid-chest area. The coffee had hit her chest, and some ran into her breasts area. It was not a large spill; it left a small line running to her left breast which remained closed. The coffee rolled approximately 8 inches from the mid-chest area. She suffered mild discomfort. She was apologizing, saying she made a mistake. The MD/PCP stated the problem was the staff person who put the coffee in the microwave. He stated no one should have reheated the coffee. The MD/PCP confirmed Resident #1 was treated due to multiple blisters. He said, There was no significant skin loss. Just blistered partial skin burn, to a second-degree burn. The burn was 1% of her body. The resident will definitely have some discoloration and hyper pigmentation. The bottom line is, they should not have reheated the coffee. The MD/PCP stated they had not discussed that incident since the day it happened. An interview was conducted on 10/11/23 at 9:32 a.m., with the Advanced Registered Nurse Practitioner (ARNP). She stated she saw the resident first. She said, I went in to see the patient that morning and she informed me she burned herself with the coffee. She said she spilled it on herself. She was on the list to be seen that day. The ARNP said staff did not come to find her or notify her when she got burned. She stated the resident was the one who told her she got burned when she entered her room. The ARNP stated Resident #1's chest area was red and looked like it was just starting to blister. She stated the resident said it was sensitive to touch. The ARNP ordered Silvadene. She stated she had not noticed any shakiness when she would see the resident, but she had weakness. She stated she could not recall what time she saw the resident and she doesn't know what time the incident had happened. A review of a physician progress note, signed by Resident #1's PCP, dated 09/19/23 at 10:04 a.m. showed, Patient is an [AGE] year-old female seen today in [name of facility] SNF [Skilled Nursing Facility] for evaluation, treatment and management chest wall burn and other related chronic conditions. Patient reports wasting coffee on her chest this morning and reports soreness to chest. No open areas noted at this time. Patient states it was a mistake that she spilled it as she was trying to take a sip . patient reports mild pain to superficial chest burn. The assessment revealed the resident was seen for superficial partial thickness burn of chest wall disorder. Burn of second degree of chest wall, initial encounter. A review of Hospital records including wound photographs showed Resident #1 was admitted to (name of hospital) on 09/25/23 with a diagnosis of Altered Mental Status. Hospital records showed the resident was discharged on 10/08/23. During her stay, Resident #1 was seen for burn wounds. On 10/04/23 a physical exam was conducted. The wound care report showed, abnormal skin type; burn, Color pink, surrounding tissue appearance dry/flaky, Fibrotic/Scarred, wound details showed, partial thickness skin loss surrounded by epithelialized hypopigmentation. Tissue appearance detail: wound bed with partial thickness, margin-distinct, outline attached. The treatment plan included: to wash with cleansing wipes, pat dry, apply thin layer of triad paste, cover with foam dressing daily and PRN (as needed). A wound care report dated 10/5/23 showed the bedside RN (Registered Nurse), requested to evaluate burn to chest. Per patient, she spilled coffee on herself several weeks ago. Area is mostly epithelialized, there is an area of small partial thickness skin loss. Review of an undated American Burn Association Educators Guide Journal titled, Scald Injury Educators, retrieved on 10/11/23, showed, Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Source: https://dds.dc.gov/sites/default/files/dc/sites/dds/publication/attachments/ABA%20Scald%20Injury%20Prevention%20Educator%27s%20Guide.pdf Review of an undated article titled, Burn depth. Nature Reviews Disease Primers, showed burns extending into the underlying skin layer (dermis) are classed as partial thickness or second-degree. These burns frequently form painful blisters. These burns range from superficial partial thickness, which are homogenous, moist, hyperemic and blanch, to deep partial thickness, which are less sensate, drier, may have a reticular pattern and do not blanch. Source: https://www.nature.com/articles/s41572-020-0145-5/figures/1 On 10/10/23 at 3:09 p.m., an interview was conducted with Staff A, CNA, who reheated the coffee. She said she was not assigned to the resident, but the resident was in her hall the day before and her breakfast tray was on her cart. She said she delivered the resident her tray between 7:30 a.m. and 7:45 a.m. She stated she set the tray down and asked the resident if she needed help with set up and the resident said she was good. Staff A stated she was new to this job and had only worked 3 weeks. She stated she did not know the resident well. Staff A said, The resident said she wanted coffee. I went to get it. I gave her the coffee and she said, 'it was ice cold.' Staff A said when she was pouring the coffee she couldn't tell if it was warm or lukewarm. Staff A said she took the coffee to the microwave and heated it up for all of 30 seconds. She said by the time she got back to the resident's room the resident had spilled her milk in her tray. She said the resident told her she knocked it over. She said she got napkins and tried to clean up some of the spilled milk. Then she gave the resident her coffee and the resident said, Thank you. Staff A said, Then I left the room and went back to my hall. At 1:00 p.m. the CNA assigned to the resident [Staff B] came and told me the resident spilled her coffee and had suffered a burn. Staff A stated the supervisor came and told her what happened and asked for a statement. She said after the statement she went back to the hall and was called to HR [Human Resources] and had been on suspension ever since. Staff A stated she did not have the resident's Kardex [a documentation system that gives a brief overview of patient's care]. Staff A stated when she arrived on shift, she did not receive a report on her resident's status. She stated the expectation was for the CNAs to look up residents on the computer. She stated she did not know anything about this resident because Resident #1 was new. She stated she had not reviewed this resident's care plan and did not know the level of assistance she required. Staff A stated she was not aware the resident had vision issues and she did not notice if the resident's hands were shaky. Staff A stated she did not receive full orientation. Staff A confirmed she had not received any training about not heating up resident drinks or foods. On 10/10/23 at 12.42 p.m., an interview was conducted with Staff B, CNA. She stated she was assigned to Resident #1 the day she was burned. She stated she worked with the resident often. Staff B said, It was morning. I saw her between 7:30 a.m. and 8:00 a.m., probably closer to 8 a.m. I received report from [Staff A] who was helping pass trays in my assigned area because I was late. When I went to see [Resident #1], she said she had spilled coffee on herself. I observed coffee stains and wetness on her gown. This was in her mid-chest area. She said it was burning and it hurt. I went and got the nurse immediately. The nurse [Staff C, LPN] came and saw her. I then got linens and cleaned her up. Staff B said, She is dark, but you could see she had been burned between her breasts. I observed some blisters. She was talking. She was like, 'sit me up.' The rest of the day she slept a lot. She watched a TV show. I took care of her. Her behavior was normal, but her skin had blisters on her chest. Staff B said the resident said to her, 'Girl, you see what she did to me, she gave me blisters with that hot coffee.' Staff B stated the facility gave them education not to reheat anything after the incident occurred. She stated reheating food/drinks was the kitchen's job. She stated CNAs did not test temperatures. On 10/10/23 at 2:33 p.m., an interview was conducted with Staff C, LPN, assigned to Resident #1 the day she suffered coffee burns. Staff C stated she was notified by a CNA (Staff B) at approximately 8:00 a.m. that Resident #1 had spilled coffee on herself. She said Staff B had reported the resident burned herself. Staff C said, I went to look at it [the burn wound], it was red and then it bubbled up later . It was in the middle of her chest area and scattered to her lower chest areas. I asked her if she had pain. She said 'Yes.' The ARNP, who was already in the building, came to see her. I was not aware the coffee was warmed up. The ARNP reported her skin had bubbled up. She saw her within 20 minutes of being notified. The ARNP ordered Silvadene. I got some out of the cart and applied it on her chest. The MD/PCP came maybe another 20 minutes later. He said to continue Silvadene and apply clean dry gauze. I gave the resident Tylenol and notified the Unit Manager [UM] and the resident's family member. Staff C stated she found out the CNA had heated the coffee. Staff C said, She should not have. Staff C stated there was no education prior to the incident at this facility. She stated the expectation was to take the drink to the kitchen or acquire fresh coffee. Staff C stated Resident #1 needed assistance with meals. She stated, She had the shakes, kind of like someone with Parkinson's or dementia tremors. Whenever I gave her meds and gave her water cup, I would hand it to her to her right hand and hold on to it, so she would not spill it. Staff C stated staff would set up the resident's tray and let her know where everything was. She was a total care. She was weak, and she had vision issues. On 10/11/23 at 10:11 a.m., a telephone interview was conducted with the ADON (Assistant Director of Nursing)/acting DON (Director of Nursing) at the time of the incident. During the interview, the ADON stated she was no longer employed at the facility. The former ADON stated she was notified of the incident by the nurse (Staff C) sometime around noon. She stated staff had not mentioned it prior to that point. She said, Honestly, yes I would have expected to have been notified sooner. She stated she went down to see the resident. She said, You could see there was a burn. The ARNP and the MD had already seen the resident. She stated she had started an investigation and figured it happened around breakfast time, but she did not know the exact time. She stated breakfast was typically between 7:30 a.m. and 8:00 a.m. She thought the burn occurred at approximately 8:30 a.m. She stated the nurse conducted a pain assessment. She stated the resident was burned because [Staff A] heated up the coffee and served it to the resident. The former ADON said, I know she was on OT [Occupational Therapy] to help with tremors, weakness, and being able to feed herself. She did not require assistance for meals, the only thing needed was for set up. She confirmed prior to the incident she had not instructed staff not to reheat foods/drinks for residents. She stated after the incident staff were instructed to go to the kitchen if food/drinks needed to be reheated. The former ADON confirmed that not reheating food had not been part of any orientation or training prior to the incident with [Resident #1]. Review of progress note, communication with family dated 09/25/23, revealed, .Resident [#1] has tremors and was unable to feed herself. Resident baseline continues to be assist for meals and family member was informed by therapy director resident continues on case load for occupational therapy and the therapist is working with resident on self-feeing due to left side weakness. On 10/10/23 at 11:50 a.m., an interview was conducted with Staff D, Speech Therapist (ST). She stated she was not present when the resident was burned. She stated the resident was on her case load and saw her 5 times a week. She stated the resident reported having spilled coffee on herself as she ate breakfast from her bed. Staff D said, I was asked to write a statement to establish her history of requesting to have her coffee reheated. A week prior, she had asked me to reheat her coffee. I was with her in her room for swallowing therapy during breakfast. I got her a fresh cup. I did not reheat it. Staff D stated she did not raise alarm related to Resident #1 requesting to have a coffee reheated. She stated she did not think much of it and did not mention it until after the burn incident. A review of a document titled, Mini nutritional Assessment, signed by the Registered Dietician (RD), dated 09/14/23, showed Resident #1's physical and mental functioning indicated she required assistance . due to motor agitation and tremors. The assessment further showed she required limited feeding assistance and required supervision during eating. On 10/10/23 at 12:27 p.m., an interview was conducted with the Certified Registered Dietician (CDM). She stated when coffee was brewed in the kitchen, the temperature would normally be 205 degrees Fahrenheit. She said, We brew the coffee before we start tray line and put it in the carafes [a small thermos]. It should be served at 150-160 degrees. The CDM stated they do not retest the coffee prior to service. The CDM stated this facility did not have policies and procedures related to hot liquids. She said, I learned the temperature parameters in a different building. The CDM confirmed she had not initiated temperature monitoring for hot liquids. She stated her expectation would be to take the temperatures before the coffee is taken out to the residents. It should be checked before you put it on the cart. The CDM stated she did not have records or temperature logs. She stated she did not have temperature parameters posted for staff to reference. She said, I don't have anything posted for the staff. I ran across an old log dated 2022. I will re-implement the temperature log. The CDM stated she had just looked up on the internet what the temperature range should be; she said, I just googled it. The temperature should be between 150 and 155 degrees. We will start monitoring effective today. On 10/10/23 at 9:48 a.m., an interview was conducted with Staff E, Cook. She stated she monitored food temperatures during tray line but not coffee temperatures. She stated the dietary aides were responsible for brewing and serving coffee. Staff E showed the dietary food logs. The logs did not include coffee temperature monitoring. Staff E stated she heard a resident was burned with hot coffee because a CNA reheated coffee in the microwave. She said, It was reheated on the floor. Not in the dining room or kitchen. Dietary did not have anything to do with it. Staff E confirmed the facility did not implement processes to prevent coffee burns following Resident #1's incident. She stated they were not checking coffee temperatures. On 10/10/23 at 9:54 a.m., an interview was conducted with Staff F, Dietary Aide. She stated the aides brewed the coffee. It was their assignment. She stated they used a coffee urn which had a water line already set. She stated the brewing temperature was preset. She stated they poured the coffee grounds and hit Start. She said, When the coffee is done brewing, it gets into a heating stage which takes about 3 minutes. The coffee then reaches a final temperature of 205 degrees F. We wait until the trays are ready to get the coffee out to the floor or to the dining room, which takes about 30 minutes. We then put it in the carafe. It is supposed to hold coffee hot for about 6 hours. She stated she could not speak of the incident when the resident was burned. She stated she heard a CNA reheated the coffee in a microwave and that was how the resident sustained burns. She stated nursing staff have microwaves in the nutrition rooms. At that time, Staff F brewed coffee and tested it. At the end of the brewing, the coffee in the urn tested 205 degrees F. Staff F waited 30 minutes and retested the coffee that was in the carafe ready to be served. It tested 175 degrees. Staff F did not know what a safe temperature range would be. Staff F confirmed they had not received education related to monitoring coffee temperatures, or reheating coffee. A telephone interview was conducted with the Registered Dietician (RD) on 10/11/23 at 10:33 a.m. She stated she heard a resident was burned with coffee. She stated she was not involved in the process of investigation or educating the staff. She stated her role was the clinical side. The RD stated the kitchen should make sure food is served at acceptable temperatures, which would be above 135 degrees and below 141 degrees. She stated she followed facility policies. The RD stated she could not answer if a reading of 178 degrees was too hot or not. She said, There is no regulation related to coffee temperatures when it is in the kitchen, but when it is in the unit being served, it should be between 130-150 degrees. The RD stated she did not know if the facility was monitoring hot liquid temperatures or not. She said, It is not a regulation to take coffee temperatures. The regulation requires food to be palatable and safe. The staff should serve food to the resident's palate and follow facility policies on safety if they had one. On 10/10/23 at 2:24 p.m., an interview was conducted with the Social Services Director (SSD). She stated she was new to the facility. She reviewed the grievance log which showed two grievances filed for Resident #1 on 09/18/23 and 09/19/23. The grievance on 09/18/23 was filed by the former ADON. The grievance showed: resident obtained a 2nd degree burn from coffee spilling on her chest area. Coffee was reheated by staff member per her request. Plan to resolve grievance included AHCA (Agency for Health Care Administration) report initiated, and DCF (Department of Children and Families) were completed. The resolution showed the grievance was resolved on 09/18/23 with a notation complainant is certified. The SSD stated she did not know how the grievance could have been resolved the same day. She stated she was not here and had not been part of the investigation. She stated she found voicemails from the Resident's family member on her office phone that were left prior to her starting. She stated she was conducting some follow-up with the family member. The SSD stated she would not have considered the grievance to be resolved as the investigation was still on-going and the resident had suffered significant burns. She stated they were still working on the investigation. A review of a document titled, Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 09/14/23, showed under cognition and communication assessment Resident #1 was impaired and lacked safety awareness. The assessment summary showed, Patient presents with impairments in balance, strength and mobility resulting in limitations and/or participation restrictions in the areas of self-care which requires skilled OT services . to facilitate independence with ADLs, facilitate sitting tolerance and postural control and increase functional activity tolerance in order to perform UB ADLs [Upper Body Activities of Daily Living] with increased independence and safety . Due to the documented physical impairments associated functional deficits, without skilled therapeutic intervention, the patient is at risk for falls and further decline in function. A review of a document titled Speech Therapy (SLP) Evaluation and Plan of Treatment, dated 09/14/23, showed Resident #1 received a bedside assessment of swallowing. Evaluation of position during eval revealed posture impacts function and is modifiable with intervention. Under supervision, the evaluation showed the patient [Resident #1] required supervision/assistance during mealtime due to swallowing/safety 50-75% of the time. The review showed identified barriers included identification of support systems were required for safe transition and multiple medication management. Patient characteristics that may impact treatment included, lacks insight into condition and risk factors, multiple conditions/history, multiple medications, and reduced numeracy skills for self-monitoring. A review of a progress note dated 09/21/23 showed, [Resident #1] ate 25% of breakfast, she did not want pancakes or sausage, only oatmeal with brown sugar. Patient ate 50% of lunch and is currently eating dinner. Dressing changes were done to chest burn, silver sulfadiazine applied, and bilateral lower leg wounds, xeroform and kerlix applied. Bilateral legs rubbed down with ammonium lactate and dry skin lotion provided by patient. Patient requested something stronger for pain than Tylenol. Request given to ARNP for refill of Tramadol. Patient informed that request was sent out. A review of a health status note dated 09/20/23 showed (late entry for 09/19/23 7:00 p.m. - 7:00 a.m. shift), Resident was given HS [Hours of Sleep] medication and took them without problems. Medicated with Tramadol for c/o [because of] pain. Blister on chest remains intact and Silvadene applied, and blister covered with ABD [abdominal] pad. A review of a Health Status Note dated 09/25/23, showed, Resident served lunch tray at this time. Pulled up in bed with CNA. Resident stated she was hurting. PRN [as needed] Tramadol administered. A review of the physician orders summary report dated 10/10/23, showed Resident #1 required Renal (Dialysis) diet, mechanical soft texture, thin consistency. The orders showed on 09/18/23 a telephone order was initiated, Silver Sulfadiazine cream 1%, apply to chest topically every shift for blisters for 7 days. Other orders included: -Acetaminophen 325mg 2 tab by mouth every 4 hours as needed for General discomfort not to exceed greater than 3000mg in 24 hours. -Tramadol HCL 50mg. Give 1 tab by mouth every 12 hours as needed for moderate pain. -Send to (Local hospital) via non-emergency transport with (name of) transport company per family request. 9/25/23 Review of Resident #1's Medication Administration Record (MAR), dated 09/01/23 to 09/31/23, revealed Resident #1 received new medications related to burn wounds. The resident received Silver Sulfadiazine cream 1%, apply topically every shift for blister for 7 days. The ointment was documented applied from 09/18/23 to 09/25/23 the day the resident was sent out to the hospital. The MAR review further showed Resident #1 continued to receive pain medications following the burn accident as follows: -9/18/23 at 3:39 p.m. Pain level 7. Given Acetaminophen 325mg (milligram) x 2 tablets. Effective -9/18/23 at 10:02 p.m. Pain level 4. Given Tramadol HCL (hydrochloride) 50mg x 1 tablets. Effective -9/19/23 at 9:30 p.m. Pain level 3. Given Acetaminophen 325mg x 2 tablets. Unknown effectiveness. -9/20/23 at 7:26 p.m. Given Acetaminophen 325mg x 2 tablets. Signed off under order for Fever. No pain level given. -9/21/23 5:12 a.m. Pain level 4. Given Acetaminophen 325 mg x 2 tablets. Effective. -9/21/23 1:59 p.m. Pain level 8. Given Acetaminophen 325 mg x 2 tablets. Effective. -9/22/23 No pain meds given. -9/24/23 2:30 a.m. Pain level 6. Given Acetaminophen 325 mg x 2 tablets. Effective. -9/24/23 12:50 p.m. Pain level 8. Given Tramadol 50 mg x 1 tablet. Effective. -9/25/23 12:31 p.m. Pain level 4. Given Tramadol 50 mg x 1 tablet. Effective. A review of a document titled, Wound Evaluation & Management Summary, dated 09/18/23, showed on wound site #5, Burn Wound chest, Wound size: 7.5 cm (centimeters) length, 4.2 cm width, depth not measurable. Surface Area: 31.50 cm2 , Exudate, None. Blister, fluid filled. Expanded evaluation performed, The development of this wound and the context surrounding the development were considered in greater depth today. Counseling offered to optimize wound healing and relevant conditions were addressed through management changes or investigations regarding conditions including Peripheral Artery Disease, Anemia, Congestive Heart Failure, impaired nutritional status discussed with patient, family, and nursing staff and/or dietician.