**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have a system in place to prevent unauthorized and unsupervised leave from the facility. This failure resulted in one resident's (R1) elopement from the facility without staff knowledge who has documented assessments related to elopement/wandering behaviors.This was identified as an immediate jeopardy which begin on 07/17/25 at 8:55pm when R1 eloped from the facility without supervision and authorization.V1 (Administrator) was informed of the immediate jeopardy and a template was presented on 07/28/25.On 08/04/25 acceptable removal plan was received after revision of the original plan submitted on 7/28/25.The Immediate Jeopardy was removed on 08/04/25, however, the non-compliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of in-service training.On 08/06/25 the surveyor confirmed by observation, interview, and record review that the removal plan was initiated, and Immediate Jeopardy was removed on 08/04/25. However, the non-compliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. FINDINGS INCLUDE:R1 medical report admission Record showed that R1 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Schizophrenia, hyperlipidemia, cerebral infarction and bilateral primary osteoarthritis of knee.V1 (Administrator said R1 placed in the facility due to being aggressive towards family.On 07/17/25 at approximately 8:55pm/9:00pm, R1 eloped from the facility unauthorized and without staff supervision. R1's police report dated 07/18/25 documents when reported by the facility as 01:23:27 07/18/25, time of occurrence 21:00:00 07/17/25 and 01:23;53 07/18/25. Offense codes listed as A433 missing Adult.R1's hospital emergency room record dated 07/18/25 showed that diagnosis includes but not limited to Dementia, PTSD (Post Traumatic Stress Disorder) schizophrenia and aggressive behavior. R1's medical record electronic physician order did not have a physician order documentation allowing him to go out independently without any supervision.R1's medical record MDS (Minimum Data Set, dated [DATE] showed R1's BIMS (Brief Interview for Mental Status) score of 11 indicating that cognitively R1 is moderately impaired.R1's previous (MDS) section C dated 12/04/2024 and 2/26/2025 scored R1 BIMS as 15 and 14 indicating that cognitively intact. Showing that R1 has decline cognitively. R1's medical record Elopement Risk Review dated 03/19/24 timed 18:48 (6:48pm) documented under comments that resident (referring to R1) is confused, voicing that he is trying to go home. Resident does actively engage in themed behavior and is a new admit. Resident will be placed on elopement protocol and will be monitored.R1's medical record recent Elopement Risk Review dated 07/21/25 four days after the incident of 07/17/25 documented that R1 is presently at risk for elopement and should be placed on elopement risk protocol. Comments documentation read R1 left from the building on 07/17/25 without authorization to go home. R1 can make his own decisions. Resident stated he knew what to do and where to go. Resident has history of hallucinatory behaviors but does not display those behaviors currently (currently). Resident is not able to live at home due to him showing aggression towards family. V13 (Receptionist) presented facility visitor registration log dated 7/17/25 that showed no documentation that R1 signed self out to the community or that the family member visit or sign out R1 to the community.V2 and V4 ADON (Assistant Director of Nurses) stated that any unusual occurrence should be documented The facility video monitor showed R1 walking around the nurse's station on the 1st floor at 8:55pm but did not show the front exit door. V1 stated that the video did not show the rest of the night footage because it has been discarded. R1's hospital visit record showed documentation that R1diagnosis includes but not limited to Dementia, PTSD (Post traumatic stress disorder, schizophrenia and aggressive behavior. R1 was treated on 07/18/25 with medications that includes Haloperidol lactate (Antipsychotic) at 3:26am and Midazolam (Versed) at 3:27am. On 07/23/25 at 2:00pm, interview conducted with V2 DON (Director of Nurse's) regarding the event of 07/17/25 with R1. V2 stated that R1 is one of our vets (veterans). Alert and oriented times 3, delusional, able to verbalize needs, needs re-direction constantly, has good days and bad days, needs supervision and cues from the staff. On the day R1 went out (referring to 07/17/25), I was on vacation I hardly took time off, but I was off. I did not do any investigation, V1 (Administrator) did the investigation so I could not tell you what happened. When asked about potential risk that could have happened to R1, V2 said Any-thing could have happened to (R1). Safety issues, accident can happen. R1 wants the son to get out of his home and that is part of why he (R1) is in the facility I think they V1 said they are in court, but he (V1) does not have the paperwork (court document) yet. V2 explained that the facility exits (in the facility) have alarms especially the front door, so if staff or resident goes through without proper code the alarm goes off to alert every-one in the building. The alarm is loud enough that everyone can hear it. When a resident is missing or eloped, the facility policies should be followed. The surveyor then asked whether it is normal occurrence for the facility residence to walk out of the facility without staff's knowledge. V2 said It is not normal for any of our resident to walk out of the building without anyone knowing about it. R1 is here (facility) to be cared for and monitored. On 07/23/25 at 3:23pm, V22 (Family) stated that I am the son, (R1) left the nursing home (facility) during the night of 07/17/25. (R1) walked back to his home which is about 4hours walk because they said he left around 9:00pm. V22 said I call the facility to ask about him, they (facility staff) did not know he was gone. V22 stated that he called the facility at 12:30am on 07/18/25 when R1 showed up at their house at 12:20am, so he called the police, they arrive with an ambulance and was advice to send R1 to the hospital. V22 stated that R1 did not recognize him was calling V22 by his brother's name, he was confused. Using the address V22 gave the surveyor R1 had walked approximately eight miles from the facility unsupervised and unauthorized to V22 home.On 07/23/25 at 3:51pm, V15 CNA (certified Nurse's Aide) stated that she was the 2nd shift CNA for R1 on 7/17/25. V15 stated that during her shift R1 was observed in the dining room socializing with peers. She made her last round at about 9:00pm 10:00pm and R1 was in the building then between 13:30am and 1:00am on 07/18/25 the facility staff called asking about R1's whereabout because he was missing. V15 stated that R1 is not capable of going out in the community without supervision, so R1 should not be out there without supervision of staff or family. He knows what time to come for medicine and dinner time, independent at times but still need staff to re-direct him.On 07/23/25 at 4:07pm, during interview with V23 RN (Registered Nurse) assigned to R1 on 11:pm to 7am shift 07/17/25, V23 stated that when I clocked in at the facility (timecard preview showed V23 clocked in at 11:09pm). V23 stated in part that V17 LPN (Licensed Practical Nurse) was at the nurse's station with V27 (RN), I got the shift change report from V17 that nothing was going on. The surveyor asked what V23 meant by nothing going and she said, to mean everything was normal with the residents assigned to her (V23). V23 stated that V17 (LPN) that worked 3pm to 11pm did not report that R1 eloped or has gone out unauthorized. V23 stated that it was after V22 (family) called the facility around 12:30am that the staff started looking for him. V1 (Administrator) was notified, and he came into the facility asked for the police be called. When the police called, he (V22) told them that he had his father, and he is on the way to the local hospital to get evaluated. V23 could not explain or give account of how R1 eloped with the door alarm on because the front door alarm goes off when coming in or out then you will have to put the code in to stop it. V23 stated in part that every staff knows the code to get in or out and the alarm did not sound on my shift. On 07/24/25 at 3:33pm, V25 (Maintenance Director) stated that all the exit doors in the facility are in working condition, the front exit door is always working. The alarm goes off when staff or resident goes through the door without the code. After 8:00pm the receptionist set the code so no one can go in or out without the alarm not going off, the staff knows the code to reset the alarm not the residents.On 07/24/25 at 4:37pm, V18 NP (Nurse Practitioner) stated that she is not the direct NP for R1 but in cases where a resident has dementia and MI (Mental illness) diagnosis these types of residents need constant supervision and are not capable of going out without someone supervision, family or staff. They should be monitored closely. If the resident has a MI (Mental Illness) diagnosis schizophrenia, takes his/her medicine and in a stable mind may be go into the community. The surveyor then asked V18 that in your professional opinion what are the risk this type of resident might face? V18 stated that they can be in a danger to self or orders, and they should be monitored /supervised.On 07/28/25 at approximately 10:23am, V27 RN (Registered Nurse) confirmed that R1 was not in the facility at the start of her shift and none of the staff was aware of R1 missing until V22 (family) called at 12:45am 07/18/25 and the staff started looking for him. When asked whether it is safe for R1 to be out there in the community at that time of the night, V27 stated that it is not safe for R1 to be out in the community at that time of the night stating No, it is not safe because we don't know where he could be, and anything could have happened to him. On 07/28/25 at 3:35pm, V36 (Physician) for R1 stated that she is familiar with R1, was made aware of R1 leaving the facility unsupervised. V1 (Administrator) called me right away after the event cannot recall what time. V36 said she talk to V1 immediately believed R1 was taken to the hospital to get him fully evaluated and to have drug test done because he was out of the facility. The surveyor asked whether V36 have seen R1 since he returned to the facility, V36 said No, I am out of the country now but when I returned, I will see him. The surveyor asked is it appropriate for R1 to go out without authorization / supervision? V36 said It shouldn't be safe for anyone in the nursing home even if they are alert and oriented because he was able to make his own decision to get to his son. The surveyor then clarifies from V36 Are you saying it is okay. V36 said I am saying is not okay, I would not want any of the resident at that time (of the day) to go out in the dark. The surveyor also asked V36 about what are the risk for R1 going out at that time without supervision and authorization, V36 said The risk can be fall like any one being at risk, there is traffic, loose your way. V36 added that R1 is alert times three knows what he was doing with BIMS of 15 at the time (tie of incident). The surveyor informed V36 that at the time of the incident R1's BIMS score was 11 and not 15. V36 stated that I don't know how they get 15 that is what I was told, R1 needs assistance and supervision to be out (out of the facility).On 07/21/25 at 1:32pm, V11 PRSC (Psychiatrist Rehabilitation Service Coordinator) assigned to R1 stated that R1 is alert oriented times three, R1 has some delusion and hallucinations, hard to redirect because he wants to do want to do against the facility policy. V11 stated she is aware about R1 going out of the facility without any supervision, I was informed on Friday (7/18/25) that (R1) left the building at 9:00pm on 7/17/25. He walked home rang the doorbell and his son answered the doorbell and then took him to the hospital for evaluation. The hospital released R1 back to us (Facility) on Friday and at that time my shift was over. V11 stated that R1 left the building because is fully aware of what he was doing, cognition is intact he wanted to go home, and he executed his plan. The receptionist leaves at 8pm, He (R1) waited till the front door was closed and left out of the building. When asked how she knows all these, V11 said V1 told her. The surveyor asked about how the residents are monitored /supervised to make sure the residents did not just go out without a pass/supervision. V22 said When the receptionist leaves there should be nurses and CNAs to redirect the residents. When asked about her professional opinion if R1 is able cognitively to go out of the facility without supervision/monitoring. V11 stated I want to say yes and no. Cognitively he was intact depending on his mental status at the time. When he is medication compliant, he is on right mind but when he refuses his medication that's when he delusional and hear voices. V11 stated I did not see him until today because he came back after the end of my shift.On 07/21/25 at 2:10pm, V12 SSD (Social Services Director) stated that she is familiar with R1, he is one of our veterans, alert but can be delusional, not easy to re-direct. I did talk to V1 (Administrator), he mentioned that R1 left the facility, but he did not give me any details of how it happened, this morning around 9am (7/21/25), V1 said the care plan should be updated. I asked V11 to do a wellness visit on (R1) and document on him. V11 stated that R1 has been on elopement risk since admission because he did not want to be here at the facility and was voicing it. R1 is at risk for elopement and need staff supervision. He hears voices, talk to himself. When asked about pass privilege, V12 stated that R1 is not on independent pass because he must be supervised either by family or staff. Family must sign him, before going into the community unless he is going with staff on appointment. The front door has an alarm, and I have his picture on the list of our residents on elopement risk at front desk (receptionist desk). On 07/23/25 at 1:58pm, V4 ADON (Assistant Director of Nurses) stated in part that the facility policy is that the CNAs are supposed to make rounds every two hours and as needed. The facility visitation is over at 8:00pm unless the administrator makes exceptions, the only time the resident can go out is if they have independent pass. R1 is ambulatory and sits in the dining room most of the time at night. When asked whether she is aware that R1 went out of the facility without supervision of staff and the reason for him been moved to another floor. V4 said I don't have the details about it the (V1) Administrator did not discuss the detail with me, so I don't know any detail about that. I just know he was coming from the hospital and need to be moved; I will have to discuss with V1 to know why he was moved. The surveyor V4 as the ADON and in her professional opinion is R1 cognitively capable of going about in the community without supervision? V4 said Hun-hum, prior to that day (7/21/25), I will have to get back to you on that one, I was told he called for a ride to come and get him.On 07/21/25 at 4:14pm, V17 LPN (Licensed Practical Nurse) stated that the last time she saw R1 was around 8pm. When asked how the staff know when the resident tries to leave the facility without supervision/ unauthorized and whether she would let any of the resident go into the community without supervision, unauthorized and unaccompanied during the night. V17 stated that No she will not allow any resident to go out; that the receptionist leaves at 8pm, the alarm on the door exit will sound if any of the resident tries to leave. V17 stated that R1 cannot function without staff supervision or family supervision in the community. Families normally will have come and sign out the residents with social services or V1 authorization. V17 stated that rounds are made every two hours the CNAs at even hours and nurses at odd hours.Facility Pass Privilege policy presented dated 7/16 documents in part that this nursing facility emphasizes and expects respectful, mature conduct from each resident both within the facility and the outside community. Some individuals admitted to the facility have history of psychiatric problems. Because of a combination of mental health, physical problems and irresponsible behavior certain residents may not be fully capable of negotiating safely in the community. Procedure listed includes but not limited to persons who demonstrate consistent maladaptive and problematic behaviors may not be candidates for independent privileges. Decisions regarding pass privileges, including, independent privileges or being accompanied by responsible individual are determined by physician orders and social services assessments. As appropriate, pass privileges may be discussed at care plan meetings which the resident is encouraged to attend. The resident is responsible for making staff aware of his/her desire to receive an independent pass privilege. Pass privilege levels listed, Level1 (Supervised Pass), Level 2 (Restricted Pass), Level 3 (Independent Pass) and resident may only move up one level at a time.Facility policy titled Unauthorized Absence dated 8/14 documents that the purpose of the policy is to ensure the ongoing health and safety when a resident has eloped/ and or is otherwise unable to be accounted for during occurring times of the day. An unauthorized absence is one that the resident is unable to be accounted for upon the scheduled return from home pass, while out on community pass, at a day treatment program and/or other similarly situated times. If a resident has eloped and / or otherwise absent from the facility without prior permission of notification, the facility is to take the following measures. The facility Elopement Risk Assessment policy presented dated 5/14 documents that the policy purpose is to identify residents who may be potentially at risk for elopement and at risk for harm. To use as a baseline to maintain a secure resident environment. Listed under Responsibility is the Social Services Department. Equipment to be used listed as the facility approved form. Procedure listed includes but not limited to a Social Service department will conduct the elopement assessment during the admission process, when there is a significant change in mood or behavior(s), and quarterly. Risk factors that will be assessed includes but not limited to verbalization of wanting to leave the facility and/or go home, inability or refusal to follow instructions diagnosis that includes but not limited to dementia and schizophrenia. In event the assessment was initiated because of an elopement (where the resident's whereabout were unknown), the elopement will be reported in accordance with the facility's Accident/Incident Unusual Occurrence Policy.Facility Incident/Accident Reports presented dated 9/14 documented in part that all accidents or incidents where there is potential for injury the report must be completed. An accident is defined as any happening, unintended event not consistent with the routine operation of the facility, that can result in bodily injury other than abuse. Listed incident / accident that report will be completed includes all accident/ incidental unusual occurrences , all unexpected events that occur that cause actual or potential harm to a resident and leaving premises without authorization (elopement).the administrator, Director of nursing, Assistant Director of nursing or Nursing supervisor must notify the following The incident/accident report is to be completed by RN (Registered Nurse) or LPN (Licensed Practical Nurse) and is to include date and time of the incident or accident., and the IDPH (Illinois Department of Public Health) The facility Supervision and Safety policy dated 3/15 presented documents that our policy strives to make environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. Our facility -oriented approach to safely addresses risk for groups residents such as wanderers, behavior, aggressiveness, confusion etc. (And so on). Staff to make visual rounds on residents minimally every two hours and more often I necessary based on resident's assessment.(CNA) saw R1 standing in the front lobby at 8:00pm, R1 told the (CAN) that he was waiting for his ride, re-directed R1 back into the facility without making the staff on 3-11pm aware on the 1st floor. The facility Discharge Against Medical Advice (AMA) documented that the purpose of the policy is to define the facility's responsibility when a resident and /or legal guardian voluntarily discharges him/herself from the facility without the consent of or an order from the attending physician. It is the policy of the facility to acknowledge the right of a resident to sign him/herself out of the facility without the consent of or an order from the attending physician providing that the resident has the decisional capacity to do so. If it has been determined that the resident is able to make his/her own decisions and chooses to exercise this right, he/she will be discharged from the facility Against Medical Advice (AMA). Procedure listed includes but not limited to prior to leaving the facility, the resident and/or guardian will be provided with explanation of the potential risks of such a discharge and alternatives to the same, any resident or legal representative choosing to discharge or be discharge without the consent of or an order from the attending physician is expected to sign AMA form. In the event the resident is signing him/herself out AMA, his /her legal representative and/or family member will be notified by facility personnel.On 08/06/25, the surveyor made observations, conducted interview, and received documentation to confirm the following removal plan was initiated. 1. R1 was reassesses by social services for elopement risk starting 07/21/25 and ending 07/28/25.2. All nine residents identified as potential to be affected by the same deficient practice were reassessed starting 7/18/25 to 7/28/25.3. The facility began re-educating the staff on elopement precaution and prevention that includes the facility elopement policy, exit door alarm system testing, system alarm response. Elopement binders.4. The facility made available elopement binders with identified resident's picture on every nurse's station starting 07/28/25.5. The facility staff are re-educated on supervision of identified wanderer/exit seeking residents starting 07/28/25 at least every-one hour. 6. The facility re-educate staff on pass privileges starting 7/28/25.7. The facility Maintenance Director re-testing all door alarm for proper functioning starting 7/18/25 to 7/28/25 as safety measures.8. All activity staff, nursing and social services will supervise the facility patio outings for elopement risk residents.9. V1 (Administrator) V2 (DON), V3 (Assistant Administrator), V4 (ADON), and V12 (SSD) re-educated on reporting incidents of elopement to proper authorities including IDPH (Illinois Department of Public Health) on 07/28/25). 10. Review of Quality Assurance Quality improvement Team monthly meeting will discuss and re-evaluate interventions in progress and if further interventions are needed it will be added and implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a resident (R1) from obtaining a severe burn from a radiator heater connected to the wall when R1's bed was pushed against the wall for one out of three residents reviewed for accidents and incidents in a total sample of four. This failure resulted in R1 suffering second and third degree burns to the left leg requiring a hospitalization where R1 received a debridement and skin graft surgery. The Immediate Jeopardy that began on 3/19/23 was removed on 3/21/23 when the facility removed the heater on the wall from R1's room. The administrator was notifed on 04/14/23. This past non-compliance occurred from 03/19/23 through 03/21/23. Findings Include: R1 is a [AGE] year old with the following diagnosis: peripheral venous insufficiency, cerebral infarction, and weakness. R1 admitted to the facility on [DATE]. A Nursing note dated 3/19/23 documents upon doing rounds, R1 was heard, moaning and complaining of left leg pain. The nurse helped turn R1 from the left side to the right side. A burn was then observed on the left lateral lower leg. The burn appeared red with a blister, when I asked what happened, R1 stated that the bed was close to the heater attached to the wall and the heat was too warm and burned. R1's leg. The burn was cleansed and left to air dry. The physician was called and orders were received to apply a burn cream twice a day and a burn wound consult. R1 denied any pain or discomfort. A Nursing note dated 3/20/23 documents the nurse practitioner evaluated R1's left leg wound and gave verbal orders to send to the burn specialist to evaluate the left leg burn wound. A Nurse Practitioner note dated 3/20/23 documents R1 was assessed due to a new wound. Per R1, R1 was sleeping with the leg up against the heater on the wall when R1 noticed the leg beginning to hurt. R1 called the nurse and that is when the nurse noted R1 had a wound on the left leg, as it was lying on the heater on the wall. R1 was repositioned immediately to get the leg off the heater and a burn was identified. After coordination with the wound team and a complete assessment, it was decided to send R1 to the hospital for further evaluation and treatment, which requires a higher level of care. The wound to the left leg extends from the thigh to below the knee. The wound is red and dry at the proximal portion of the wound. There is darkness to the middle portion of the wound. There is a large serous filled blister at the distal portion of the wound just below the knee. A Nursing note dated 3/20/23 documents R1 was admitted to the hospital with a diagnosis of a full thickness, third-degree burn to the left leg. R1 is scheduled to have surgery in the morning. A Nursing note dated 3/23/23 documents R1 had a debridement to the left leg burn site with a skin graft. The Final Investigative Report Form dated 3/19/23 documents R1 was lying in bed and complained of pain to the left leg. Upon assessment, the left leg was noted with redness and a clear fluid filled blister area. The doctor was made aware and treatment orders were received, as well as a consult for a burn wound. The next morning, the nurse practitioner and the wound care nurse assessed R1's leg. The nurse practitioner gave orders to send R1 out to the hospital for a burn consult. R1 was admitted to the hospital and remains in the hospital this time. The Hospital Records dated 3/20/23 documents R1 presented to the emergency room with a burn. R1's bed was next to the radiator. R1 had pain to the left knee where the burn was but endorse it has improved. The physical exam shows left knee erythematous (redness) with evidenced of a popped blister with cream over line. The left medial knee has a palm size blister. Plastic surgery/burn physician was consulted. The assessment from the burn physician indicated R1 sustained a full and partial thickness burn to the left lower extremity. R1 reported sleeping in R1's bed, which is next to the radiator when R1 felt the radiator burn R1's leg. The burn is 2% total body surface area to the left distal thigh, knee, and proximal lower leg. The central portion of the burn is full thickness with edges of partial thickness. A large blister is noted distantly. R1 was admitted to the burn intensive care unit. On 3/23/23, a fascial excision (excision of the full thickness and subcutaneous tissue to create a reliable bed for skin grafting) of the burn and autograft placement was performed with the donor site being from the left thigh. On 3/31/23 at 1:56PM, this surveyor went to make observation in the room where R1 stayed. The radiator heater previously attached to the wall was removed. There is an empty space on the wall where the radiator used to sit. The empty space shows the radiator heater was attached to the wall about 1 foot from the floor and was approximately 6 feet long down the length of the wall. At 2:01PM, R2 walked in the room and was interviewed. When asked what happened to R1, R2 stated R1 burned R1's left leg on the heater that used to be on the wall. R2 endorsed that night R1 was making noises causing R2 to wake up and that is when everyone started coming in the room to check on R1. R2 denied R1 screaming out for help but was moaning and saying Ouch. It hurts. R2 reported seeing the burn the next morning and described it starting from the lateral, mid-thigh and extending to the just below the lateral knee with a fluid filled blister the size of a golf ball. R2 also stated the wound was red in color. R2 stated R1 went to the hospital the next day because the blister got larger. On 3/31/23 at 2:50PM, V3 (Nurse) stated, I came in on Monday morning and the burn looked really bad. I thought to myself R1 needs a burn unit. We got orders to send R1 to a hospital burn unit. There was a heater on the wall, and R1's bed was pushed against the wall. R1 turned that way towards the wall in bed, and R1's leg came off the bed and was touching the heater. The heater was like an old radiator type of heater. R1 had kind of two spots of where the burn was. Then below the knee R1 had a very large blister. I would say it was about the size of a fist. There was another blister on the side of the knee that had popped. You could tell a blister was there. R1's pretty much total care but R1 can turn. R1 is overall weak. R1 does have venous insufficiency, so R1 probably couldn't feel what was burning R1 because of the lack of blood flow. R1 might not have been strong enough to get his leg back over after it was touching the heater, or R1 might have been in too much pain to lift it off alone. On 3/31/23 at 3:39PM, V4 (Maintenance Director) stated, I don't really have anything to do with the heaters. We only check those when they're broken. It's a hardwired space heater. The ones that are mounted to the walls are in working condition. Only the rooms at the end of the halls have the heaters connected to the wall because they are right next to a stairwell so it could be colder in their rooms from some drafts. I did not check any temperatures in that room of the heater that I can remember. I know there's a dial on there with three different settings that the residents can access if they want to. I don't check the knobs. If you left your skin on there for too long, it would probably burn. No, I still don't have to check any temperatures of the heaters. On 3/31/23 at 3:46PM, V5 (Nurse) stated, I answered the call light and R1 was complaining of heat coming from the heater that was attached to the wall. R1 asked to be pushed away from the wall because R1 was too hot. I pushed the bed away and R1 moaned in pain. R1 started talking about R1's left leg hurting. It was covered with a blanket, so I couldn't see it. When I took the blanket off to look at it, I saw the skin was off superficially, and R1 had a small blister. The blister was on the left lower lateral leg near the knee. The red area went all the way up on the lateral side of the thigh. It didn't go all the way up the side, but probably to the middle of the thigh. I would say the blister started off as a golf ball size then got a little bit bigger. No, I did not tell anyone when it got bigger. That's usually what blisters do. I went into check on R1 for my first round around 11PM and R1 was sleeping. R1 wasn't complaining of anything so that did not prompt me to do anything. R1 can turn from side to side. R1 uses a wheelchair to get around. R1 couldn't really say what happened or why R1 kept R1's leg there. I don't know all the diagnoses of the residents so if R1 does have a diagnosis of that (PVD), then that could be a reason R1 kept R1's leg there. R1 might not have felt it getting hot. R1's bed was up against the wall when I came in but because the blanket was covering R1. I could not see if R1's leg was on the heater the first time I rounded on R1 so I didn't do anything then. I can't really remember exactly what time it happened but I want to say it was between 2 and 3 AM. On 3/31/23 at 4:28PM, V6 (CNA) stated, I first saw R1 around 10PM when I came in and did my first rounds. R1 was sleeping then. The nurse (V5) came in around 11PM and she did her first rounds and saw R1 sleeping too. I can't remember what time it happened but I saw R1 again still sleeping after midnight. I was doing my rounds again and the nurse called me into R1's room to show me the burn. R1 had a burn on the side of R1s knee with a blister just below the knee. It was probably a little bit bigger than a gold ball. R1 is able to turn by himself in bed. I think when R1 turned R1 was just sleeping on the heater and didn't realize it until R1 was burned. When I went into R1's room to check on R1, it looked like R1 was just sleeping under the blankets. I saw R1's bed up against the wall but I couldn't see R1's leg touching the heater because the blankets were touching it. I don't know why R1's bed was against the wall. I don't remember R1's bed being against the wall before. On 3/31/23 at 4:40PM, V7 (Nurse) stated, I worked the evening shift the day before it happened. R1 didn't complain of anything to me that shift when I was leaving. I do remember R1'ss bed was up against the wall, but I didn't think R1 could touch the heater. I didn't ask R1 why R1's bed was against the wall. The burn was a big red area on the side of his leg. It went from the thigh to a little below the knee. It was probably as thick as the top part of the heater. There was a blister on it too. It was probably the size of a golf ball. On 4/3/23 at 4:17PM, V8 (Burn Unit Physician) stated, R1 had both second and third degree burns to the left leg. Second degree means it goes partially through the dermis which is the second layer of skin under the epidermis. A third degree burn is a full thickness burn which goes all the way through the epidermis and dermis. This burn was more complicated because it was near a joint. A third degree burn around a joint can cause a contracture. R1 ended up needing a skin graft to assist in healing the area. Skin grafts are the main course of treatment for extensive, more serious burns. It would take much longer to heal and a greater risk for infection if no skin graft was done. For a burn that is second or third degree, it would need to be something 108 degrees or higher that touches the skins for about 2 - 3 minutes. I can't say exactly how long he had his leg on the heater, but most people have the instinct to immediately remove their body from something that feels hot. We know he at least had it on the heater 2 - 3 minutes if it was 108 degrees. Yes, he does have a history of peripheral vascular disease so that could have distorted his perception of how hot the heater really was. PVD causes decreased sensation because of the decrease of circulation and the narrowing of the blood vessels. Any burn with a blister that is growing in size should be seen as soon as possible. A burn is considered an open wound so you increase the risk of infection. Burns also cause dehydration through fluid loss. Because this was over a joint, this would be considered an area that needed to be treated immediately because of the location. With a burn around a joint, the skin, muscles, and tendons can tighten causing much more severe damage. On 4/4/23 at 10:49AM, V9 (Nurse Practitioner) stated, The burn just didn't look great. My gut said to send R1 out. It was a large wound to the left thigh that traveled down past the knee. There was a lot of redness with a blister. The blister was the size of maybe one of the cutie oranges. After speaking with the wound nurse and the floor nurse, we decided R1 needed a specialized burn unit to care for this wound. R1 told me R1 rolled over in R1's sleep and R1 felt R1's leg getting hot. R1 put on the call light to get the nurse to help R1 and they found the burn on R1's leg. On 4/4/23 at 11:03AM, V10 (Wound Care Nurse) stated, I saw R1 when I came in on Monday. I measured the area and assessed R1. I was told R1 laid R1's leg on the heater. The wound was an open red area from the thigh all the way down past the knee a little. I was on the lateral side. R1 also had a blister on the wound closer towards the bottom. It was big. I would say probably the size of a grapefruit. On 4/4/23 at 4:00PM, V2 (DON) stated, We found the cause of the burn was the bed being against the wall. R1 told me it made R1 feel more secure when R1 was moving in the bed. R1 was mostly independent with bed mobility. R1 just wasn't able to transfer alone. We don't know why R1 kept R1's leg there long enough to get burned. Doing more thorough rounds would help prevent or decrease injuries like this. On 4/6/23 at 11:08AM, This surveyor walked in the room mid-dressing change to the left leg. There were 2 sites noted. The wound to the top of the left thigh was the donor site. It is pink and a rectangle shape. The second site was the graft site which is located about inch above the lateral left knee to about the middle of the calf. That wound is red with dark red edges around the whole wound. The thigh was treated with Silvadene, xeroform, and a dry abdominal pad. The lateral knee was treated with xeroform and a dry abdominal pad. R1 has a purple discoloration completely around both legs starting from the ankle extending up the leg about 3-4 inches. The surveyor questioned V11 (Outside Facility Wound Care Nurse) what the discoloration was on the legs and V11 stated, R1 has PVD. That can cause discoloration to the legs because of the lack of circulation. On 4/6/23 at 11:16AM, V11 stated, The wound to the top of the thigh is the donor site. That is 10.5cm x 16cm. The lower leg is 22cm x 13.5cm. The wound to the top of the thigh has gotten smaller R1 admitted to us, but the graft site has remained the same. R1 admitted to us on 3/30/23 from the hospital burn unit. R1 is not able to roll himself when we do the dressing changes. R1 can assist in helping us turn, but R1 can't do it alone. On 4/6/23 at 11:22AM, R1 stated, I went to bed that night sometime between 9 and 10PM. The CNA (V12) put me to bed that night. While V12 was putting me to bed, V12 pushed my bed against the wall. I don't know how it happened or why V12 did it. I didn't ask for that. I don't remember having my bed against the wall before. I didn't feel it right away but when I was trying to go to sleep, my leg was hot. I knew I was touching the heater then. I had a blanket under my leg so I thought I would have been ok. I didn't think I was going to burn myself. The pain kept getting worse and I couldn't take it anymore so I put on my call light. The nurse (V5) came in my room and helped me. I told V5 to push my bed away from the wall because I was too hot. When V5 moved me, I told V5 my leg really hurt. V5 looked at it and told me I was burned on me leg. I had my leg on the heater probably about an hour or a little more than that. I know it wasn't very long after V5 got there that I called for help. I tried to sleep but I was sleeping on and off because my leg was so hot. I didn't move my leg off the heater. The nurse had to do it for me. I can't move my legs too good with the blankets on top of them. I guess I'm not strong enough. I use a lift to get in my wheelchair and that is how they put me back in bed that night. I sometimes need help adjusting in bed. I can use my arms good and push myself up a little, but my legs don't work so good anymore. I didn't go back to that facility because after this happened there is too much danger there. This burn made me realize I don't feel safe with them taking care of me. On 4/6/23 at 1:36PM, V12 stated, I put R1 to bed around 8:30 - 9PM. I put R1 in with a lift. We use that because R1's unstable on R1's feet and unsteady with R1's gait. That night, R1 asked me to scoot R1's bed against the wall because R1 wasn't feeling well. R1 said R1 wanted R1's bed against the wall, and R1 was afraid of hanging out of the bed a little bit. No, I didn't tell anyone R1 was feeling this way. I just did what R1 asked. R1 never asked me to do that before. I did my last round about 10:15 PM and R1 was sleeping. I walked over and I watched R1 breathe and R1 didn't say he had any problems then. R1 did have the blanket covering R1's body. I didn't let anyone know I pushed the bed against the wall. I didn't think he could touch the heater. The Treatment Nurse Initial Skin Alteration Review dated 3/20/23 documents R1 has a full thickness wound to the left knee extending to the lower left leg. Per this assessment, a full thickness wound is defined as skin loss with extensive destruction, tissue necrosis, or damage to underlying structures, such as muscle, tendon, or bone. It may present as a deep crater and may even tunnel into surrounding subcutaneous tissues. The size of the wound is documented as 26 cm x 10 cm. It is 30% slough tissue, 40% red (smooth), and 30% clear fluid filled blister. There is a small amount of serous drainage. A predisposing risk factor for developing the wound is immobility and PVD. The Side Rail Review dated 3/20/23 documents R1 needs extensive assist with bed mobility. R1 is not able to turn from side to side unassisted while in bed. The Care Plan dated 11/24/21 documents R1 has peripheral vascular disease (PVD) and is at an increased risk of skin integrity issues. R1 has potential for diminished blood flow to the bilateral lower extremities. The Care Plan dated 4/11/22 documents R1 needs a mechanical lift for transfers due to lower extremity strength, impaired range of motion of the lower extremities, and weakness. The Care Plan dated 3/24/23 documents R1 has an alteration of skin, integrity, related to impaired mobility status, decreased sensory perception, comorbidities, and PVD. The Minimum Data Set (MDS) dated [DATE] documents R1 is an extensive two-person physical assist with bed mobility and transfers. Section I of the MDS documents R1 has a diagnosis of peripheral venous insufficiency. Section M of the MDS documents R1 does not have any pressure ulcers or burns. Prior to the survey date the facility took the following actions to correct the noncomplaince. All rooms in facility, all units were visited, and beds were rearranged as necessary to ensure no beds are pushed against the walls or close to heating units on March 20, 2023. This continued March 21, 2023. Any resident who resisted received education Residents bed was immediately removed from the wall and heating unit on March 19, 2023. Physician notified and treatment and burn consult orders obtained on March 19, 2023. Attempted to call responsible family member on March 19t, 2023 without success. Sister returned call on March 20, 2023and was notified and spoke with resident via Phone. On March 20, 2023 Maintenance checked resident heating unit for proper functioning and working properly. Unit has proper protection cover in place now and at time of the incident. On March 20, 2023 and continued on March 21, 2023 Maintenance checked all heating units to ensure proper functioning and that proper protection covers are in place On March 20, 2023 the facility began educating the staff on new safety protocol. This education continued until all staff were educated which was March 21, 2023. Focus of education Abstaining from positioning the beds against the wall Abstaining from positioning the beds close to the heating units Ensuring proper functioning and protection of the wall heating units Consequences for staff noncompliance On March 20, 2023 residents injured area was visually assessed by facility wound care nure and nurse practitioner and treatment rendered per physician order. On march20, 2023 resident was sent to University of Chicago ER for evaluation and admitted on the burn unit. On march 20, 2023 a Root cause analysis (RCA} was completed. Acting medical director was notified on March 19, 2023. Education with Nurses began on March 20, 2023 and continued on March 21, 2323 with focus on: Burn assessment and documentation Physician detailed notification First aid for burns ER visit or burn consult follow up Administrator will be responsible for overall compliance to plan of correction in conjunction with Director of Nursing and Designees monitoring during routine rounds while entering every room daily. The quality assurance quality improvement team meets monthly. This event will also be brought to next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly. Completion date: March 22, 2023