Based on observation, interview and record review, the facility failed to ensure Resident B was free from staff-to-resident physical abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in Resident B sustaining 14 severe first-degree burns (a first-degree burn affects the outer layer of skin. Burn sites were red, painful, and dry without blisters) on an ear, a lip, the neck, the upper back, the breasts, the abdomen, the bilateral thighs, the bilateral buttocks, and the perineal area. Finding includes: The immediate jeopardy began on January 6, 2024, when it was identified the resident had 14 burns that were caused from a hair dryer. Resident B sustained burns in 14 different locations across her body, which included, but were not limited to her breasts, pubic area, bottom, back of the neck, ear, and mouth area. The Executive Director (ED), Regional [NAME] President of Operations, Regional Director of Clinical Services, and Director of Nursing Services (DNS) were notified of the immediate jeopardy on 1/9/24 at 2:54 p.m. The immediate jeopardy was removed on 1/10/24, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. An incident report to the Indiana Department of Health, dated 1/6/24, indicated the resident was found with 11 raised circular areas upon skin inspection. During investigation of the skin issues, from 1/6/23, the Nurse Practitioner (NP) determined the marks were burns. During an interview, on 1/9/24 at 8:45 a.m., the DNS and the ED were in attendance. The ED indicated she received a call from the DNS, on 1/6/24, indicating Resident B had 11 circular areas found on her body. A reportable was sent into Indiana Department of Health. They began their investigation. On 1/7/24, the DNS received a call from a staff member who indicated the circular areas on Resident B looked like they were made by a hair dryer. At that time, a white hair dryer was observed in the ED's office with a large circle and a smaller inner circle with eight lines connecting the large and smaller circles together. The DNS indicated the resident had been burned by the hair dryer on multiple areas of her body. The DNS showed a picture of one of the burned areas on the resident and it was observed to have a large circle with a smaller inner circle with eight lines connecting the large and smaller circles together just as the white hair dryer. The ED indicated once the resident's daughter was with the resident, the resident indicated she was hurt with a hair dryer, by a middle-aged white female who was a little heavy with blonde hair. A housekeeper, a nurse who matched the description, and the CNA who gave the resident her shower, on 1/6/24, were all suspended on 1/8/24. During an observation, on 1/9/24 at 9:54 a.m., the resident was sitting in her wheelchair. She was placed in bed by two CNAs. She had burn wounds to her chin, right ear, lower left jaw, right cheek, right and left breasts, lower left abdomen, right and left inner thigh areas, pubic area, right buttock and three on the back of her neck. Several of the burns were circular in nature with lines intersecting throughout the circle and were red in color. The resident was observed to have a flat affect and was grabbing for staff member's hands during the observation. When she was placed back into her wheelchair she had tears in her eyes, with a frown, was very soft spoken, and complained of a headache. The record for Resident B was reviewed on 1/9/24 at 2:20 p.m. Diagnoses included, but were not limited to, aphasia (a language disorder caused by damage in a specific area of brain which controls language expression and comprehension), anxiety disorder, cognitive communication deficit, unspecified dementia, and psychotic disorder with delusions due to known physiological condition. A care plan, dated as last reviewed 11/7/23, indicated the resident exhibited a cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of less than 13. Interventions included, but were not limited to, provide simple instructions, give resident choices throughout the day regarding decisions, provide resident with prompts and cues and encourage participation in daily activities particularly regarding orientation, socialization, and stimulation. A care plan, dated as last reviewed 11/7/23, indicated the resident may become combative with care and try to hit staff. Interventions included, but were not limited to, reapproach later, and try a different caregiver. A care plan, dated as last reviewed 11/7/23, indicated the resident had episodes of eating her feces, and taking it out of brief and throwing it. Interventions included, but were not limited to, offer gum or hard candy, keep physician and family informed, mental health services in place, offer snack and drink, offer re-directional activities, and assess for toileting, pain, hunger. A care plan, dated as last reviewed 11/7/23, indicated the resident's cognition varied throughout the day. The resident was slow to respond at times in conversation. Interventions included, but were not limited to, encourage social interaction, provide simple instructions, and repeat as needed, give the resident choices throughout the day regarding decisions as able, and encourage participation in daily activities particularly regarding orientation, socialization, and stimulation. A care plan, dated as last reviewed 11/7/23, indicated the resident required assistance with toileting incontinence care due to impaired mobility, impaired vision, medications, impaired cognition, and the resident was incontinent. Interventions included, but were not limited to, check at least every 2 hours for incontinence, assist with elimination, assist with toileting and incontinent care as needed, document any abnormal findings, and notify the physician, and assess and document skin condition weekly and as needed. A care plan, dated as last reviewed 11/7/23, indicated the resident required assistance with Activities of Daily Living (ADLs) including bed mobility, transfers, eating, and toileting related to impaired mobility, incontinence, impaired cognition, impaired vision, medications, impaired communication. Resident prefers to not shower at times. Resident has dementia and expressive language disorder. Interventions included, but were not limited to, prefers to get up before breakfast, shower 2 times a week in the p.m., and go to bed after 10 p.m., or when tired, assist with toileting and/or incontinent care as needed: incontinent, assist with bathing as needed per resident preference, and offer showers two times per week, partial bath in between. A Quarterly Minimum Data Set (MDS) assessment, dated 11/7/23, indicated the resident had a score of 11 which indicated she was moderately cognitively impaired. She exhibited no behaviors and required substantial/maximal assistance with showering/bathing. A nursing progress note, dated 1/6/2024 at 11:06 a.m., recorded as a late entry on 1/7/24 at 7:07 a.m., indicated a red facial rash was noted. There was no signs or symptoms of infection, drainage, pain, or itching. A new order for Hydrocortisone cream every shift to the area was ordered. The progress note was written by LPN 1. A nursing progress note, dated 1/6/24 at 10:34 p.m., indicated at approximately 8:45 p.m., the CNA came to the writer with concerns regarding rash type areas covering the resident's body. Upon assessment, the resident was found to have 13 circular raised rash areas to the following: right cheek, right nipple, left inner breast, right buttock, right inner thigh, left inner thigh, across the pubis, and the left posterior neck/shoulder, left lower lip, and right back of the neck. Some areas have blistering noted along the edges. Measurements were obtained. The resident denied knowing what/how the areas happened, pain or itching to the areas. The DNS and physician were notified. The progress note was written by RN 2. A social services progress note, dated 1/8/24 at 12:15 p.m., recorded as a late entry on 1/8/24 at 1:25 p.m., indicated Social Services (SS) met with the resident on this date. The resident presented with a flat affect per her usual demeanor. She did not display any signs or symptoms of psychosocial distress. No crying or tearfulness. A social services progress note, dated 1/8/24 at 3:15 p.m., recorded as a late entry on 1/8/24 at 4:01 p.m., indicated the mental health Nurse Practitioner (NP) was in the facility and completed a trauma screen, recommendations to follow. An Interdisciplinary Team (IDT) initial wound review note, dated 1/8/24 at 7:41 p.m., indicated the describe of the new wound/skin injury was a burn to the right cheek, the lower lip into the left cheek, right ear, left breast, right nipple, right buttock, right posterior neck, left posterior neck, left upper shoulder below the left posterior neck, right inner thigh time two (2), left inner thigh, and pubis. The root-cause determination was a burn. A nursing progress note, dated 1/9/24 at 3:32 a.m., indicated treatment was done to the areas as ordered and tolerated well. The areas to the lower lip and cheek were peeling and the resident was licking her chin. No tearfulness, or signs and symptoms of fear or anxiety was noted this shift. A nursing progress note, dated 1/9/24 at 4:08 a.m., indicated the resident was turned and repositioned. The resident started crying when turned and facial grimacing was noted. Pain meds to be given as ordered. A psychiatry note, dated 1/8/24, indicated the reason for the visit was a trauma assessment. It was reported the resident was found to have approximately 13 circular raised rash areas to the following: right cheek, right nipple, left inner breast, right buttock, right inner thigh, left inner thigh, across the pubis, and the left posterior neck and shoulder. Some areas have blistering noted along the edges. The resident denied knowing what/how the areas happened at the time of discovery. The resident displayed a flat affect per her usual demeanor. She was soft spoken and reached out for the writer's hand as if to seek comfort multiple times during the visit. When asked about the area to her skin, she first reported she did not know what happened. After further discussion and efforts to make the patient feel at ease, she reported the areas have been there since Saturday and someone hurt her with the hair dryer. She reported she was unsure who hurt her and indicated she never saw her before, and she had brown hair. She did report she was getting a shower at the time of the incident but could not recall specific details of what happened leading up to the incident. She had shared similar accounts of the event with minor variation. The variation was likely attributable both to mild cognitive impairment present and the impact of the trauma upon capacities for recalling specific/component aspects of event that transpired. The resident indicated she was not afraid of anyone; she was just a little bit sad. Sometimes it hurts. She was tired of all the questions and had a headache. The assessment and plan indicated it was recommended to avoid the use of a hair dryer in the future and to monitor for psychosocial distress related to bathing/showering and the use of the shower room and limit exposure to shower room if distress occurs. A nurse practitioners note, dated 1/8/24, indicated the resident had multiple wounds located on her mouth, right cheek, right ear, three spots on the top of her shoulders, right nipple, left breast, inside both thighs, across her pubis and a couple on her abdomen. The wounds were red, raised, and scabbed, all appearing to be the same stage. The resident had a flat affect, which was normal for her. She did appear tearful at the beginning of the encounter. The wounds were consistent with burns. A wound management detail report completed by the facility, dated 1/8/24, indicated the resident had the following wounds: 1. A burn to the right ear which measured 3 centimeters by 1 centimeter. 2. A burn to the back of the neck which measured 3.5 centimeters by 4 centimeters. 3. A burn to the left upper back which measured 1 centimeter by 3 centimeters. 4. A burn to the back of the neck which measured 4 centimeters by 4 centimeters. 5. A burn to the left thigh which measured 2.5 centimeters by 2 centimeters. 6. A burn to the right buttocks which measured 3.5 centimeters by 3.5 centimeter. 7. A burn to the right cheek which measured 4 centimeters by 3 centimeters. 8. A burn to the right breast which measured 4 centimeters by 4.5 centimeters. 9. A burn to the perineal area which measured 8 centimeters by 6 centimeters. 10. A burn to the right thigh which measured 2 centimeters by 2 centimeters. 11. A burn to the right thigh which measured 4 centimeters by 3.5 centimeter. 12. A burn to the left lower quadrant of the abdomen which measured 1.5 centimeters by 4 centimeters. 13. A burn to the left breast which measured 3 centimeters by 4 centimeters. 14. A burn to the lower lip which measured 4 centimeters by 10 centimeters. In a witness statement, dated 1/8/24, LPN 1 indicated she saw CNA 3 take Resident B for a shower Saturday morning. She saw a new area on the resident's chin which looked chapped. In a witness statement, dated 1/8/24, CNA 4 indicated on Friday night into Saturday morning there were no marks on the resident's skin. On Saturday, CNA 5 found the marks on the resident. In a witness statement, dated 1/8/24, CNA 3 indicated she gave Resident B a shower on Saturday morning. Her chin and lips looked like cracked skin. She provided her care after lunch (after 1), and she did not see any areas on her skin. The resident was in bed from 9 a.m., until 11:30 and then the resident was up for lunch and laid back down after lunch. In a witness statement, dated 1/8/24, CNA 5 indicated she cared for Resident B for the evening shift on Saturday. The resident was in bed from 2 p.m., until around 8:45 p.m., when she provided her care and found the markings on her skin. In a witness statement, dated 1/8/24, CNA 6 indicated she saw Resident B on Saturday after breakfast and her chin and ear were red. In a witness statement, dated 1/8/24, the Executive Director (ED) indicated Resident B indicated the injuries occurred in the shower room. When asked if someone did this to her, she indicated the girl got a little carried away. She indicated it was someone who worked here, and she was wearing scrubs. During a phone interview, on 1/9/24 at 3:46 p.m., LPN 1 indicated CNA 3 was the CNA who gave Resident B her shower Saturday morning. CNA 3 notified her the resident had a rash on her face after she got her out of the shower before breakfast. During a phone interview, on 1/10/24 at 8:56 a.m., the resident's medical physician indicated the burn wounds were all the same age, so they all happened at the same time. The burns were severe first-degree burns with a concern for a secondary Staph infection from the resident licking her chin. During an interview, on 1/10/24 at 10:20 a.m., CNA 3 indicated she gave Resident B a shower around 7:00 a.m., on Saturday 1/6/24. After her shower, she took the resident to breakfast. When she brought the resident back to her unit after breakfast, she noticed a rash on her chin. She did not notice any marks on the resident during her shower or throughout the rest of her shift besides her chin. During an interview, on 1/10/24 at 11:05 a.m., CNA 5 indicated she worked the evening shift, on Saturday 1/6/24. Her shift started at 2:00 p.m. When she started her shift, CNA 3 reported to her, she had just provided Resident B with peri-care. CNA 5 did not check or change the resident until around 8:45 p.m. The resident did not get up for dinner and received her meal in bed. Around 8:45 p.m., she went to get the resident ready for bed and provide peri-care. When she removed her gown, she saw red, circular marks on her breasts. She discovered more marks on her thighs and peri-area and immediately went and found a nurse. During a phone interview, on 1/10/24 at 10:30 a.m., CNA 7 indicated Resident B had dried feces on her at the start of the shift, Saturday 1/6/24, and she needed a shower. CNA 3 was the CNA responsible for caring for Resident B. She offered to help CNA 3 give Resident B a shower, but CNA 3 indicated she did not need help. So, CNA 7 went to help with breakfast. There were no marks noted on Resident B prior to her getting into the shower. CNA 7 went into Resident B's room, at approximately 8:30 a.m., when CNA 3 was buttoning up Resident B's clothes. CNA 7 observed a red mark on her chin and abdomen, but she thought the red mark was from where the feces were scrubbed off or the water may have been too warm. A current policy, titled Resident Rights: Know Your Rights under Federal Nursing Home Regulations, dated March 15, 2017 and provided by the DNS on 1/9/24 at 9:45 a.m., indicated Resident Rights: You have the right to a dignified existence, self-determination and communication with and access to the persons and services inside and outside the facility .Respect and Dignity: You have a right to be treated with respect and dignity, including: The right to be free from abuse A current policy, titled Abuse Prohibition, Reporting and Investigation, dated June 2023 and provided by the DNS on 1/9/24 at 9:45 a.m., indicated Purpose of Policy: Provide guidelines to prohibit and prevent abuse .of residents . Policy: It is the policy of America Senior Communities to provide each resident with an environment that is free from abuse .This includes but is not limited to .physical abuse .Definitions/Examples of Abuse: Willful, used in the definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury to harm. Abuse-Willful infliction of injury, unreasonable .intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause of physical harm, pain, or mental anguish. Abuse includes .physical .Physical Abuse-A willful act against a resident by another resident, staff member or other individual(s). Examples may include but not be limited to hitting, slapping, punching, and choking .Identification: Abuse includes: 1. Staff to resident abuse of any type .Types of abuse .4. Physical abuse The National Library of Medicine website, dated 8/8/2023, indicated .First Degree Burns .Outcomes The prognosis for the majority of people with a first-degree burn is excellent. However, children and the elderly may require admission depending on the degree and location of the burn. Besides pain, hypothermia is a potential complication The Immediate Jeopardy that began on 1/6/24 was removed on 1/10/24, when the facility completed the following: Psychiatric services completed an assessment on the resident and screened Resident B for trauma. The resident was placed on 1:1 for comfort. All residents were interviewed for abuse and any residents who were not able to be interviewed had skin assessments completed. In-servicing on abuse and behavior management was completed to all staff members. The ED met with the Resident Council President to discuss reporting concerns of abuse immediately and the ED will attend the next resident council meeting with permission. All hair dryers were removed from the shower rooms. Nursing Management will make rounds daily to observe for any new resident behaviors or new skin areas. Home office consultants will review incidents and accidents upon routine visits reported to the Executive Director and Director of Nursing Services. Quality Assurance tools will be used weekly for four weeks, then monthly for five months and then quarterly thereafter. This Federal tag relates to Complaint IN00425631. 3.1-27(a)(1)