Based on observation, record review, and interview, the facility failed to provide a safe mechanically lifted transfer to prevent a major injury (Resident C), and safe activities of daily living (ADL) during a bed bath requiring bed mobility to prevent injury (Resident B) for 2 of 3 residents reviewed for accidents. Findings include: 1. A clinical record review was completed on 3/13/2023 at 11:18 A.M. Diagnoses included, but were not limited to: necrotizing fasciitis, left lower extremity below the knee amputation, sepsis, anemia, and chronic kidney disease. An admission Minimum Data Set (MDS) Assessment reviewed on 1/16/2023, indicated Resident C had moderate cognitive impairment. She required extensive assistance with two or more staff members for bed mobility, transfers, and toileting. She had range of motion impairment on one side of the lower extremities. Her vision and hearing were adequate, and she was able to be understood and understood others. Resident C was receiving occupational and physical therapies since 1/9/2023, and speech therapy since 1/12/2023. A Care Plan initiated on 1/10/2023, indicated Resident C had a physical functioning deficit. A Physical Therapy Evaluation on 1/9/2023, indicated Resident C was dependent with transferring and required a mechanical lift for the transfers. A Physical Therapy Progress Report for 1/9/2023 through 1/20/2023, indicated Resident C required substantial/maximal assistance for sit to stand, chair/bed-to-chair transfer, and toilet transfer. She continues to have no weight bearing to the left lower extremity. On 1/30/2023, a Physical Therapy Treatment Encounter Note, indicated Resident C had worked on wheelchair to mat table transfers using a sliding board with moderate assistance to complete the task, sit to stand inside the parallel bars with moderate assistance for 20 second standing tolerance. A Change of Condition Nurse's Note on 1/31/2023 at 6:27 A.M., indicated Resident C was complaining of severe pain and the inability to lift her left shoulder. The assessing nurse noted the left shoulder with swelling, deformity, and bruising, and bruising to the left wrist. Resident C was sent to the Emergency Department via EMS (Emergency Medical Services). On 1/31/2023 at 7:02 A.M., a Nurse's Note indicated Resident C stated a (mechanical) lift was being used to complete a transfer, and that's when the injury occurred, around 8:00 P.M. on 1/30/2023. A Hospital Triage Note on 1/31/2023 at 7:18 A.M., indicated, .Patient states she resides at [facility name] and they were using the lift on patient around 2000 [8:00 P.M.], patient states her arm was stuck and they continued to move her, and she heard a pop. EMS placed her in a arm sling, and received 25 mcg [micrograms] of Fentanyl and 4 mg [milligrams] Zofran. Patient rates pain 8/10 A Hospital Emergency Note on 1/31/2023 at 7:48 A.M., indicated, .the left shoulder appears to be internally rotated and adducted with swelling to anterior aspect. Pain with movement of the left shoulder A computer tomography scan (CT scan) was performed in the Emergency Department. The CT scan results indicated, .hematoma and questionable tear of the left pectoralis major muscle and possible tear of the supraspinatus tendon. Resident was admitted to the hospital to the Orthopedic Unit A Hospital Social Worker (SW) Note on 1/31/2023 at 11:42 A.M., indicated, .SW was asked to assist with disposition and follow up. SW notified by forensics that this patient had concerns regarding her care last night at the facility .She was using the stand lift when she experienced pain in her L [left] shoulder and asked the staff to stop. They didn't and she continued to have pain overnight in her L [left] arm. This morning she was sent out for evaluation of the arm .Spoke with nurse at [facility's name] regarding the concerns. Explained that we would be filing a report with the state .The family does not want the patient to return to the facility On 2/1/2023 at 5:49 P.M., an Oncology Consultation Note indicated the CT scan from 1/31/2023 showed, .within the left pectoralis major muscle, there is a heterogeneous mass identified measuring 6.8 cm x 12.2 cm x 8.4 cm. Given the history of recent injury, this most likely represents an intramuscular hematoma possibly from a tear of the pectoralis major muscle A facility-initiated investigation was completed on 1/31/2023. CNA (Certified Nursing Assistant) 8 indicated she assisted CNA 5 with a transfer in Resident C's bathroom. She indicated when she walked into the bathroom CNA 5 and Resident C were in the middle of a transfer over the toilet, and Resident C was slipping down like she couldn't hold her weight. She indicated Resident C was lowered and the stand-up waist belt was resituated, and the transfer was completed. In a separate written statement, CNA 8 indicated she had gotten the call light string caught in the waist belt of the sit-to-stand lift and the call light string made a popping noise when it snapped. She indicated Resident C got anxious during the transfer, and she informed Resident C to calm down and breathe. CNA 5 was also interviewed for the facility-initiated investigation. He indicated he was in the bathroom with Resident C standing up from the lift in front of the toilet and her incontinence brief got stuck between the toilet and Resident C's legs. CNA 5 indicated CNA 8 came to assist when Resident C began yelling, she was going to fall. On 3/14/2023 at 11:57 A.M., a telephone call was placed to Resident C's son. He indicated the facility Administrator informed him an investigation would be completed related to the injury. He indicated his mother was able to describe what happened with the male and female that assisted her with her transfers, and the female employee was suspended. He indicated the staff was using a Hoyer lift (non-weight bearing mechanical lift) and his mom's arm got caught in the transfer. During an interview on 3/14/2023 at 1:23 P.M., the Director of Nursing indicated, a Lift/Transfer Assessment will be completed at admission, and then quarterly. The assessment does not take the place of therapy recommendations. She indicated staff would know a resident's transfer needs by the report provided by the transferring facility, and then therapy would give recommendations after that time. During an interview on 3/15/2023 at 11:28 A.M., PTA (Physical Therapy Assistant) 6 indicated that the therapy department communicated with the nursing department regarding the safest transfer of residents on their services. A Therapy to Nursing Communication Form was used at one time to communicate to the Unit Manager to ensure the care plan was updated, but that eventually went to verbal communication. She indicated the therapy department has been asked to use the communication form again from the facility management. On 3/15/2023 at 11:30 A.M., COTA (Certified Occupational Therapy Assistant) 7 indicated that Resident C was to use a Hoyer mechanical lift. She indicated therapy had tried to use the sit-to-stand lift, and Resident C was not safe using that mechanical life. COTA 7 indicated staff continued to use the sit-to-stand lift, despite the safety issue, and Resident C's injury occurred when using the sit-to-stand lift. On 3/14/2023 at 3:11 P.M., the Director of Nursing provided a policy titled, Safe Resident Handling/Transfer. The policy indicated, .It is the policy if this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .13. Resident lifting and transferring will be performed according to the resident's individual plan of care .14. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device 2. A clinical record review was initiated on 3/13/2023 at 1:17 P.M. Diagnoses included, but were not limited to: quadriplegia, contractures, and adult failure to thrive. A Care Plan initiated on 10/17/2022, indicated Resident B had an active diagnosis of complete quadriplegia with a goal of no issues related to hygiene and ADLs (activities of daily living). The Care Plan goals indicated Resident B required total assistance with bed mobility, transfers, and toileting related to spinal injury. A Significant Change Minimum Data Set (MDS) Assessment was completed on 12/27/2022. The assessment indicated Resident B was cognitively intact. She was dependent with two or more staff members assistance for bed mobility, transferring, toileting, and bathing. A Nurse's Note on 3/1/2023 at 10:55 A.M., indicated Resident B rolled out of bed while she received a bed bath. Resident B was found on the floor between the bed and wall on her left side. Resident B sustained a bruise to her left forehead, that measured 4 cm (centimeters) by 3.2 cm. On 3/1/2023 an Education/Inservice Form was completed and signed by 18 staff members. The form indicated, .Resident B - Air mattress setting should be checked for proper weight setting when rolling, to side position patient in the center of the bed, ensure that her bolsters are in place as needed when rolling and repositioning An Interdisciplinary Team (IDT) Note on 3/2/2023 at 9:33 A.M., indicated interventions put in place post-fall included education to staff and bolsters applied to the mattress for tactile boundaries. A Care Plan initiated on 3/2/2023, indicated Resident B was at risk for falls. Interventions for falls initiated on 3/1/2023 included education given to staff. During an observation and interview on 3/13/2023 at 3:22 P.M., QMA (qualified medication assistant) 1 indicated Resident B was not able to move her upper or lower extremities, or reposition herself. Both feet were observed to have foot drop, and the upper extremities had contractures at the elbow and wrist. Resident B had a heel floating device in place to keep her heels off the bed. She was on an air mattress and no bolsters were present. On 3/14/2023 at 9:47 A.M., LPN (licensed practical nurse) 3 indicated Resident B needed total assistance and one staff member could complete the assistance. She indicated Resident B could not move her arms or legs. During an observation and interview on 3/14/2023 at 9:57 A.M., Resident B indicated she was receiving a bed bath by CNA 4, when he stopped holding onto her, and she fell out of bed. She indicated CNA 4 had her too close to the edge of the bed. She indicated sometimes she received assistance of two CNA's and other times one CNA. She was on an air mattress and no bolsters were present. On 3/14/2023 at 1:42 P.M., the Director of Nursing indicated staff would find assistance required on the electronic medical record's Kardex system. She indicated the care plan should follow the MDS Assessment unless the resident has had a change with the MDS Assessment or change to the plan of care. A review of the Kardex report was completed on 3/14/2023 at 1:54 P.M. The Kardex did not have assistance required for bathing and/or bed baths. The Kardex indicated Resident B required complete dependence on staff for bed mobility. During an interview on 3/15/2023 at 10:27 A.M., CNA 4 indicated a resident's assistance level can be found on the Kardex, and if the information was not in that location he would speak with a nurse. He indicated Resident B required a Hoyer lift, and was totally dependent for bed mobility with the assistance of two staff members as Resident B cannot move on her own. CNA 4 indicated he was providing a bed bath on his own when Resident B fell from the bed, and he should have waited for another staff member to complete the bed bath. He indicated he was provided education on air mattresses, proper bed mobility, transfers, and bathing the next day after the incident. On 3/15/2023 at 1:12 P.M., the Director of Nursing provided the policy titled, Activities of Daily Living (ADLs). The policy indicated, .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .4. The facility will maintain individual objectives of the care plan and periodic review and evaluation This Federal tag relates to Complaint IN00401294. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on interview and record review, the facility failed to ensure physician orders were carried out in a timely manner for a resident who was admitted to the facility after ventral hernia repair surgery as a result the resident required hospitalization for debridement and IV therapy for 1 of 3 Residents reviwed (Resident G) B. Based on record review and interview, the facility failed to ensure admission orders for surgical treatment and timely physician follow up appointment for a resident with fracture of neck of left femur, and surgical treatment for a resident with a left below the knee amputation for 3 of 3 charts reviewed for physician orders. (Resident E, F, G) Findings include: 1. The clinical record review for Resident G was conducted on 2/1/2023 at 9:00 A.M. Resident G was admitted to the facility on [DATE] following ventral hernia repair. Diagnosis included, but not limited to: ventral hernia repair, and encounter for surgical aftercare following surgery on the skin an subcutaneous tissue. The Hospital Discharge form titled, After Visit Summary, dated 12/15/2022, indicated the resident had a post operation visit scheduled for 12/22/2022, a list of medications to be administered and instruction to read the attachments on surgical drain care and abdominal hernia repair. The attached form titled, Surgical Drain Care, indicated after surgery, fluid may collect inside your body and could make infection problems more likely. A Jackson Pratt (JP) drain carried the fluid into a collection bulb. The form indicated to empty the JP collection bulb when it appeared to be half full and the measure the amount of fluid removed from the drain. Then squeeze the bulb until it is flat, as this removes air and wound create a suction that pulls fluid into the drain. Another attached form titled, Abdominal Hernia Repair, indicated to .wash area with warm soapy water, and pat dry. Don't use hydrogen peroxide or alcohol, which can slow healing. You may cover the area with gauze bandage if it weeps or rubs against clothing. Change the bandage every day The antibiotics listed for administration included Amoxicillin 875-125 mg two times a day for 7 days (last dose was in A.M.) and Linezolid 600 mg two times a day (last doses was in A.M.) The Medication Administration Record (MAR) order date 12/15/2022, indicated .Linezolid 600 mg (milligrams), give 1 tablet by mouth two times a day for infection, discontinue on 12/30/2022 . On the following dates/times the MAR indicated by a code of 7 referencing see Nurses Notes, the following were missed doses 12/16/2022 at 9 A.M. and 9 P.M. dose, 12/19/2022 at 9 A.M., 12/20/2022 at 9 A.M., 12/21/2022 at 9 A.M. and 9 P.M., 12/26/2022 at 9 P.M. (3-hold/see nurses notes), 12/27/2022 at 9 A.M. and 9 P.M., 12/28/2022 at 9 A.M. and 9 P.M., 12/29/2022 at 9 A.M. She received doses on 12/17/2022 at 9 A.M. and 9 P.M., 12/18/2022 at 9 A.M. and 9 P.M., 12/19/2022 at 9 P.M., 12/20/2022 at 9 P.M., 12/22/2022 at 9 A.M., 12/23/2022 at 9 A.M. and 9 P. M., 12/24/2022 at 9 A.M. and P.M., 12/25/2022 at 9 A. M. and 9 P.M., 12/26/2022 at 9 A.M. The MAR, order date 12/15/2022, indicated .Amoxicillin-Pot Clavulanate tablet 875-125 mg, give 1 tablet by mouth every 12 hours for bacterial infection related to encounter for surgical aftercare following surgery on the skin and subcutaneous tissue for 7 days On 12/15/2022 the 6 P.M. dose and 12/17/2022 - 9 A.M. dose was missed. The Treatment Administration Record (TAR) did not indicate an order was put into place for the abdominal incision site upon admission or JP drains. A Treatment Administration Record (TAR) indicated .Record output from drain-LLQ [left lower quadrant] (1 of 2) every shift ., dated 12/19/2022. The TAR indicated the first time an output was documented was on 12/20/2022, on the evening shift with 10 milliliters of drainage, but did not describe the drainage. There was no documentation indicating the amount of drainage from the LLQ-JP drain on the following dates/shifts: 12/21-evening and night shift, and 12/27-day and-night shift. A TAR indicated .Record output from drain-RLQ [right lower quadrant] (2 of 2) every shift ., dated 12/19/2022. The TAR indicated a nurse had recorded her initials only on the night shift, no indication of the amount fluid, had been documented. The recorded output, for RLQ was, on 12/20/2022, and indicated there was 75 milliliters of drainage. There was no documentation indicating the amount of drainage from the RLQ JP drainage on the following dates/shifts: 12/20-evening and night shift, 2/22-night shift, 12/23-day shift and 12/27-day and night shift. The post-surgery follow up appointment, dated 12/22/2022, contained the following orders, Keflex 500 mg every 8 hours for 14 days at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and Bactrim DS 800/160 mg, twice a day at 6:00 A.M. and 6:00 P.M. Both medications had a start date of 12/22/2022 and stop date of 1/5/2023. And daily dry dressing changes over incision. After the resident seen the surgeon the Medication Administration Record (MAR), for December 2022 indicated the resident was administered the Keflex, on 12/22/2022 at 10:00 P.M., on 12/24/2022 at 2:00 P.M. and 10:00 P.M. The missed doses were on 12/23/2022 at 6:00 A.M., and on 12/24/2022 the MAR indicated the Keflex was discontinued. The Bactrim DS missed doses were on 12/23/2022 at 6:00 A. M., 12/24/2022 at 6:00 A.M. and 6:00 P.M., and 12/25 /2022 at 6:00 A.M. The Bactrim DS was documented as administered as administered on 12/30/2022 when the resident was admitted to the hospital on [DATE]. The Treatment Administration Record indicated the resident received a dressing change on 12/24/2022, 12/25/2022, 12/26/2022, 12/28/2022, 12/29/2022 and 12/30/2022. The missed treatments were on 12/23/2022 and 12/27/2022. A Surgeon's Progress Note, dated 12/29/2022, indicated, . Pt last seen on 12/22/2022 for a PO appointment with Dr. Folstein. Pt resides at a home and it was noted that her bandages were not being changed as a result of moist dressing on her incision and infection. Bactrim and keflex prescribed for 14 days. Our office spoke to the nurse at home for specific instructions regarding incision care-daily dry dressing changes--keeping site clean, dry, and intact. Upon assessment, pt has a very dirty and wet dressing on incision. The result of poor dressing changes, cleanliness, and keeping incision dry led to skin breakdown along surgical incision site and now may result in surgical debridement. Leading to admission to the ER A Care Plan, dated 12/16/2022, indicated the resident had altered skin integrity related to a post-surgical wound with JP drain. The interventions included but were not limited to: JP drain as ordered, monitor for signs/symptoms of infection, treatments as ordered and weekly wound assessments. During a phone interview, on 2/3/2023 at 11:19 A.M., the pharmacy tech from Alixa RX, indicated that the Linezolid came from CVS the backup pharmacy on 12/17/2022 with a 5- day supply/total of 10 pills. On 12/28/2022 the pharmacy sent another 5-day supply/total of 10 pills. During an interview, on 2/3/2022 at 12:11 P.M., the Director of Nursing (DON) indicated the process for obtaining new admission medication is to enter the order in Pointclick care and if med is not in the EDK (Emergency Drug Kit) they receive it from the backup pharmacy CVS. She indicated that Bactrim, Amoxicillin and Keflex are in the EDK box and should have been obtained from there. If the medication is not available, then a call is made to the Physician to clarify the new start date with an entry documented in the progress notes. The Linezolid was delivered on 12/17/2022 at 12:12 P.M. and the documentation in the electronic medical record (EMR) indicated awaiting delivery from pharmacy. On 12/19/2022, the documentation in EMR indicated that it was not given and was in the cart (nurse no longer works here). On 12/20/2022 at 9 A.M. and 12/21/2022 at 9 A.M. and 9 P.M. documenting indicated not given. On 12/26/2022 thru 12/28/2022 documentation indicated pending pharmacy run. She indicate that the doctor should have been notified of all the dates it was missing and documented in the progress notes. And no documentation on why the Keflex was not administered on 12/23/2022 and 12/24/2022 at 6:00 A.M. in the EMR. During a phone interview, on 2/3/2023 at 3:12 P.M., the Nurse Practitioner indicated she did not discontinue the Keflex on 12/24/2022. During a phone interview, on 2/3/2023 at 3:24 P.M., the Registered Nurse indicated she does not know why she discontinued the Keflex order. During an interview, on 2/3/2023 at 12:47 P.M., the DON indicated the abdominal wound was not on the admission assessment with measurements and description of it until 12/19/2022 and should have been completed within 24 hours of admit. And she indicated the treatment for the abdominal hernia repair was for a home patient and did not feel it was an order to clean and change daily. She did indicated she should have a treatment order for the JP sites and the emptying of the drains which began on 12/19/2022. There was no documentation in the EMR on way there was no record of output of the drains on 12/20, 12/21, 12/22, 12/23, and 12/27; and no reason for not doing the treatment to abdominal wound on 12/23/2022 and 12/27/2022. 2. The clinical review for Resident E was reviewed on 1/31/2023 at 11:00 A.M. The diagnoses included, but not limited to, necrotizing fasciitis, orthopedic aftercare following surgical amputation, and acquired absence of left leg below knee(L BKA) Resident was admitted to the facility on [DATE]. A Care Plan, dated 1/12/2023, indicated the resident has altered skin integrity related to BKA surgical wound to left stump. The interventions included but were not limited to: conduct weekly skin inspection, monitor for signs and symptoms of infection, treatments as ordered. Physician Order Sheet - Sanctuary of Holy Cross dated 12/21/2022, indicated wound-incision care left BKA apply betadine and cover with dry gauze or ABD only twice a day. The Treatment Administration Record, dated 1/2023, indicated on 1/13/2023 an order of betadine external solution 10% apply to the left BKA topically every evening shift for surgical site. May cleanse with NS or wound wash , apply betadine cover with ABD and secure with gauze or border dressing. During an interview, on 2/2/2023 at 2:47 P.M., the Director of Nursing indicated that the treatment order for the left below the knee was not transcribed upon admission and should have been. 3. The clinical record for Resident F was reviewed on 1/31/2023 at 2:00 P.M. The diagnoses included, but not limited to, fracture of unspecified part of neck of left femur, muscle weakness and abnormalities of gait and mobility. Resident was admitted to the facility on [DATE]. The Hospital Discharge form titled, After Summary Instructions, dated 1/12/2023, indicated Wound/Incision Care for patient instructions: Daily dressing changes. Cover with ABD and tape. May leave open to air after post op day 7 if healed and no longer draining. And schedule an appointment with J. Yeargler, MD as soon as possible for a visit in 2 weeks, specialty: Orthopaedic. The Hospital Discharge summary, dated [DATE] indicated Resident F underwent hemiarthroplasty on 1/8/2023. A Care Plan, dated 1/13/2023 indicated altered skin integrity related to surgical wound to left hip. The interventions included but were not limited to: treatment as ordered, monitor for signs and symptoms of infection, weekly wound assessment. During an interview, on 1/31/2023 at 3:30 A.M., the Director of Nursing indicated that she was following up on scheduling his follow up appointment with the surgeon yesterday, which should have been made when he admitted . And indicated the treatment depends what day he came out of post op whether he could be open to air or not. On 1/31/2023 at 4:24 P.M., the DON indicated that he did not have an order for dressing change when he admitted and should have because he was 4 day post op. On 2/2/2023 at 11:40 A.M., the Regional Nurse indicated they have no orders no policies or procedures on physician orders or transcribing of, and the admission process. On 2/1/2023 at 11:40 A.M., the Director of Nursing provided a policy titled, Wound Treatment Management, dated 2022, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with current standard of practice and physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .6. Guidelines for dressing selection may be utilized in obtaining physician orders .c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatment will be monitored through ongoing assessment of the wound. Considerations for needed modification include: a. Lack of progression towards healing. B. Changes in the characteristics of the wound This Federal tag related to compalint IN00400017. 3.1-37(a)(b)

Based on record review and interview the facility failed to prevent burns from hot liquids by serving it at an inappropriate temperature resulting in a partial thickness to full thickness burn.(Resident D). Finding includes: An Incident Report, dated 1/20/23, indicated .Description added: Resident was in room and yelled. Staff responded and noted resident had spilt her hot tea .Action Taken: Resident assessed, NP [Nurse Practitioner] notified with new orders .Type of injury: Belly area has a 48 cm [centimeter] by 22 cm open blister area with redness noted by nurse During an interview, with Resident D, on 2/1/23 at 9:55 A.M., Resident D indicated she was sitting in her wheelchair with the overbed table across her lap, she was served hot tea in a Styrofoam cup that did not have a lid. She indicated she prefers not to have a lid on her cup because she cannot open the lid because she has contracted hands. She indicated that when the tea spilled it landed on her abdomen and she pulled her shirt away and she yelled for help. Staff came right away to assist her. During an interview and observation, on 2/1/23 at 10:00 A.M., with LPN 3 and Resident D, he said the area to Resident D's abdomen was better, it was healing. During the observation of Resident D's abdominal area, the skin to the abdomen had multiple brown scabs on her skin with the surrounding tissue a slightly reddened color. At that time, it appeared to be a healing wound. The multiple scabbed areas presented about the size of a nickel or dime. The clinical record for Resident D, was reviewed on 2/1/23 at 10:40 A.M. Diagnoses included, but not limited to: paraplegia unspecified, muscle weakness generalized and other lack of coordination. A Quarterly MDS (Minimum Data Set) assessment, dated 12/20/22 indicated the resident was cognitively intact and required supervision of 1 with eating. The MDS did not indicate any use of assisted devices for eating. A Nurse Practioner for Wound Care-Progress Notes, dated 1/23/23, indicated the resident was seen for a new abdominal burn .New areas of partial [epidermis& dermis damage] and full thickness [ includes all 3 layers of skin damage] tissue loss across abdomen with multiple fluid-filled blisters. Unable to sense pain; had spilled hot tea across her abdomen and couldn't remove clothing fast enough due to hand contractures. Will manage burn with thin layer Silvadene cream the cover with single layer xeroform; protect with ABD [abdominal type of dressing] and secure with medipore tape outside of wound boarders; change every 48 hrs. [hours] and prn[as needed] saturation. Keep site clean and dry and protect from further tissue damage A Tissue Analytics, dated 1/23/23 , indicated the burn wound measured 9.04cm x 4.05cm x0.20. The wound has scant serious fluid, with no odor with epithelium intact. Wound dressing to be completed 3 x's per week. A Tissue Analysis, dated 1/26/23, indicated the burn wound measured 7.07cm x 3.07 cm x 0.01 cm. Another Tissue Analysis dated 1/30/23 indicated the burn wound measured 7.49 cm x 7.19 cm x.0.10 cm. The Treatment Administration Record (TAR) for January 2023, indicated a treatment for the burn was started on 1/19/23 and included .clean area with normal saline and pat dry, apply medihoney every shift. The TAR indicated the first treatment was first documented on 1/20/23 on night shift. The last date and time the treatment was completed was on 1/24/23, day shift. The TAR indicated there was treatment change, on 1/24/23, to apply Silver Sulfadiazine Cream 1% to the abdominal wound. During an interview, on 2/3/23 at 10:58 A.M., the Unit Manager indicated when hot liquids are served to residents it is supposed to have a lid on it. During an interview, on 2/3/23 at 11:34 A.M., CNA7 indicated she was the one who brought the hot tea to the resident. She indicated hot tea was served to the resident in a Styrofoam cup without a lid, per the resident's request. During an interview, with the Dietary Manager, conducted on 2/1/23 at 11:30 A.M., she indicated they have a commercial coffee urn that they take water from and pour into a carafe for Residents tea and hot chocolate. The water temperature she said, had to be at 164 degrees Fahrenheit in order for the tea and hot chocolate to be palatable. During an inteview, with CNA 6 on 2/1/23 at 2:45 P.M., indicated she would get a cup from the kitchen or Styrofoam cup as most residents like larger cups. She indicated she would get the hot water from the machine in the kitchen and take it to the Resident. Hot water in a Coffee Carafe on the 200 unit on 2/1/23 at 11:30 A.M., was 144 degrees Farenheit. The temperature was retreived by the Dietary Manager 10 minutes after being brought to the unit. Hot water in a Coffee Carafe, dated 1/20/23 through 2/2/23, indicated temperatures of the hot water were 162 degrees Fahrenheit. Hot water from the Coffee/Hot Water Machine, dated 1/20/23 through 2/2/23, indicated the temperatures of the hot water were 162 degrees Fahrenheit to 165 degrees Fahrenheit. A form titled, Hot Beverage Safety, undated, indicated .Guideline Statement: A hot beverage is something many of our residents look forward to. These beverages must be served at a temperature that is both palatable and safe for the resident The form indicated water from commercial coffee urns .will be in the 185 to 200 degree range, which is recommended temperature for brewing tea Serving Resident section indicated .Do not use styroform cups for hot beverage .Residents who travel in a wheelchaie with hot beverages should be provided with a wheelchair cup holder . The form stated .All residents should be evaluated for Hot Beverage Safety on admission, with any change of conditon and annual assessment using the Hot Liquid Safety Evaluation . On 2/3/23 At 3:18 P.M , the Administer indicated the above form and its information was used for education only and is not a policy. Causation of Cutaneous Burns, retrieved from the National Center of Biotechnology Information (NCBI) website on 2/3/23 at https://www.ncbi.nlm.nih.gov/articles/PMC 1934304/?page=16 indicated the time and temperture relationship to serious burns with the following temperatures and the time required for a 3rd degree burn (full thickness burn going through the dermis and affecting deeper tissue) to occur: 155 degrees Fahrenheit (F)-1 second 148degrees F-2 seconds 140 degrees F-5 seconds 133 degrees F-15 seconds On 2/3/23 at 11:08 AM ., The Unit Manager provided a policy titiled, Hot Liquid Safety, dated 2022 and indicated it was the one currently used by the facility. The policy indicated .Policy Explanation and Cimpliace Guidelines: 1. Hot liquids can cause scaling and burns 2. The temperature of hot liquids will be checked in the dietary department prior to distrubution to th nursing units. If the temperature is greater than 140 Fahrenheit, hold the liquid in the dietary department until it reaches an apporiate temperature .4. Staff shall respond to immediately to spills or other accidents with hot liquids to minimize the risk for burns. Follow procedures regarding incidents/accidents should anyone experience exposure to hot liquids . The policy contained additional information regarding the time and tempurture requided for 3rd degree burn to occur. The policy indicated, at 155 degrees, it would take 1 second to recieve a third-degree burn. This Federal tag relates to complaint IN00399787. 1.3-21(a)(1)(2)