**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize procedures for pressure ulcer (wounds caused by pressure) assessment, documentation, and management for one resident (Resident #272) of one resident reviewed, resulting in a lack of accurate and timely assessments, lack of implementation of meaningful interventions, and Resident #272 developing two unstageable (full thickness tissue loss with unknown depth) pressure ulcers and a Stage two (partial thickness loss of tissue presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcer, unnecessary pain, the likelihood for additional wound development/progression, and decline in overall health status. Findings include: Resident #272: An observation of Resident #272 was completed on 1/8/24 at 11:59 AM. Resident #272 was sitting in a wheelchair in their room with Family Members Witness A and Witness B. An interview was completed at this time. Resident #272 was noted to be pleasant, hard of hearing, and did not consistently respond to questions when asked. When queried regarding the reason they were admitted to the facility, Witness A revealed the Resident fell at home and went to the hospital where they were diagnosed with a small stroke which affected their left side, a UTI (Urinary Tract Infection), and problems with their coumadin (blood thinner medication). When queried how long they had been sitting up in the wheelchair, Resident #272 revealed staff got them up at 7:00 (AM). Resident #272 stated they ate in the dining room and had been up since. Family Member Witness A and Witness B both disclosed Resident #272 was sitting in their wheelchair when they arrived at the facility at 9:30 AM. The Resident's Left Upper Extremity (LUE) including their arm and hand were visibly edematous and a Hoyer (mechanical lift) sling was in place under them in the wheelchair. When queried, Resident #272 and Family Witness A and B revealed the Resident was unable to move themselves without assistance and had to be transferred using a mechanical lift. When asked if they had any pressure ulcers and/or wounds on their skin, Family Witness A stated, (Resident #272) does have something on their butt. It hurts them a lot. When asked if they had a wound or sore on their bottom, Resident #272 confirmed they did. Resident #272 was then asked if the sore hurt and replied, Yes. Resident #272 also verbalized complaints of discomfort in their legs and Witness B proceeded to complete assisted passive Range of Motion (ROM) to the Resident's lower legs. When queried if facility staff had assisted them to reposition in their wheelchair since they have been sitting up, Resident #272 disclosed they had not. Witness A and Witness B added that Resident #272 had not been repositioned since they had been at the facility. Record review revealed Resident #272 was admitted to the facility on [DATE]. Review of the Electronic Medical Record revealed no documentation of medical diagnoses. Review of Resident #272's admission Observation and Data Collection Assessment documentation, dated 1/5/24 at 4:42 PM, revealed the Resident was orientated to person and place only, required assistance to complete Activities of Daily Living (ADL), was incontinent of bowel, had an indwelling urinary catheter, and required a mechanical lift for transferring. Further review of Resident #272's admission Observation and Data Collection Assessment detailed the following, Skin Color: Normal . Temperature: Warm . Turgor: Normal . Skin Impairment: Skin events available; Bruise, Burn, Incision, Pressure-Stasis Diabetic, wound, Rash/Lesion, Skin Tear/Laceration: Yes, complete appropriate Wound Event for further assessment . Braden Scale for pressure ulcer predictability . Sensory Perception: 4. No Impairment . Moisture: 4. Rarely Moist . Activity: 1. Bedfast . Mobility: Completely Immobile . Nutrition: 2. Probably Inadequate . Friction and Shear: 2. Potential Problem . Score: 14 . low to moderate (pressure ulcer) risk . A Baseline Care Plan Goal- Resident will have intact skin or improving skin integrity was included in the admission Assessment. The baseline care plan included the interventions, Turn and reposition for comfort with care and Monitor fluid and nutrition intake. Resident #272 did not have a comprehensive care plan in place related to pressure ulcers and/or skin integrity. Further review of Resident #272's Electronic Medical Record (EMR) revealed no Wound Event documentation related to a pressure ulcer as indicated in the admission Observation and Data Collection. Review of progress note documentation in Resident #272's EMR revealed one note related to skin. The note, dated 1/5/24 at 7:10 PM, detailed, Skin Assessment: Resident has several bruising to bilateral upper extremities, chest, back of both hands, left shoulder, right shoulder, both antecubital area, left side of head, left side chin/neck, abrasion below left eye, bruise to right upper thigh and right knee, back of left knee, lateral right calf bruise and large bruise to buttock/coccyx and right hip. Both forearms are edematous and back of both hands have swelling . At 8:00 AM on 1/9/24, Resident #272 was observed in the restorative area in the main dining room of the facility. The Resident was sitting in their wheelchair with a Hoyer sling in place under them. Certified Nursing Assistant (CNA) G was assisting the Resident to eat. When queried how long they had been sitting up in their chair, Resident #272 revealed staff got them up around 7:00 AM for breakfast. A review of Resident #272's Health Care Provider orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed no wound care orders and/or treatments. On 1/9/24 at 9:10 AM, Resident #272 was heard yelling out for help from the hallway. From the doorway of the room, Resident #272 was observed sitting in a stationary chair in their room. The Resident was fidgeting in the chair while yelling, Help, Help and Hello, Hello repeatedly and appeared uncomfortable. There were no staff were observed in the hallway. At 9:22 AM, Visitor Witness K arrived at the facility and entered Resident #272's room. This Surveyor entered the room at this time. A pressure reduction cushion was not observed in the stationary chair where Resident #272 was sitting. At 9:38 AM on 1/9/24, Certified Nursing Assistant (CNA) G entered Resident #272's room. An interview was completed at this time. CNA G was asked about Resident #272's skin integrity and revealed they did not know as they had not gotten the Resident out of bed. When asked about Resident #272's ADL care, CNA G revealed the Resident was dependent upon staff for all care, were unable to reposition themselves, and required a Hoyer lift for transferring. When queried if Resident #272 had a pressure reduction cushion in place on the stationary chair, CNA G replied, No. When asked if Resident #272 was at risk for pressure ulcer development, CNA G indicated they were. CNA G was then queried why the Resident did not have a pressure reduction cushion in place and was unable to provide an explanation. When asked, CNA G revealed the facility does have pressure reduction cushions for use on stationary chairs. When queried regarding the last time Resident #272 had been repositioned, CNA G indicated they the Resident was repositioned when they were transferred to the stationary chair from their wheelchair following breakfast. On 1/9/24 at 10:38 AM, an interview was conducted with CNA G. CNA G revealed they had observed Resident #272's skin and stated, Their coccyx area is opened up. It's still red and bruised. On 1/9/24 at 10:56 AM, Resident #272's call light was noted to be on, and the Resident could be heard from the hallway of the facility yelling out, Help, Help and Hello, Hello repeatedly. Multiple facility staff were observed walking past Resident #272's room without addressing and/or assisting the Resident. At 11:03 AM, a staff member was observed entering Resident #272's room and the Resident was heard saying they had a bowel movement from the hallway. The staff member proceeded to exit the room. A skin and peri-care observation for Resident #272 was completed on 11:16 AM on 1/9/24 with CNA G, Physical Therapist I, and Occupational Therapist J. Resident #272 was in bed, positioned on their back. Scattered bruises in various stages of healing were noted on their neck, chest, arms, legs, hips. Resident #272 had been incontinent of stool and CNA G CNA G prepared supplies to provide care. The Resident was turned on their side by the three staff present and incontinence care was provided. A white colored cream was present on the Resident's buttocks and coccyx area which was removed with incontinence care. A dark, deep purple colored and irregularly shaped area Deep Tissue Injury (DTI) unstageable pressure ulcer was observed on the Resident's right buttock/coccyx. The skin surrounding the wound bed was observed to be reddened. A separate dark purple/red unstageable pressure ulcer with a circular shape was present on the Resident's coccyx. This area extended towards the left buttocks where an open pressure ulcer/wound was present with exposed tissue and a scant amount of visible drainage. The open area was irregularly shaped and slightly larger than a quarter. CNA G was queried regarding the white colored cream and revealed Wound Care Registered Nurse (RN) D had assessed the Resident earlier in the day and applied the cream. When queried, Resident #272 revealed their bottom was painful. A clean brief was placed on the Resident, but a treatment was not applied. Review of Resident #272's EMR revealed the following assessment documentation dated 1/9/24: - Wound Management Detail Report . Pressure Ulcer . Right Buttocks . Date/Time Identified: 1/9/24 10:24 AM . Length: 3.5 (centimeters [cm]) . Width: 2 (cm) . Stage: Unstageable - Deep Tissue . Comments: Area noted upon admission and displays as intact purple discoloration, resident educated on the importance of repositioning, and floating heels to offload pressure . - Wound Management Detail Report . Unspecified Ulcer . Coccyx . Date/Time Identified: 1/9/24 10:39 AM . Length: 6 (cm) . Width: 5.5 (cm) . Tissue Type: Epithelial Tissue . Percent of wound covered by epithelialization tissue: 10 . Area noted upon admission, displays as 90% intact purple discoloration and 10% epithelial tissue noted near coccyx area extending into L buttock . An interview was conducted MDS RN C on 1/10/24 at 9:04 AM. When queried regarding Resident #272, MDS RN C revealed they had not started the Resident's electronic MDS. Resident #272's admission Assessment documentation was reviewed with RN C at this time. RN C was asked where Wound Event follow up documentation for skin impairment was located as indicated in Resident #272's admission Assessment documentation. After reviewing Resident #272's EMR, RN C stated there was No wound event documentation completed. When asked why wound event documentation was not completed, RN C was unable to provide an explanation. When queried if Resident #272 had a pressure ulcer when they were admitted to the facility, RN C revealed there was no documentation of indicating the Resident had a pressure ulcer when they were admitted . An interview was conducted with Wound Care RN D on 1/10/24 at 9:14 AM. When queried if Resident #272 had pressure ulcers, RN D confirmed they did. When asked if the pressure ulcers were facility acquired, RN D indicated the wounds were present when the Resident was admitted . RN D was then asked where documentation of a pressure ulcer upon admission was located and replied, They (nursing staff) documented as bruising with no open area. RN D was asked where documentation of bruising was completed and replied that the event documentation for bruising was deleted. RN D then stated the admission nurses skin note indicated the Resident had bruising. When queried if bruising was the same thing as an unstageable DTI pressure ulcer and/or an open wound, RN D replied they were not. When asked how they were able to discern the bruising documented in the note on 1/5/24 was the same area as the DTI pressure ulcers, RN D revealed they could not confirm it was the same. When queried regarding facility policy/procedure for Residents admitted with a pressure ulcer and/or wound, RN D revealed facility nursing staff open a Wound Event for a pressure ulcer but do not stage and/or measure pressure ulcers. When asked, RN D elaborated that staff identify pressure ulcers, initiate treatments/interventions, and notify them (wound care nurse) for evaluation and staging. RN D was asked about wound measurements and revealed they measure wounds weekly. When queried if the facility takes pictures of Resident wounds/bruising, RN D stated, No. RN D was then asked how they knew Resident #272's DTI pressure ulcers were not facility acquired when there was no detailed wound assessment documentation upon admission and no wound images, RN D verbalized understanding. When queried regarding one wound type not being identified in the wound assessment evaluation completed on 1/9/24, RN D revealed both wounds were pressure ulcers. When queried if the open pressure ulcer was a stage two, RN D revealed they did not specify the wound stage in the assessment because the area may be one large DTI pressure ulcer. When asked if the pressure ulcer opened while at the facility, RN D replied, Yes. When queried if Resident #272 was at a high risk for pressure ulcer development, RN D indicated they were. A review of the Braden Score assessment for pressure ulcer risk completed as part of Resident #272's admission assessment was conducted with RN D at this time. When queried if Resident #272's sensory perception being documented as No Impairment when the Resident was unable to turn and reposition themselves was accurate, RN D revealed they would have assessed the Resident as Slightly Limited. RN D was then asked if Rarely Moist was accurate, considering Resident #272's mobility and incontinence, and indicated Occasionally Moist would be more accurate. When queried regarding Friction and Shear, RN D relayed they would have selected Problem due to the Resident requiring a Hoyer lift for transfers. A calculation of the Braden Score with RN D's responses revealed a score of 11 which categorized the Resident as High to Very High-Pressure Ulcer Risk and directed staff to implement specific interventions as part of the baseline care plan. When queried regarding the discrepancies and accuracy of the Resident's pressure ulcer risk, RN D confirmed the discrepancies and revealed staff would be educated regarding Braden scale completion. When queried what interventions were implemented when Resident #272 was admitted for pressure prevention, RN D replied, All mattresses are pressure reduction and preventative ointment following incontinence was in place. RN D was asked about the preventive ointment and revealed it is a standard protective ointment applied by CNA staff for any resident who is incontinent. When queried why the ointment was not applied during observation of incontinence care, RN D did not provide an explanation. With further inquiry, RN D revealed no specific pressure reduction interventions were in implemented at the time of admission. When asked if the first time they assessed the Resident's pressure ulcers was four days after they were admitted on [DATE], RN D confirmed it was. RN D was queried why they did not assess Resident #272's skin/wounds sooner, RN D revealed they identified documentation of bruising during record review of Resident #272's admission and assessed the Resident's skin due to the location of the bruising. When queried regarding the frequency in which Resident #272 should be turned and repositioned, RN D revealed they should be repositioned every two hours. RN D was informed of observations and interviews of the Resident not being turned and repositioned. When queried why Resident #272 was not turned and repositioned every two hours, RN D did not provide an explanation. When asked if a pressure ulcer can develop in four days, RN D confirmed they can. RN D was then asked to provide documentation demonstrating Resident #272's pressure ulcers were present upon admission to the facility and revealed they were unable to provide documentation. When queried if the pressure ulcers would be considered facility acquired, RN D did not provide a response. Review of Resident #272's hospital Integumentary Assessment documentation dated 1/4/24 revealed the Resident was at high risk for pressure ulcer development (Braden Score 15), had pressure prevention interventions in place, and did not have a pressure ulcer. Review of hospital discharge medications and treatments, dated 1/5/24, revealed no pressure ulcer wound care orders/treatments. An interview was completed with the Director of Nursing (DON) on 1/10/24 at 2:38 PM. When queried regarding Resident #272's pressure ulcers and lack of detailed documentation of the Resident's skin upon admission to the facility, the DON stated, Could have been a bad choice of words or could have been a bruise. When queried regarding lack of implementation of meaningful interventions based upon the Resident's risk and accuracy of Braden scale assessment completion, the DON indicated they had been informed of the concern and would work to educate staff. When queried regarding lack of turning and repositioning and pressure reduction devices, the DON verbalized understanding but did not provide further explanation. A facility policy/procedure related to Pressure Ulcer Prevention and Care was requested on 1/8/24 at 3:56 PM but not received by the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Numbers MI00138100 and MI00137191. Based on observation, interview and record review, the facility failed to 1.) Prevent an unauthorized exit for Resident #222, 2.) Follow a care-planned transfer status for Resident #1, and 3.) Follow standards of practice with a removal of a sling underneath Resident #5 for three residents (Resident #1, Resident #5 and Resident #222) of six residents reviewed for accidents, supervision and falls, resulting in Resident #222 exiting the building without supervision with the potential for injury and bodily harm; Resident #1 sustaining a fracture, surgery and pain to the left lower leg, and decreased mobility; and Resident #5 with a fracture to the left thigh, pain and decreased mobility. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on 9/24/21 and readmission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, kidney disease, heart failure, diabetes, obstructive sleep apnea, anxiety disorder, difficulty in walking, lateral subluxation of left patella, fracture of lower end of left femur, and periprosthetic fracture around internal prosthetic left knee joint. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11/15 that indicated moderately impaired cognition and the Resident was dependent on staff for mobility and lower body dressing. On 1/8/24 at 11:31 AM, an observation was made of Resident #1 in her room sitting in their wheelchair. The Resident was observed to have a leg brace on her left leg. The Resident was interviewed, answered questions and engaged in conversation. The Resident was queried regarding having any falls at the facility. The Resident indicated she had a fall a couple months ago and stated, I broke the femur bone, had to redo the knee. I told them I felt I was going to fall, she (Certified Resident Care Associate) said no, you are not going to fall. I went down and my knee popped. When asked if the staff were using a gait belt, the Resident indicated they were not using a gait belt and stated, She was not holding onto me. The Resident indicated that before the fall, she was going anywhere, reported going out for outings and things, and voiced frustration of decreased mobility and stated, now I am stuck right here all the time. A review of Resident #1's progress notes revealed the Resident had a fall on 11/8/23 and on 11/13/23 with the following progress notes that revealed: -11/8/23 at 11:03 PM, Resident was toileting with CRCA (Certified Resident Care Associate aka (also known as) Certified Nursing Assistant (CNA)) at her side. Writer heard resident cry out, writer entered bathroom and observed resident sitting on the bathroom floor in front of the toilet bowl, holding on to the toilet roll dispenser. Writer laid resident head down on a pillow for comfort until other staff arrived to assist in getting resident off the floor. CRCA stated the resident was standing and beginning to pivot to sit on toilet, suddenly her legs must have buckled and she was assisted to a sitting position on the floor. Writer noted a bruised bump on right knee, possibly from bumping her knee on the toilet roll dispenser as she was falling to a sitting position. Monitor bump QS (every shift) x (times) 3 days for any changes. Writer noted w/c (wheelchair) was in locked position right behind resident, resident was wearing non skid footwear. Resident is upset but easily calmed, stating, It scared me I don't know why it happened . -11/10/23 at 10:06 AM, IDT (interdisciplinary team) fall review: Resident is being reviewed for fall event on 11/8. Resident was transferring from w/c to the toilet, knees buckled and resident was lowered to the floor with assistance. Small abrasion to right knee noted which is now resolved. No further injury noted. Resident denies pain and continues to move around in w/c with no issues. The goal is to prevent injury. New intervention implemented is to increase assistance with transfers from a 1 PA (physical assist) to 2PA (two-person physical assist) and refer resident to therapy for further evaluation. Increase assistance noted during transfer and ambulation. New referral in place. PD and plan of care updated. Will continue with current interventions in place . -11/13/23 at 10:43 PM, 10 pm resident was being transferred from w/c to bed by CRCA. Resident stood up and began to pivot, legs buckled, resident was lowered to floor with assistance. Left foot was observed against the bedside furniture. Resident c/o (complains of) pain to left ankle. (On call provider group) was notified, writer spoke with (Name) NP (nurse practitioner), N.O. (new orders) X-ray to left ankle 2 view; keep resident in bed until results and further orders . -11/14/23 at 12:49 PM, Resident x ray results . Left knee ½ views: Acute periprosthetic fracture of the distal femur . Resident notified of x-ray result. ACE wrap and ice applied to left knee. Tramadol and Tylenol given for pain . sending resident to ER (emergency room) . -11/21/23 at 10:21 PM, Resident returned from hospital following left femur fracture and left knee replacement surgery with brace to left leg . On 1/9/24 at 11:45 AM, an interview was conducted with the Director of Nursing (DON) and Clinical Support (CS) F regarding Resident #1's fall on 11/8 and 11/13. The DON indicated the fall on 11/8 was in the bathroom when the Residents knees buckled and the Resident was lowered to the floor. When asked about the Resident's transfer assistance at that time the DON indicated the Resident was a one person assist and after the fall on 11/8, the transfer intervention was changed to two-person assist. When asked about gait belt use the DON indicated the staff had the gait belt on the resident. When asked about hands on when using the gait belt, the DON and CS indicated that with a two person assist, both staff were to have hands on the Resident when transferring when the Resident was a 2 person assist with transfers. The CS indicated that when the fall occurred on 11/13, there was only one staff with hands on during the transfer and indicated that was the opportunity that we identified for doing education with the staff and audits of Residents' transfer status'. The CS reported the staff actually transferring the Resident was not aware that the Resident's transfer status changed after the previous fall on 11/8. The CS reported that it had been changed on the care plan, but the staff had not looked at it. On 1/9/24 at 6:05 PM, an interview was conducted with CRCA L regarding Resident #1's fall on 11/13/23. The CRCA indicated she was assigned care of the Resident that day and had been assigned the hall before. The CRCA indicated she was not made aware of a change in Resident transfer status at shift report and had not had time to review care plans for changes. The CRCA reported not being aware that the Resident had been made a two-person assist. The CRCA indicated that another CRCA was outside the room nearby but was not in the room to assist with the transfer of Resident #1 when she had fallen. The CRCA indicated she had a hold of the gait belt and lowered the Resident to the floor after the Resident's knees buckled. When queried regarding communication of changes with Resident status, the CRCA reported that care plans were to be checked but indicated that when they come in on the nightshift, they have dinner trays to pass and the time needed to review care plans was not available at the beginning of the shift. The CRCA indicated that she did not remember getting an update on transfer status for Resident #1 with report from the exiting shift CRCA. On 1/10/24 at 8:52 AM, an interview was conducted with CRCA O regarding Resident #1's fall on 11/13/23. The CRCA indicated she was not in the room when the fall occurred but was nearby the room. The CRCA indicated they were not aware that the transfer status for Resident #1 had changed to a two-person assist. The CRCA was asked about care plan review and reported we don't get time to look at the care plan upon start of the night shift, by the time we have time, it is time to chart and there was no time for charting until 10:00 PM. An interview was conducted with Confidential Staff Q when queried regarding CRCA allocated time to review care plan updates or changes, the Confidential Staff indicated that CRCA's, when coming onto shift at 6 PM, there was not time to review care plans and CRCA's don't always get updates on changes in report. The Confidential Staff indicated that upon coming into shift the CRCA's pass dinner trays immediately with no time to get to read the care plan and that care plans were not always updated with changes at the time the changes are made. Resident #5: A review of Resident #5's medical record revealed an admission into the facility on [DATE] with re-admission on [DATE] with diagnoses that included muscular dystrophy, depression, paraplegia, falls, contractures of bilateral knees, muscle wasting and atrophy, muscle weakness and fracture of lower end of left femur. A review of the MDS revealed a BIMS score of 15/15 that indicated intact cognition and the Resident dependent on staff for mobility such as roll left to right, sit to lying, lying to sitting, for transfers, bathing and dressing activities. On 1/7/24 at 11:03 AM, an observation was made of Resident #5 sitting up in his electric wheelchair. The Resident was dressed and well groomed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about any accidents that occurred in the last year. The Resident reported that he sustained a fracture in his left lower thigh area when staff were repositioning him in the bed and stated, They were trying to position me in bed, raised the head of the bed and two or three heave-ho, on one heave-ho, my leg felt like it snapped in two, my one heel dug into the mattress, they didn't do it in sequence, my leg popped loud. The Resident indicated he had x-rays done but did not get further testing done, had gone to the hospital, was in a lot of pain, and had to wear a black and blue Velcro cast on his leg. A review of Resident #5's progress notes in the electronic medical record revealed the following: -7/1/23 at 5:46 PM, CRCA's transferred resident into bed with mechanical lift. Per CRCA, resident asked them to lean him forward to get sling out from under him. Resident states he felt his knee pop and now it is painful. No redness or edema noted, no dislocation noted. Resident received PRN (as needed) Norco at 1707 (5:07 PM). (Provider service) notified and received order for left knee X-ray. -7/1/23 at 6:01 PM, Writer into see resident d/t (due to) increased pain to left knee. Resident does have Muscular Dystrophy and contractures to his bilateral knees. When asked what happened, he said after he was assisted to bed with x 2 assist CAN he was assisted to sit up to remove sling for positioning, he said he felt a pop in his left knee, and it was sore after. He rated pain 5/10 and his floor nurse in room for this conversation and obtained x-ray orders from Theoria. -7/2/23 at 9:15 AM, X-ray results: Cannot definitively exclude fracture of the distal femur. CT (computerized tomography) recommended. (On call provider service) notified and received orders to keep on bed rest until rounding provider can assess tomorrow. Resident notified and resident requesting to be transferred to ER . Resident c/o pain 8/10 to left knee, no redness or edema noted, PRN Norco administered at 0800 (8:00 AM). -7/2/23 at 3:07 PM, Resident returned from (Hospital) ED (emergency department). X-ray results: Examination is limited due to patient's body hiatus. Fracture of the distal left femur involving proximal aspect of the medial condyle, recommend further assessment with CT exam. Small to moderate suprapatellar joint effusion. Orders for follow up with ortho. Resident returned to facility with soft immobilizer to LLE (Left lower extremity), states pain is 7/10 at this time. (On call provider) notified. Received orders to leave resident on bed rest with immobilizer in place until rounding and therapy can assess tomorrow, increase Norco to 7.5/325 mg q(every) 4 h (hours) PRN. On 1/9/24 at 11:11 AM, an interview was conducted with the DON regarding Resident #5's fracture to the left femur that occurred when care provided during transferring Resident #5 on 7/1/23. The DON indicated that during a transfer with the mechanical lift to bed, the CRCA's had removed the sling from the Resident. The Resident requested to lean forward and take it out in the back of him and heard a pop to the left knee when leaning forward. The DON reported that the CRCA's were trying to make the Resident happy and followed his request on getting the sling out, but that they normally turn a Resident from side to side to remove the sling. The DON indicated the proper way was to remove the sling when turning the resident side to side and stated, despite Resident request always follow procedures. A review of the care plan did not reveal interventions or changes after the incident on 7/1/23. The DON indicated there was no update to the care plan at that time but reported the staff were educated and return demonstrations with mechanical lift transfers were done and the Resident was educated. Resident #222: Review of intake documentation dated as received on 5/9/23 revealed, On Sunday May 7th while visiting (different Resident) I overheard the staff bringing in a resident that had gotten into the parking lot. They discussed they won't report this, they cover up everything here. I don't know who they are. The patient seemed confused and ill . I just felt someone should know . another family member told me these things happen all the time . Please make sure (Resident #222) is ok. The intake further revealed a second complaint was received on 5/10/23 and attached to the original intake which detailed, We don't have adequate staff, so a resident got out of the building. Record review revealed Resident #222 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heart rhythm), tobacco use, alcohol abuse, alcoholic fatty liver, altered mental status, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision/touching to partial/moderate assistance with mobility. Resident #222 was discharged home with home health care on 5/12/23 and passed away on 12/12/23. Review of progress note documentation in Resident #222's Electronic Medical Record (EMR) revealed the following: - 5/7/23 at 3:38 PM Health Care Provider Note: Exit Seeking Event . Nurse advised (Resident #222) was observed outside the facility sitting on the curb this afternoon. The resident was escorted back to room. No reported injury. Staff will continue to monitor . Care team notified. - 5/7/23 at 4:18 PM Nurses' Note: IDT: Approx 3:05 PM informed by (Assisted Living Facility) RCA (Resident Care Aide) of this resident returned to room after being witnessed and assisted indoors from grassy area in center median of AL (Assisted Living) parking lot. Physical examination determines no apparent injury, resident denies discomfort, no skin impairments noted. Gait strong and even, ROM x 4. Resident observed ambulating within room and unit without assistive device. Resident states they 'decided to go for a walk because it was such a nice day' and that they intended to 'sit on a bench' but instead 'sat onto curb' and was 'looking for 4 leaf clovers.' Resident with BIMS (Brief Interview Mental Status Score) 9 (moderately cognitively impaired). Resident denies falling while outside, RCA reporting observing resident laying on ground then sitting up on curb. Neuro checks initiated and WNL, vital signs WNL and on-going. Safety discussed with resident and invited to explore facility courtyard areas, locations explained. Wander guard use explained and resident/son agreeable to placement . 15 min visual checks initiated x 24 hrs. ED (Executive Director) informed. - 5/7/23 at 4:45 PM Nurses' Note: Resident observed ambulating in 100-hallway with 2 CNA's (Certified Nursing Assistants) toward room at 3 PM. CNA's reported they were told resident was outside of building in the north parking lot. They went outside and observed resident sitting on the curb next to sidewalk. Aides assisted resident to standing and brought inside. Resident was observed at 2 PM by 100 hall aide. 100 hall nurse and aide were assisting other residents at the time. Resident was assessed by nurse. Resident had no skin issues or c/o (complain of) pain. Resident calm and cooperative. Stated went outside to see how nice it was and decided to sit down on the curb then was unable to stand . Wander guard placed on left ankle. Resident was agreeable to wander guard and was educated about letting staff know when would like to go outside. Son informed and agreed to wander guard. (Provider) notified as well as weekend supervisor. Resident has been calm and cooperative since event, ate snack and talked to (family) on phone in room. Resting quietly in bed at this time. 15-minute checks continue. - 5/8/23 at 1:17 PM and Edited 5/9/23 at 12:25 PM: The resident did not exit seek . planned to go outside for a walk and enjoy the sunshine. (Resident) stated lives alone at home and goes out when likes. She has had no actions noted or spoken word that wants to exit and leave the facility. (Resident) had agreed to have a bracelet (wander guard) applied that would alarm upon going for a walk as a reminder to sign self out . agreed. (Resident) is deciding if would like to keep this reminder . had reeducation provided by ED this date about letting us know when going out . agreed. Review of Assessment/Evaluation documentation in Resident #222's EMR revealed no documentation of wander/elopement assessment completion prior to or following the unauthorized facility exit on 5/7/23. Review of Resident #222's admission Observation and Data Collection assessment dated [DATE] at 4:03 PM detailed the Resident was at moderate risk for falls, used a wheelchair for mobility, and required assistance for transfers and ADL care completion. The assessment further included a section titled, Exit/Elopement Review which indicated the Resident was not a risk for exit/elopement. Review of Resident #222's care plans revealed a care entitled, Profile Care Guide (Start: 4/26/23; Revised: 5/10/23). The care plan included the interventions: - Safety: Encourage and assist (Resident #222) with transfers. Offer to take resident outside when it's nice. - Transfers and ambulation: Independent with 2ww (wheeled walker). Remind resident to use walker if does not have it . Another care plan entitled, Falls: Resident is a risk for falling R/T (related to): decreased mobility weakness, malnutrition, non-compliant with transfer status i.e. does not use walker at times was initiated on 5/3/23 and revised: 5/10/23 in Resident #222's EMR. The care plan included the interventions: - Staff to assist resident with transfers as needed (Start Date: 5/3/23) - Encouraged/remind resident to ask for assistance when wanting to go outside (Start Date: 5/8/23) Resident #222 did not have a care plan related to exit seeking/wandering and/or elopement. Review of Resident #222's Health care provider orders revealed the order, Transfer Status: 1PA (Person Assist) with gait belt and 2ww. Ambulation Status: to restroom with staff with gait belt and 2ww (Ordered: 4/26/23; Discontinued: 5/9/23). All Resident #222's Incident and Accident (I and A) forms and any applicable investigation documentation during their stay at facility were requested. Review of provided documentation revealed the following: - Safety Events . Exit Seeking Event . Event Date: 5/7/23 3:00 PM .Date Recorded: 5/7/23 3:29 PM . Closed Date: 5/8/23 . Description: Resident observed in AL parking lot . Was the Resident seen exiting the building? No . Where was the resident found? On property . When was the Resident found .? 5/7/23 3:00 PM . behaviors prior to exit seeking . ambulates hallways independently within (sic) assistive device . Mental Status . Confusion . Exit Seeking Risk Factors . alcohol abuse, tobacco abuse . Interventions . Wandering alert device applied . Evaluate medications . 15 min visual checks X 24 hours . Evaluation Notes: No exit seeking occurred . see note . Reported to State: No. - Safety Events . Fall Event . Event Date: 5/7/23 3:00 PM .Date Recorded: 5/12/23 7:41 PM . Description: Fall .Location .Outside on Facility Grounds . What was Resident doing just prior to fall? Ambulation . observed sitting on curb outside . Was fall witnessed? No- Initiate 'Neuro check' order set . Did Resident hit head? Unknown- Initiate neuro checks . Safety equipment in place and functioning at time of incident? Other . res did not use walker . No injury noted . Mental Status . No Changes . New Interventions . Wander guard applied . Physician Notified . 6/19/23 5:56 AM . No documentation of neuro checks following the incident on 5/7/23 were present in the EMR. No documentation of interviews and/or additional investigation documentation was provided. An interview was conducted with the Director of Nursing (DON) and Clinical Support Registered Nurse (RN) F on 1/9/24 at 3:15 PM. When queried regarding Resident #222's exit from the building on 5/7/23, RN F stated they believed it had occurred on Sunday, Mother's Day. The DON specified they were not employed at the facility when the incident occurred. When asked if the facility completed an investigation, as no investigation documentation had been included with the provided I and A forms, RN F indicated an investigation had been completed, they were trying to locate it, and would provide a copy. When asked if Resident #222 had an elopement/exit risk assessment completed following admission, RN F replied, No, the first admit assessment only unless there are behaviors displayed. When queried why the I and A report for the fall was completed on 5/12/23 and indicated the fall occurred on 5/7/23, RN F replied, They (nursing staff) weren't sure if (Resident #222) fell so I told them to do the fall (I and A). When queried if they told staff to complete the I and A on 5/12/23, after the I and A for the exit I and A had been closed, RN F was unable to recall the date submitted. RN F was asked where Resident #222 was found and replied, Out in the front parking lot. RN F was then asked to show this Surveyor where Resident #222 was outside, and a tour was completed. Resident #222 exited through the front/main facility door of the Assisted Living of the facility which faced [NAME] Road (heavily traveled and busy road). A desk with a staff member was present at the front/main entrance door. When if there was a staff member working at the entrance on 5/7/23 when Resident #23 exited the building, RN F stated, I am not sure. After exiting the building, RN F specified Resident #222 was seen sitting in the grassy area of the parking lot which separates the perpendicular parking spots by someone in the Assisted Living of the facility. RN F was asked where Resident #222 was sitting and pointed to the fifth or sixth parking spot (approximately 45 feet north and fifty feet west of the building entrance). Review of facility provided investigation documentation included the following: - Undated Summary Document: May 7, 2023, Event . Short Term . Any attempts to leave prior or request for early discharge? No. Fell in parking or did they sit down in parking lot? If unwitnessed complete the I&A. No injury, resident on (Assisted Living) saw (Resident) from the parking lot. 2:00 PM in room . 3:00 PM someone states (Resident #222) is in the parking lot . Sitting on curb walked back in . Smoker . Said they were going out for a walk. Explained process with requests to go outside. (Spouse) was a resident previously. Was (Resident #222) attempting to smoke due to smoking history? Ambulatory at baseline. Recommendations: Offer patch for smoking . Remove bracelet . is able to leave if chooses . Review the LOA (Leave of Absence) process . when would like to go outside . (Resident #222) does not want to feel like they are a prisoner here so let's ensure we make it clear they are not a prisoner, and we just want them to be safe. No history of elopement for hospital records . No risk factors noted here . - Individual 15 Minute Monitoring Log - Statement of Witness Form . RN EE . 5/7/23 . Resident observed ambulating in 100-hallway with two CNA's toward their room at 3:00 PM. CNA's reported they were told resident was outside of building in the north parking lot. They went outside and observed resident sitting on the curb next to sidewalk. Aides assisted resident to standing and brought inside. Resident was observed at 2:00 PM by the 100-hall aide. 100 hall aide RN and aide were assisting other residents at the time. Resident was assessed by RN . Stated went outside to see how nice it was and decide to sit down on the curb then was unable to stand . wander guard placed on left ankle. Resident was agreeable to wander guard and educated about letting staff know when they would like to go out. - Statement of Witness Form . Licensed Practical Nurse (LPN) EE . Weekend Supervisor . 5/7/23 . ADHS (Assistant Director of Health Services) notified at 3:08 PM of resident observed in grassy center median of AL parking lot; reported to writer at 3:05 PM. ADHS contacted (Administrator). Administrator spoke with writer at 3:24 PM details . Resident without apparent injury . wander guard left ankle with resident and son consent. - Completed Elopement Drill Records for March, April, May, and June 2023. On 1/9/24 at 4:17 PM, an interview was completed with the facility Administrator. When queried what occurred when Resident #222 exited the facility, the Administrator stated, I was notified that (Resident #222) was found outside. The Administrator was asked who notified them and replied, It was our weekend supervisor who is a PRN (casual status staff) now and a DON who is no longer here. When queried who had found the Resident, the Administrator revealed an individual residing on the AL side of the facility had seen the outside from their window. When asked if any facility staff were aware Resident #222 was outside of the building in the parking lot, the Administrator replied that staff were unaware Resident #222 had exited the building. The Administrator then stated, I know that (Resident #222) was out on an LOA (Leave of Absence) the day before with their family. When asked if Resident #222 exited from the same door on 5/7/23 as they did when they left to go on an LOA with their family, the Administrator verified it was the same door. When queried regarding Resident #222's ambulation status when they exited the facility, the Administrator specified the Resident was modified independent (independent with an assistive device) with a two wheeled walker and stated, (Resident #222) didn't always use their walker. When queried regarding the discrepancies identified in the Resident's Health Care Provider orders and care plan interventions related to ambulation and transferring, the Administrator stated, I would feel more comfortable asking MDS (staff). The Administrator was asked why Resident #222's fall care plan was not initiated until 5/3/23 when the Resident was admitted on [DATE] and replied, If we observed (Resident #222) without a walker or something but did provide further explanation. When queried if that was the reason the fall care plan was initiated for Resident #222, the Administrator validated it was. When queried how long Resident #222 had been outside prior to being seen by someone from the AL side of the facility, the Administrator revealed they did not know. The Administrator was then asked if the facility utilized video camera monitoring and revealed the facility does not have recording video camera surveillance at the exit doors. When queried regarding the Resident's risk factors for exit seeking/elopement including but not limited to BIMS indicating moderately impaired cognition, fall risk, history of alcohol abuse, tobacco use, ambulation status, and recent LOA, in addition to staff not knowing the Resident had exited the building, the Administrator replied, I understand what you're saying and verbalized confirmation of safety concerns. Review of facility provided investigation documentation included the following: - Undated Summary Document: May 7, 2023, Event . Short Term . Any attempts to leave prior or request for early discharge? No. Fell in parking or did they sit down in parking lot? If unwitnessed complete the I&A. No injury, resident on (Assisted Living) saw (Resident) from the parking lot. 2:00 PM in room . 3:00 PM someone states (Resident #222) is in the parking lot . Sitting on curb walked back in . Smoker . Said they were going out for a walk. Explained process with requests to go outside. (Spouse) was a resident previously. Was (Resident #222) attempting to smoke due to smoking history? Ambulatory at baseline. Recommendations: Offer patch for smoking . Remove bracelet . is able to leave if chooses . Review the LOA (Leave of Absence) process . when would like to go outside . (Resident #222) does not want to feel like they are a prisoner here so let's ensure we make it clear they are not a prisoner, and we just want them to be safe. No history of elopement for hospital records . No risk factors noted here . - Individual 15 Minute Monitoring Log - Statement of Witness Form . RN EE . 5/7/23 . Resident observed ambulating in 100-hallway with two CNA's toward their room at 3:00 PM. CNA's reported they were told resident was outside of building in the north parking lot. They went outside and observed resident sitting on the curb next to sidewalk. Aides assisted resident to standing and brought inside. Resident was observed at 2:00 PM by the 100-hall aide. 100 hall aide RN and aide were assisting other residents at the time. Resident was assessed by RN . Stated went outside to see how nice it was and decide to sit down on the curb then was unable to stand . wander guard placed on left ankle. Resident was agreeable to wander guard and educated about letting staff know when they would like to go out. - Statement of Witness Form . Licensed Practical Nurse (LPN) EE . Weekend Supervisor . 5/7/23 . ADHS (Assistant Director of Health Services) notified at 3:08 PM of resident observed in grassy center median of AL parking lot; reported to writer at 3:05 PM. ADHS contacted (Administrator). Administrator spoke with writer at 3:24 PM details . Resident without apparent injury . wander guard left ankle with resident and son consent. - Completed Elopement Drill Records for March, April, May, and June 2023. An interview was conducted with RN F following review of the pro[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #218: A review of Resident #218's medical record revealed an admission into the facility on 2/18/22 and died at the facility on 9/19/22. The Resident had diagnoses that included Covid-19 acute respiratory disease, Alzheimer's disease, dementia, cerebral ischemia, heart disease, atrial fibrillation, kidney disease, diabetes, stroke, anxiety disorder, retention of urine, and pain. The Resident had been under Hospice services. A review of Resident #218's Minimum Data Set assessments (MDS) for Resident #218 revealed the following: -Dated 2/24/22, OBRA admission assessment, Section C revealed the Brief Interview for Mental Status score of 4/15 that indicated severe cognitive impairment. Section G Functional Status for Activities of Daily Living (ADL) Assistance indicated the Resident needed extensive assistance with two-person physical assist with bed mobility and transfers. -Dated 5/26/22, OBRA Quarterly review, Section C revealed the Brief Interview for Mental Status score of 8/15 that indicated moderate cognitive impairment. Section G Functional Status for Activities of Daily Living (ADL) Assistance indicated the Resident needed extensive assistance with one-person physical assist with bed mobility and transfers. -Dated 8/15/22, OBRA Significant change in status assessment, Section C revealed the Resident had moderately impaired cognitive skills for daily decision making. Section G Functional Status for Activities of Daily Living (ADL) Assistance indicated the Resident needed extensive assistance with two-person physical assist with bed mobility and transfers. A review of Resident #218's progress notes revealed the following: -7/23/22 at 5:36 AM, .Writer assisted CRCA (Certified Resident Care Associate (CNA)) with patient care this shift; writer calmly and patiently approached resident with permission to care for him, res showed some resistance, but was easily convinced we would be quick and efficient . -7/24/22 at 4:59 AM, .Resident became agitated with HS (nighttime) cares but was easily redirected . -7/25/22 at 5:15 AM, .Resident became agitated with HS cares but was easily redirected . -7/26/22 at 3:49 AM, . early last shift res (resident) experienced some agitation, was easily redirected and allowed writer to collect bold pressure and check blood sugar . -7/29/22 at 5:05 AM, Resident continues on hospice care, Resident became combative with incontinence care in the night. Resident also became agitated this morning when writer woke resident up to check BP but was easily redirected. -7/31/22 at 10:30 AM, Writer called to resident's room in response to CNA calling out for her help. Upon entering room writer noted resident on floor on his stomach. ROM (range of motion) performed to all 4 extremities with no c/o (complaints of) pain resident assisted to his back and 3 abrasions to his forehead, 1 abrasion to the bridge of his nose, along with a bruise beginning to form to his right upper forehead. Resident c/o mild pain to his forehead but to no other areas of his body. Resident assisted x 3 to his w/c (wheelchair) and nurse performed neuro checks which were normal. (Physician) and hospice notified . -7/31/22 at 2:16 PM, IDT (interdisciplinary team) fall review: . Fall was witnessed by CRCA (Certified Resident Care Associate, (CNA)) who states during transfer from bed to w/c resident lost balance when attempting to turn and fell forward. Current transfer status 1 PA (physical assist) with gait belt, transfer status updated to 2 PA with gait belt due to staff reporting increase assistance needed with transfers . -8/1/22 at 9:39 AM, Resident observed with bruise around right thumb and wrist, unable to move thumb or wrist at this time. Nurse practitioner ordering x-ray . -8/1/22 at 3:39 PM, Resident x-ray shows mildly displaced intra-articular fx (fracture) at medial base of the first metacarpal right hand, (Physician group) informed and hospice informed. Wife informed. -8/6/22 at 10:57 AM, IDT met to discuss resident's fall on 7/31. Resident was being assisted with care. He was transferring into his wheelchair when he lost his balance. CRCA did attempt to stop resident from falling but was unable to. Resident's POC (plan of care) show he was a standby assist with transfers at the time of fall. The next day resident complained of pain to hand. X-ray showed fracture. Resident sent to hospital for treatment where he was casted and returned to facility. Facility contacted hospice and got order for PT (physical therapy) to evaluate for transfer status. At the time of the fall staff downgraded residents transfer status. This will remain in place until PT evaluation. At the time of the fall the POC was being followed. Reviewed by IDT . On 10/4/22 at 2:15 PM, an interview was conducted with the Director of Nursing (DON) and the Clinical Support Nurse (CSN) W regarding Resident #218's fall on 7/31/22 while the CNA was transferring the resident that resulted in facial abrasions and a fracture to the hand. The CSN indicated that the physician order was for one person assist with gait belt, but the CNA was following the care profile that indicated the Resident was a standby assist. The CSN indicated they had identified that there was a mismatch in the transfer orders between hospice and the care guide. The DON indicated that the care guide is what the CNAs use when caring for a resident and was what the care plan was. The CSN reported that they had educated the staff to ensure all care plans and orders matched and were up to date. Documentation of aggressive behavior from Resident #218 with care was reviewed. The DON was asked about assessment and re-evaluation from therapy for safe transfers with the change in the Resident and showing aggressive behaviors. The DON indicated that the aggressive behavior was with care and not during transfers and stated, I don't believe that would be a criteria to downgrade transfer status to 2 person assist. The DON was asked when did decline start occurring with Resident #218. The DON reviewed the medical record and stated, On 4/29 (4/29/22) that was my first note on his decline. When asked what kind of decline the Resident was experiencing, the DON reported stroke like symptoms, elevated blood pressures, drooping of the left side, not able to lift his arms, and explained that he would have episodes and that when he came back around, he would be slow to respond. The DON was asked if the Resident was showing these signs and symptoms during the transfer when the fall occurred. The DON indicated she did not know and reported that the episodes were isolated and stated, As his diagnoses progressed, they got more frequent. The CSN and DON were asked if a gait belt was in use during the time of the transfer and fall. The DON indicated she was unsure. The CSN reviewed documentation and indicated that a gait belt was not in use and reported that the matrix (MDS) was one person assist and the care plan/care profile was standby assist with the physician order that was a one person assist with gait belt. The CSN reported that the CRCA (CNA) can't see the orders, so they were following the care profile. On 10/5/22 at 10:01 AM, an interview was conducted with CNA G who had transferred Resident #218 when the fall occurred. The CNA indicated she had got him out of bed and reported the care guide had the Resident as a standby assistance. The CNA reported that when he transferred, he was confused with what he wanted to do, and stated, He was confused when he stood up and was confused on how to turn to get into the wheelchair. When asked about the Resident's history of confusion, the CNA reported the Resident was always confused with transferring, and needed cuing with directions. The CNA stated, He was so timid with how to do it. Usually, I grab his pants and guide him to where he is supposed to transfer to. The CNA indicated she had been cuing the Resident and when he went to sit down had missed the seat of the wheelchair. When asked about gait belt use, the CNA stated, Use of a gait belt is usually done with transfers. Usually, I use a gait belt on everyone. The care plan (for Resident #218) did not have it on there. On 10/5/22 at 10:40 AM, an interview was conducted with Therapy Director, QQ. The Therapy Director was asked about gait belt use and indicated that a gait belt was used for all transfers unless the Resident was independent or modified independent. The Therapy Director indicated that gait belts were available in the Resident rooms and that staff were to use them with transfers. The Therapy Director was asked if a gait belt were to be used with a standby assist for transfers and he had reported that a gait belt should be used for standby assistance. Based on observation, interview and record review, the facility 1) Failed to ensure that safe practices were in place to prevent a burn from hot coffee for one resident (Resident #14) and 2.) Failed to ensure fall that prevention measures were developed and implemented to prevent a fall for one resident (Resident #218), resulting in Resident #14 sustaining a burn injury on his right thigh without additional measures to ensure all residents were protected from similar burn injuries and Resident #218 falling without preventive measures identified and implemented to aid in preventing additional falls and a fracture to the hand. Findings Include: Resident #14: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #14 was admitted to the facility on [DATE] with diagnoses: history of a stroke, arthritis, neuralgia (nerve pain), left upper limb carpal tunnel syndrome, right shoulder pain, right hand stiffness, glaucoma, weakness, hypertension. The MDS assessment dated [DATE] revealed Resident #14 had full cognitive abilities and needed 1-person extensive assistance with dressing and hygiene and 1-person limited assistance with bathing. On 10/03/22 at 9:59 AM, during a tour of the facility, Resident #14 was observed sitting in a wheelchair in his room watching TV. He was alert and sociable and readily engaged in conversation. A review of an Event Report dated 9/5/2022 and Event Date: 9/4/2022, by Nurse GG revealed, Skin Integrity Events: Burn Event: . Location of Burn #: right thigh . Degree of Burn #1: Second Degree/Superficial Partial Thickness- Extends through the epidermis downward into the superficial into the dermal layer, dermal structures are intact. Characterized by large blisters, edema, pain shiny surface . Additional comments for Burn #1: Length 2 cm, width 4.5 cm, blister ruptured . Pain of burn . (nothing was recorded) . Activity during when burn occurred: (options were: drinking hot liquid; from appliance, describe; while eating; other, describe) nothing was checked; Skin risk re-assessment: (it was blank, no options were checked); New Interventions- Immediate Actions taken: (it was blank, no options were checked); Burn Re-assessment: Follow-up- Week 1 , Week 2 and Week 3 were blank. There was no documented Follow-up. On the Event Report dated 9/5/2022 for Resident #14, Treatments was documented Apply Xeroform to left outer thigh open area (burn) after NS (normal saline) cleanse. Cover with ABD (dressing) and secure with paper tape QD (daily), 9/5/2022-9/8/2022. A review of the progress notes for Resident #14 provided the following: 9/05/2022 at 2:55 PM, Pt (patient) reports to writer that on 9/04 in the evening approx. 930pm Pt had been carrying hot coffee on right side of chair and had tipped over causing burn to right thigh. Pt states he didn't tell anyone because It was late and there was nothing anyone could do about it. States, it was too late to call my son and have him go to the pharmacy. Writer educated res on notifying nursing staff so appropriate measures could be taken to assure no infection would take place. Informed res we order meds through our pharmacy. Area was assessed and noted with blistered area ruptured. Xeroform dressing applied after NS cleanse. Area covered and orders placed for treatments. NP (Nurse Practitioner) notified and will assess on 9/06. A provider note by NP, Sep 6, 2022, General: Patient is an [AGE] year old male with past medical history . CVA (stroke) who is a long term resident of the facility .Patient is being seen this morning for a burn to his right thigh. Patient states he accidentally dumped coffee on himself that resulted in a burn. Patient states this happened this morning. Patient states pain with palpation, mild in nature. Noted to have a second degree/partial thickness burn to outer right thigh. First presentation of burn possibly could be a deroofed blister from burn. Noncircumferential, less then 1 palm size of a burn. Reddened/erythema skin noted to base of wound. No drainage noted. Peeled skin is noted to outer layer of burn. Patient was noted to have a dressing on wound with antibiotic ointment. Will order Silvadene cream at this time, cleanse area with NS and apply Silvadene cream with abd and tape down. Wound to be monitored and dressing changed 1 time daily or as soiled . 9/7/2022, a progress note, CNA (nurse aide) assisted res with shower this am; hair washed. Nails cleaned. No trim. Right thigh with area of burn; skin appears open . 9/9/2022, a progress note by NP Q, .F/u (follow-up) on burn to right thigh . Patient is being seen this morning for follow up on burn to right thigh. It was noted from patient that he split hot coffee on his leg a few days ago. Patient was evaluated then with Silvadene (burn treatment) cream Ordered. On assessment patient is sitting in wheelchair getting cleaned up for the day. On assessment patient is denying any chest pain shortness of breath fever chills or cough. Patient states that he feels that his burn is trending towards improvement. Site is measured where it is 4cm x 4cm with surrounding erythema (redness), continues to be reddened at the base, with slight continuation of appearance of deroofed blister. Site is free from signs or symptoms of infection. Will continue with Silvadene BID (twice a day) and continue to monitor site . On 10/5/2022 at 10:15 AM, a Healthcare surveyor obtained the temperature of the coffee at the coffee and juice bar in the Town Square dayroom. The coffee temperature was 166.1 degrees Fahrenheit. O 10/5/2022 at 4:15 PM, the Food Service Director E and Corporate Food Service Director F were interviewed about the coffee temperatures at the coffee and juice bar, where residents were able to obtain their own coffee and they said they had temped the coffee and it was fine. Reviewed with them it had caused a 2nd degree burn on Resident #14's leg. They were asked if any additional measures were in place to prevent this from happening again and said the coffee was fine. An interview with the Director of Nursing/DON on 10/5/2022 at 10:45 PM, about Resident #14 developing a burn on his right thigh from a hot coffee spill, she said the resident had not notified anyone of the spill until the next day. She said he had a blister on his leg from the hot coffee and after a few days did not want a dressing on it any longer. The DON said the facility had provided the resident with a cup holder for his wheelchair and he tried it and said he didn't like it. The DON was asked if the facility had tried a different cup holder or any other measures to aid in preventing future hot coffee spills and she said she would have to check on it. During an interview with Nurse V on 10/5/2022 at 3:12 PM, about Resident #14's hot coffee spill and burn to his right thigh, the nurse stated All I know is when I came in the next day, they said he had spilled some coffee on his leg and there was a blister. He is usually eating his dinner about 6:30 PM; then later he propels in his wheelchair to Times Square where there is a coffee and juice bar. He usually goes there in the evening and gets a cup of coffee and propels himself back with the coffee. I believe they put a cup holder on the wheelchair. I asked him about it and he said, 'I don't like it.' I said it was for safety.' The Nurse was asked if any resident could go to the coffee and juice bar and get their own coffee and she said if they were able to, they could. On 10/10/22 at 9:15 AM, the DON and Clinical Support Nurse W were interviewed about the hot coffee burn that Resident #14 received. They were asked what interventions were put in place to ensure that it would not happen again. Both nurses talked about Resident #14 not liking the cup holder on his wheelchair. When asked if anything else had been tried, they said it hadn't. The nurses were asked if anything had been put in place so that other residents didn't receive a burn and there was no response. A review of the physician orders for Resident #14 did not identify any orders for prevention of burns from hot coffee. A review of the Care Plans for Resident #14 dated 9/6/2022 provided, Resident demonstrates non-compliance with physician orders and/or plan of care as evidenced by: [NAME] did not inform staff that he spilled hot coffee on his leg until the following day, dated 9/6/2022 with Interventions: 9/13/2022: Burn Intervention: intervention for burn includes adding a cup holder to chair; . (Resident #14) finally allowed cup holder to be attached to his wheelchair. Cup holder in place; 9/29/2022- per (Resident #14's) preference he states he does not need the cup holder on his wheelchair. 9/6/2022: Educate resident regarding physician orders and risk and benefits of compliance. 9/6/2022: Encourage resident to actively participate in care plan and decision making. 9/6/2022: Encourage resident to participate in decision making by offering choices . 9/6/2022: Staff educated (resident) to notify nursing staff immediately if he spills coffee on his self so appropriate measures can be taken to assure no infection will take place. The Care Plan did not offer any additional interventions to prevent Resident #14 from receiving another burn from hot coffee or other hot liquids. A policy for accidents was requested on 10/10/2022 at 1:30 PM and not received prior to exit on 10/10/2022 at 4:30 PM.