**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the development of facility-acquired pressure ulcer injuries for one resident (Resident #8), resulting in facility-acquired (in-house) development of pressure ulcers, pain, discomfort, and the likelihood for prolonged illness or hospitalization. Findings include: Record review of the facility provided 'Skilled Nursing Facility Skin Conditions Prevention and Treatment' policy, dated 11/20/2023, revealed the purpose was to promote the prevention of pressure ulcer development, healing of those that are present and prevention of additional pressure wounds. Pressure injury- is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination of shear. Stage II (2): Partial thickness skin loss with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage IV (4): Full-thickness skin and tissue lose with exposed or directly palpable fascia, muscle, tendon, ligament. cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Record review of the facility- provided Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS-802 matrix revealed Resident #8 to have a facility-acquired Stage IV pressure ulcer. Resident #8: Record review of Resident #8's Minimum Data Set (MDS), dated [DATE], revealed an elderly female with a Brief Interview of Mental Status (BIMS) score of 14 out of 15, cognitively intact and able to make decisions. Medical diagnoses included: Debility, heart failure, high blood pressure, diabetes, anxiety, and depression. Section GG: Functional abilities assessed Resident #8 as substantial/maximal assistance (helper/staff does more than half the effort) for: laying to sitting on side of bed, sit-to- standing, chair/bed-to chair transfer, toileting transfer and tub/shower transfers. Record review of the Section M: Skin Conditions- revealed no pressure ulcers or skin injuries. Record review of Resident #8's Electronic Medical Record (EMR) census tab revealed that the resident was out of the facility for hospital care in October of 2023, returned/re-admitted to the facility and has remained at the facility since that date. An interview on 03/04/24 at 10:41 AM with Resident #8 revealed that she did have a left hip wound. Resident #8 stated that she did not know if she came with it, but that they (staff) are doing dressing daily and they measure it. Resident #8 stated that she did believe that she got the sore at the facility because she went to the hospital last October and when she came back, she wasn't moving a lot. Record review of Resident #8's Minimum Data Set (MDS), dated [DATE], revealed an elderly female with a Brief Interview of Mental Status (BIMS) score of 14 out of 15, cognitively intact able to make decisions. Medical diagnoses included: Debility, heart failure, high blood pressure, diabetes, anxiety, and depression. Section GG: Functional abilities assessed Resident #8 as substantial/maximal assistance (helper/staff does more than half the effort) for: laying to sitting on side of bed, sit-to- standing, chair/bed-to chair transfer, and toileting transfer. Record review of the Section M: Skin Conditions- revealed a pressure ulcer staged at Level IV-full thickness skin and tissue loss. An interview on 03/04/24 02:31 PM with Registered Nurse (RN)/Wound Care Nurse I revealed that Resident #8 likes to lay on her left side. The left hip wound started in December 2023 at the facility and was a facility-acquired pressure ulcer. RN I stated that skin assessments found a bump or sack on the outside aspect of the left hip in November 2023. In December of 2023 the left hip bump/sack sides/rim of wound became necrotic with dry eschar. The facility started treatment of Santyl ointment debridement of the wound area, and the necrotic tissue came off. RN I stated that he was able to see wound bed and depth and staged the wound at a Stage IV pressure ulcer. RN I stated that the wound has a depth of around 2.7 cm (centimeters) and changed treatment to Melgisorb antimicrobial alginate cut to fit the wound bed and used to absorb exudate (drainage). Record review of Resident #8's 'Wound Management Detail Reports', dated 12/19/2023 through 2/28/2024, revealed a left hip wound that started on 12/19/2023 at 11:27 AM measuring length 3 cm X width 3.2 cm X depth 0.2 cm with serosanguineous exudate, Stage III. The wound management report on 01/19/2024 at 3:13 PM noted length 2.4 cm X width 1.5 cm X depth 1 cm with moderate exudate of seropurulent (yellow or tan, cloudy and thick) drainage with mild foul odor. The wound was staged as a Stage IV pressure ulcer-full thickness skin and tissue loss. Observation of wound care on 03/05/24 at 09:04 AM with Registered Nurse (RN) I (wound care nurse) revealed an old dressing date 3/4/24 was removed. Observed wound bed pink and with moderate serosanguineous drainage, no odor. Dermal wound cleanser spray was applied and the wound bed was dabbed with 4 x 4 gauze. Wound measurements taken: 1.3 cm length, X 1.1 cm width, X depth 1.9 cm. Observed treatment of Melgisorb alginate cut to size, (debride with silver per RN I), applied to wound bed, and covered with an Allevyn 4 x 4 foam border dressing. An interview was conducted on 03/05/24 at 09:12 AM with Resident #8 while in the room with Registered Nurse (RN) I, Resident #8 stated that the wound was painful, and rated at a scale of 7-8 out of 10. Resident #8 stated that it goes down to a 5 after she gets her pain pill. Resident #8 stated that she kept complaining of pain after her fall a while ago. RN I and state surveyor observe Fentanyl patch to right shoulder, dated 03/04/24, for pain control. In an interview on 03/06/24 at 10:35 AM with the Director of Nursing (DON) regarding Resident #8's Stage IV pressure ulcer, the DON stated that the Stage IV pressure ulcer was facility-acquired and Resident #8 had a [NAME]-sized lump to that area. Resident #8 had a fall on October 10/26/2023, where she slid off of the edge of the bed. There was no noted injury at that time, but she kept complaining of pain. The facility did further testing and found a hematoma to the left hip area in November 2023, which is how they believe it opened. It was facility-acquired. Record review of Resident #8's 10/26/2023 at 1:30 AM 'Event Report' noted a fall in the resident's room with no witnesses. The resident complained of pain rated at moderate (distressing/miserable per report). The resident put on the (call) light and was found on her knees next to bed, laying over the bed. Record review of Resident #8's left hip X-Ray dated, 11/24/2023 (30-days post fall), revealed a contusion/hematoma peri trochanteric without an acute fracture noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for fall prevention for one resident (Resident #6) of five residents reviewed, resulting in a lack of implementation of Physical Therapy recommendations, lack of enactment and reevaluation of planned care plan interventions, and Resident #6 experiencing a fall with a head laceration necessitating emergency medical treatment, staples, unnecessary pain, and the likelihood for additional falls with injury. Findings include: Resident #6: On 3/4/24 at 11:23 AM, Resident #6 was not in their room. An observation of their room was completed. There were no fall prevention interventions, including a fall mat observed in the room. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included dementia, left hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), atrial fibrillation (irregular heart rhythm), and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial/maximum assistance for toileting hygiene and transferring. Review of Resident #6's Electronic Medical Record (EMR) revealed an Event Report dated 11/07/23 pertaining to an unwitnessed fall. The Event detailed, Fall . Shower room bathroom . Does resident exhibit or complain of pain related to the fall? . Yes, LLE (Left Lower Extremity) . Note any injury to the head, extremities, or trunk . Abrasion . Laceration . ROM (Range of Motion) Painful/Limited in Lower Extremity . Possible Contributing Factors . Recent Change in Appetite . Recent Decline in ADL Abilities . adaptive equipment in use at the time of the fall? No . Immediate measure taken . First Aid . Direct Pressure to Wound . Sent to ER . Change in Mental Status of new onset . Laceration with uncontrolled bleeding . New onset of moderate to severe pain . Evaluation Notes: Per documentation and statements, resident was put on the toilet in the large shower room between 0845-0850. At 0905 resident was observed on the floor on left side with head between the front wheels of wheelchair . taken to the ER due to bleeding from the Occipital head and pain with palpation of the left hip was positioned angled to the right on the toilet seat. Resident has a history of falling asleep sitting in wheelchair. Resident has left hemiplegia from a previous CVA. The wheelchair was positioned in front of the toilet and the brakes were locked. Resident receives many medications that increase the risk for falls. Resident has a suprapubic catheter in place . recently placed on Part B services (therapy) due to increased weakness post COVID. Root Cause: Resident most likely fell asleep and leaned to the left and fell off of the toilet . most likely received the laceration to the left Occipital area from the inner foot pedal mechanism on the wheelchair . received a large contusion to left hip . was care planned to not be left alone in the bathroom . Further review of Resident #6's EMR documentation revealed the following: - 11/7/23 at 9:05 AM: Resident on floor in large shower room laying on left side with head laying in between lock wheelchair front wheels complaining of lower back hurting. Noted blood on floor under left side of head. Resident does not know how fell on floor . Resident does complain of head hurting . to head where bleeding was happening . complains of left hip pain upon palpation and redness noted . Resident was assisted on back board and onto gurney and taken to ER . Unable to obtain BP due to position of resident . - 11/7/23 at 9:05 AM: At approximately 0905 on 11-7-2023. This writer heard a faint voice yelling for help. Thinking it was another resident's TV, I initially checked room with loud TV playing. When I made my way back to the station, I heard resident's voice faintly from shower room bathroom, saying 'help me.' I opened shower room door and observed resident on floor, partially under wheelchair with head between front wheels, left side lying, pants down between legs, with catheter attached to bag under chair. This writer yelled for help, stating resident was on floor. When asking what happened, resident said they did not know how they fell . Staff moved wheelchair out of way and observed moderate amount of dark red blood to resident's hair, sweater, and puddle on floor. Observed resident's head, coagulated blood appeared to be coming from left posterior side of head. Resident states head hurts. Applied pressure using washcloth until DON (Director of Nursing) arrived, who then held pressure. This writer assessed, limited ROM to both LUE (Left Upper Extremity) and LLE (Left Lower Extremity), as per resident baseline d/t (due to) history of CVA (Cerebrovascular Accident- Stroke) with left affected side . pain to left hip with palpation, with noted redness . Unable to check upper back and complete LUE due to heavy sweater. Attempted to check mentation, resident alert to self only. Vitals attempted by aides. Back board applied under resident, and resident lifted onto hospital bed to be transported to ER. - 11/7/23 at 10:59 AM: Resident brought back to room with head x-ray negative along with x-ray of left hip was negative. 2 staples to back of left side of head present . abrasion noted on left buttock region and back of left side of head has 2 staples intact with dried blood noted . - 11/7/23 at 12:40 PM: Resident . was given Tylenol . due to head hurting . - 11/7/23 at 8:35 PM: Resident with complaint of left hip pain, upon assessment left hip with large firm protrusion approximately the size of palm of hand, red in color, no noted bruising. Noted internal rotation of left hip and difficult for resident to have moved without increased pain. Will notify Doctor. - 11/7/23 at 8:38 PM: Doctor notified by phone with resident condition, order received for CT stat . and Norco (narcotic pain medication) 5-325 mg (milligrams) every 6 hours as needed for pain . Review of Resident #6's EMR revealed a care plan entitled, (Resident #6) at risk for falling R/T (related to) CVA (stroke) with Left Hemiparesis, history of falls at home, impaired mobility, weakness . (Start: 1/14/19; Edited: 12/12/23). The care plan included the interventions: - Provide resident with safety device/appliance: bilateral bed bolsters for awareness of edge of bed (Start: 4/7/20; Edited: 12/12/23) - Soft mat to active side of bed . (Start: 6/10/19) - Place resident in a fall prevention program (Start: 1/14/19) Review of Resident #6's hospital documentation dated 11/7/23 at 9:24 AM revealed, ED Provider Note . Patient has longstanding history of dementia . atrial fibrillation (currently on Xarelto [blood thinner]) . and prior stroke . presents to the emergency room . after fell from the toilet . struck the left occiput (back) area of head on the floor and was complaining of left hip pain. The incident was not witnessed by (staff) did hear the patient hollering for help . did have some active bleeding from the left occiput . unknown loss of consciousness . mild left hip pain . (Resident #6) is heavily demented .does not remember the fall . The hospital ER documentation revealed Resident #6's head laceration was closed with staples and the Resident was transferred back to the facility. Review of left hip CT results dated 11/7/23 at 9:11 PM in Resident #6's EMR revealed the Resident had a subcutaneous contusion (bruise under the skin) in their upper, outer left thigh. On 3/6/24 at 8:51 AM, Resident #6's room was dark with the lights off and the window blinds closed. The Resident was in bed, positioned on their back with their eyes closed. A fall mat was not present in the room. An interview was completed on 3/6/24 at 8:58 AM with Certified Nursing Assistant (CNA) N. When queried if they were working on 11/7/23, CNA N revealed they were. When queried regarding Resident #6's fall on 11/7/23, CNA N stated, I wasn't in there. (Resident #6) was in the shower room alone. When asked the reason Resident #6 was in the shower room, CNA N indicated the Resident was using the restroom. CNA N was asked if Resident #6 required assistance to use the restroom in November 2023 and revealed they did. CNA N stated, (Resident #6) leans so bad and I don't like leaving them alone anyway. When asked to clarify if they were referring to the Resident currently or in November at the time of the fall, CNA N verbalized they were referring to when the Resident fell in November but indicated the Resident still leans. When queried if they had assisted Resident #6 to use the restroom in November 2023 prior to their fall, CNA N revealed they had and specified they always stayed with them because they were uncomfortable leaving them alone due to the Resident being unable to sit up straight without assistance. CNA N was then asked if Resident #6 is supposed to have a fall mat in their room and replied, Used to but they took it out. When queried who took it out and when, CNA N indicated they could not recall. When queried how they know what level of assistance and/or care plan interventions residents require, CNA N replied it was in the computer (EMR). When asked, CNA N showed this Surveyor what saw when they looked at Resident #6's EMR care plan. The care plan displayed on their screen only showed the care plan title and no interventions. When asked if they knew how to view the specific interventions for each care plan, CNA N replied, I really don't. An interview and observation of Resident #6 was completed with Registered Nurse (RN) Q on 3/6/24 at 9:21 AM. Upon entering the Resident's room, Resident #6 was observed in bed, positioned on their back with their eyes closed. RN Q was asked if the Resident had a fall mat in place and after looking replied, No. After exiting Resident #6's room, their care plan was reviewed with RN Q. When queried, RN Q confirmed the Resident's care plan specified the Resident should have a fall mat and they did not have one. On 3/6/24 at 9:30 AM, an interview was conducted with RN I. When queried regarding Resident #6 not having a fall mat per their care plan intervention, RN I stated, They are not supposed to have a fall mat. When asked why they are not supposed to have a fall mat when it is on their care plan, RN I replied, I don't know. RN I then stated, I am guessing they just put it (fall mat intervention) on there (care plan). I will just take it off. When asked if they were going to complete a fall risk assessment prior to discontinuing the evaluation, RN I did not provide a response. When queried why the intervention was implemented in the first place, RN I indicated the Resident most likely had a fall, but the intervention was no longer needed. RN I was asked why the intervention was on the care plan if it was no longer appropriate and stated, That is on me. I have reviewed the care plan a couple of times. When asked, RN I stated, If it (fall mat) is on the care plan, it should be in there (Resident #6's) room. An interview was completed with the Director of Nursing (DON) on 3/6/24 at 9:50 AM. When queried regarding Resident #6's fall mat not being in place, the DON indicated they were aware of the concern. The DON indicated they have been working with the nursing staff to have them help update Resident care plans with any changes. On 3/6/24 at 10:07 AM, an interview was completed with CNA M. When asked what occurred when Resident #6 fell on [DATE], CNA M revealed they assisted the Resident into the shower room, transferred them onto the toilet, and then left them alone to have a bowel movement. CNA M revealed as they were waiting outside of the shower room for Resident #6, another call light went off and they went to answer it. When queried what time of the day the fall occurred, CNA M stated, It was right after breakfast. CNA M was then asked if they observed and/or assisted the Resident after the fall and stated, I helped get (Resident #6) into the bed and took them to the ER. I don't understand how they fell that way. (Resident #6) was sitting perfectly strait on toilet. When asked to explain, CNA M stated, I sat (Resident #6) perfectly (on the toilet). I got (Resident #6) positioned on the toilet and the wheelchair was kind of in front of them locked. When asked if Resident #6 would try to stand up on their own, Resident #6 indicated the Resident did not attempt to stand on their own. CNA M indicated the Resident would lean when they were sitting and always hangs on to the metal bar in the shower room bathroom no matter what. When asked if they normally wait by the door when Resident #6 was using the restroom, CNA M did not provide a direct response but stated, We always let everyone know the Resident was in the restroom. At 10:38 AM on 3/6/24, an interview was conducted with Physical Therapy Assistant (PTA) P and Occupational Therapist (OT) O. When queried if Resident #6 was receiving therapy in November 2023, PTA P and OT O reviewed the Resident's EMR and revealed the Resident was First seen by therapy on 11/2/23 for an initial evaluation. A review of Resident #6's Physical Therapy Initial Evaluation dated 11/2/23 was completed with PTA P and OT O at this time. The Evaluation form detailed, Subjective: Recent onset of COVID 19 infection led to isolation, resulted in weakness, tightness of LLE (Left Lower Extremity), poor posture, decreased functional transfers/bed mobilities . Patient wants to be able to use LLE, sit straight, and help CNA's with transfers . Sitting with Back Unsupported but Feet supported on the Floor or on a Stool: Unable to sit without support 10 seconds . Observations . Patient is wheelchair bound, has a 45 contracture present on LLE . Poor postural awareness . Balance: sitting/standing static, dynamic: Poor . Transfers, Bed mobilities . Max . Dependent . Assessment . decreased P (Passive)/AA (Active Assisted)/AROM (Active Range of Motion), Decreased Motor Control on both LE's, Trunk . Impaired sitting/standing balance . When queried if sitting on a toilet was considered Sitting with Back Unsupported but Feet supported ., OT O stated it was. PTA P and OT O were then asked if Resident #6 was safe to leave unattended while sitting on the toilet, per the therapy evaluation. Both staff verbalized the Resident required assistance to maintain sitting balance and should not have been left unattended in the bathroom. When asked how therapy recommendation are communicated to nursing staff, OT O indicated therapy staff verbally communicate with nursing staff and nursing staff also have access to review therapy documentation in the EMR. An interview was conducted with the DON and facility Administrator on 3/6/24 at 11:40 AM. When queried regarding the facility policy/procedure related to communication of ADL care assistance from therapy, both the DON and Administrator indicated that evaluations, concerns, and changes are discussed at the morning meeting. When asked if Therapy staff enter orders in the EMR and/or update Resident care plans related to ADL assistance/transfer status, the Administrator and DON revealed Therapy staff do not. When queried why Resident #6's was left unattended on the toilet on 11/7/23 after their therapy evaluation on 11/2/23 detailed they were unable to sit without support for 10 seconds, both the DON and Administrator indicated they were unaware of the evaluation. The Administrator and DON reviewed Resident #6's Physical Therapy Initial Evaluation. When asked if the Resident should have been left unattended in the bathroom when they were unable to sit without support, both the Administrator and DON verified the Resident should not have been left unattended. Review of facility policy/procedure entitled, Skilled Nursing Facility; Falls Management (Reviewed 4/21/23) detailed, The Falls Management Process guides the staff through a structured risk assessment and planning process, is utilized to evaluate appropriate interventions to minimize the risk of falls and fall related injuries . The personal safety of each resident of the Skilled Nursing Facility is of primary importance . Any decisions to remove or modify safety or fall prevention measures, will be made by the multi-disciplinary Falls Committee team members. 9. Orders to remove safety devices or to decrease the level of assistance to the resident will be written after the multi-disciplinary Falls Committee team has had an opportunity to review the recommendations. 10. Care Plans will be updated to communicate changes to the staff to reflect the orders written .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00140583. Based on observation, interview and record review, the facility failed to ensure necessary supervision for one resident (Resident #101), who was left in the dining room unsupervised with a hot cup of coffee, which did not have a lid on it. The resident spilled the hot coffee on her lower abdomen and upper thigh area, resulting in first and second degree burns, pain, wound care and prolonged healing time. Findings Include: Resident #101: Review of the Face Sheet, Minimum Data Set (resident assessment tool) dated 9/22/23, progress notes dated 10/20/23, physician's orders dated 10/20/23 through 11/16/23 and care plans dated 9/21/23, revealed that Resident #101 was 81 years-old, admitted to the facility on [DATE], had decreased cognition, (and thus was not able to be interviewed), dependent on staff for all Activities of Daily Living and required set-up with eating. The resident's diagnoses included, right-sided hemiplegia and weakness, hemorrhagic stroke, decreased expressive communication, Dementia, depression and anxiety. Review of the MDS dated [DATE], revealed a BIMS of 6 (cognitive evaluation with decreased cognition). The resident had a history of stroke with right-sided weakness. Review of the resident's facility restorative, mood, and communication care plans, dated 9/21/23, revealed that the resident had communication difficulties, Dementia and had a right-sided weakness due to a stroke. Review of the Incident Report, Investigation Report and staff statements, dated 10/20/23, revealed on 10/20/23 in the main dining room, Resident #101 was sitting at a table waiting for her breakfast. She was served hot coffee by staff without a lid on it (the lids provided did not fit the cups correctly). The resident started screaming and staff ran into dining room and found the resident had spilled her hot coffee on her lap (lower abdomen and upper thighs). Staff immediately pulled her clothing up off her skin and wheeled her to her room and assessed her. She had first and second degree burns on her thigh and dime size area on her abdomen. The Dietary Department did not temp the coffee on the morning of 10/20/23 (no documentation of temp taken on that date was available), brought it down and staff served it to the resident without a lid. The physician, Administrator and Family were all notified on 10/20/23 per facility policy. Review of the nursing notes, dated 10/20/23 at 11:42 AM, stated At approximately 0700 this writer (Nurse, RN D)heard a resident screaming very loudly. I attended to resident who was in main dining room at table directly in front of south window (by nurses station). I immediately yelled for help, and grabbed at her clothing, holding it away from her skin. We wheeled resident into her room, removed clothing, placed her into bed and I assessed immediate damages. I observed multiple large red raised areas to the skin on her thighs, extending from anterior, inner and posterior thighs. Small dime size red, raised area to right ABD. I applied cool wash clothes delivered by aides and placed ice packs covered in towels to area. This writer left room to notify physician and on-call Administrator. New orders per DR (Physician MD G) to give Ibuprofen 400 mg Q (every) 6 hours PRN (as needed), and apply lidocaine jelly topically for pain. Review of the facility Wound Management Report, dated 10/23/23, revealed length 15, width 13, exudate present= no, wound healing status= stable. Review of physician's orders, dated 10/20/23 through 11/14/23, revealed that the resident was receiving Tylenol 325 mg, Ibuprofen 600 mg and Tramadol (schedule IV pain medication) at the time of the survey (11/16/23). Observation of Resident #101 was done on 11/15/23 at 10:15 AM. The resident was in bed and when showed her burns, the State Surveyor observed that the abdomen was healed and she had approximately 10 cm in length on the right inner thigh and 6 cm in length scabbed burn on the left inner thigh. Both thighs were slight pink colored around the scabbed areas. The resident was not able to be interviewed due to decreased cognition. During an interview done on 11/15/23 at 10:15 AM, Wound Nurse, RN F said both wounds on the resident's thighs have scabbed over and are not infected. The resident's abdominal wound had healed. Wound Nurse F said he gave the pain mediation, Tramadol, prior to all dressing changes and it seemed to be working. They should have temped the coffee and had a lid on it. Review of the hospital progress notes, dated 10/22/23 through 11/6/23, revealed the resident had received second degree burns to bi-lateral thighs from hot coffee. The hospital progress notes stated, Pt (patient) has 1st and 2nd degree burn injuries from an accidental hot coffee spill on 10/20/23 to lower abdomen and to b/l (bi-lateral) anterior and medial thighs. She has less then 5% surface area affected and burns are not circumferential so low risk of compartment syndrome (fluid shift). Blisters are no longer present. Her pain is well controlled with Tylenol/Ibuprofen and topical lidocaine as prescribed. She is denying any pain at this time. During a phone interview done on 11/15/23 at 11:06 AM, Nurse RN G revealed she took the resident to her room, removed her clothing and put cool cloths and ice packs on the resident's burn areas and immediately called the physician for orders. Nurse G stated We should have had lids and temped the coffee and had clothing protectors and supervise. During an interview on 11/15/23 at 8:45 AM, Nurse, RN D stated I was sitting at the nurses' desk; I heard (the resident) screaming and pulling up the right leg. I told (Nurse G) to look at her. She called me and she had already had pants pulled away, we took her to her room, took off pants, put cold cloths and ice to the area. The area was red with no blisters at the time on the thighs and right lower abdominal area. The lids they had did not fit properly, we tried to push them down but they did not go, they did not temp either. The coffee should not have been served until breakfast. During an interview done on 11/15/23 at 8:31 AM, Nursing Assistant/CNA C stated I got to work, we got her up and put her in the dining room at the time, I put her in the dining room, I gave her the coffee (from the coffee pot across from the nursing station) and put it (the hot coffee) within reach on her left side. Lights were going off I answered them. I was in a resident's room and they said she was screaming. They already had her in her room and had taken care of her. We did have enough staff for the day. This could have been prevented if it was tempted (the coffee from the kitchen) correctly and if a lid was on it. There should have been someone in the ding room. During an interview on 11/15/23 at 9:00 AM, Dietary Manager E stated The tops that fit we use to have them, no one told me the tops didn't fit; I did go and get the proper ones. Dietary Manager E said the kitchen did not temp the hot coffee before they delivered it on 10/20/23, and they should have. During an interview on 11/15/23 at 9:13 AM, Physician A stated She has second degree burns, most of the wounds are healed now; there is no signs of infection now. She will make a full recovery; it could have been prevented. During an interview on 11/15/23 at 10:00 AM, Social Worker B stated it could have been prevented if we would have implemented covers. During an interview on 11/15/23 at 11:18 AM, the Director of Nursing/DON stated temping the coffee, lids on and no assessment (hot liquids screening) should have been done prior to the incident. Review of the facility Burns, Nutritional and Infection care plans, dated 11/8/23 (after the burns), revealed due to the residents hot coffee burn she was at risk for infection, required a clothing protector (for foods and liquids), required a plastic mug with a lid for all hot liquids and was to be supervised with hot beverages. Review of the facility Wounds care plan, dated 11/15/23, revealed that Resident #101 received burns and was at risk for infection and required wound care. Review of the facility Hot Beverage Risk Screening tool, dated 10/27/23 (after the residents burn from coffee), revealed that the resident was at risk for hot beverage spills and burns due to cognition, Dementia, stroke, and right-sided weakness. The resident was referred to therapy services for continued screening. Review of the therapy Hot Beverage Screening Form, undated but completed after the resident's burn on 10/20/23, revealed that the resident presented with a posterior lean in wheelchair, poor safety awareness and flaccidity in right dominant side. Recommend to position resident upright in chair, clothing protector with backing and continue with one handle cup with lid. Review of the facility Hot Liquid Consumption policy, dated 4/2009 and up-dated 10/2023, stated Hot liquid temperatures will be taken by the Food and Nutrition Department on the Skilled Nursing Unit when delivered to ensure that hot liquids do not exceeds 150 degree. Temperatures will be recorded on coffee log that is located on the coffee cart in skilled by the Food and Nutrition Department. All residents will be assessed by nursing upon admission and quarterly with referrals to Occupational Therapy as needed based on the assessment. All residents consuming meals in their room must use a lid on when consume hot beverages to ensure safety.