**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure professional standards of care were followed while waiting for emergency medical services for 1 of 3 residents (R1) reviewed for quality of care. This resulted in harm when a trained medication aide (TMA) and a police officer were awaiting EMS arrival when R1's change in condition worsened and the nurse was not notified. Findings include: R1's care plan since admission dated [DATE] to print date [DATE], identified R1's advanced directive: full code and directed staff follow POLST guidelines. R1 had CHF and directed staff to check breath sounds and monitor/document for labored breathing, use of accessory muscles while breathing, and monitor oxygen settings. R1's quarterly Minimum Data Set, dated [DATE], identified intact cognition and no behaviors. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), diabetes mellitus (DM), arthritis, upper impairment of bilateral extremities, anxiety, depression, and respiratory failure. Medications included a diuretic (increased urine production used to reduce fluid buildup in the body), insulin, and dependent on continuous oxygen, atrial fibrillation (AFIB), COVID-19, pulmonary hypertension, and acute kidney failure. R1's physician orders identified: -Oxygen 4 liters (L) via nasal cannula (NC) continuous. May titrate 2 to 5 L/minute as needed to maintain Sa02 above 88% and 4 L/minute via BIPAP at night every shift. Order date [DATE]. -Cardiopulmonary resuscitation (CPR) (performed when a person is unresponsive, not breathing, and does not have a pulse), full code/full treatment. Order date [DATE]. -BIPAP per home settings. 10/5, 35%, back up rate 12. On at night/off in morning (a.m.) two times a day and as needed for naps. Order date [DATE]. -Cardiopulmonary resuscitation (CPR) (full code)/full treatment. Order date [DATE]. Review of R1's Provider Orders for Life-Sustaining Treatment (POLST) form signed on [DATE] at 8:34 a.m. identified R1 was a full code, CPR would be started, and the ambulance would be called for transport to the hospital. R1's emergency room (ER) visit on [DATE], identified R1 presented with two days of pain 4 out 10 in her bilateral shoulders, arms, knees, and legs, worsening cough with sputum production. R1 complained of SOB, occasional weakness, oxygen normally at 3 L increased to 4 L last night, and denied fever or chills. R1's vital signs were temperature (T) 99.2 Fahrenheit (F), heart rate (HR) 76, respirations (R) 20, blood pressure (BP) 122/45, oxygen saturation level (SaO2) 93% and oxygen on at 4 L. Physical assessment identified mild inspiratory rhonchi and slight expiratory wheezes in the bilateral upper lung field. No significant basilar crackles, no respiratory distress, and speaking full sentences without difficulty. Skin is warm and dry. Troponin blood levels elevated at 25 and positive for COVID. discharged back to facility in stable condition. Focused respiratory assessment related to active illness or exposure. Notify provider if changes in respiratory status are noted for every shift for respiratory status. Check for 8 days start date [DATE] and discontinue [DATE] at 6:10 a.m. R1's treatment assessment record (TAR) identified an order dated [DATE] at 3:57 p.m. focused respiratory assessment related to active illness or exposure every shift. Notify provider if changes in respiratory status are noted. R1's TAR documentation from [DATE] through [DATE] identified: -[DATE] at 2:30 p.m. non-productive cough, diminished lung sounds, O2 on at 4 L, no shortness of breath (SOB), no sputum, T 97.3 F, HR 68, R 18, and SaO2 97%. -[DATE] at 6:30 a.m. non-productive cough, lung sounds diminished, O2 on at 4 L shortness of breath (SOB), no sputum, temperature 96.4 F, HR 70, R 18, and SaO2 97%. -[DATE] at 2:30 p.m. no cough, lung sounds diminished, O2 on at 4 L, no SOB, no sputum, T 97.7 F, HR 89, R 18, and SaO2 94%. -[DATE] at 10:30 p.m. cough, lung sounds diminished, O2 at 4 L, no SOB, no sputum, temperature 96.5 F, HR 68, R 18, and SaO2 93%. -[DATE] at 6:30 a.m. non-productive cough, lung sounds diminished, O2 at 4 L, SOB, no sputum, T 97.2 F, HR 91, SaO2 91 %. -[DATE] at 2:30 p.m. non-productive cough, lung sounds diminished, O2 at 4 L, SOB, no sputum, T 97.6 F, HR 89, R 18, and SaO2 94%. - [DATE] at 10:30 p.m. non-productive cough, lung sounds diminished, O2 at 4 L, SOB, no sputum, temperature 98.2 F, pulse 80, respirations 18, and SaO2 92 %. -[DATE] at 6:30 a.m. no assessment documented on TAR. -[DATE] at 2:30 p.m. productive cough, crackles in the lungs O2 at 4 liters, SOB, yellow sputum, temperature 97.2 F, pulse 64, respirations 20, and SaO2 91 % documented on TAR. [DATE] at 8:07 a.m. R1's progress notes identified R1 was seen by nurse practitioner (NP) following emergency room (ER) visit and COVID positive. She was resting in bed at the time of visit with use of a continuous positive airway pressure (CPAP). R1 was alert and complained of overall pain stating, it hurts from the top of my head to the tips of my toes. Denies nausea/vomiting (N/V). Lung sounds were diminished, SaO2 92% on 4 liters of oxygen per nasal cannula (NC), respirations 18 and unlabored, temperature 97.6 Fahrenheit (F), and non-productive cough. R1 continued isolation due to COVID positive and able to call and make her needs known. R1's call light log dated [DATE] identified call light was activated at 12:39 a.m. and responded to in 1 minute 28 seconds. The 911 call initiated on [DATE] 0059:34 was listened to at the police department with the chief of police (COP) and identified: the facility nurse identified who she was, name of nursing home and a resident needed to go to ER, full code. Please send someone right away. room [ROOM NUMBER] long term care. Police officer (PO)-A report dated [DATE], identified on [DATE] at 12:59 a.m. officers were dispatched to the facility for a patient needing to go to ER and was full code. Officer arrived at facility at approximately 1:02 a.m. and at 1:03 a.m. dialed phone number seeking to be let into building. No answer tried another phone number and was advised staff was on their way to let him in. At 1:05 a.m. PO observed a staff member walking toward the front entrance calm and non-emergent. At approximately 1:07 a.m. was let into the facility building and led to R1's room. R1 laid flat on her bed with trained medical assistant (TMA)-A present. Initial observations of R1 identified labored breathing with an oxygen mask on. TMA-A was unable to find a radial pulse and able to locate one on R1's carotid. PO checked R1's right wrist for a pulse, observed the extremity to be cool to the touch and no pulse. PO completed a sternal rub to attempt to gain her attention and unsuccessful. R1's breathing became further in between breaths as compared to the initial observation and around that time EMS had arrived, determined CPR was appropriate for the circumstances and was initiated. Measures taken by EMS and assisting police were unsuccessful and at 1:42 a.m. R1 was determined to be dead. EMS report dated [DATE] at 2:01 a.m. identified dispatch was notified on [DATE] at 1:02 a.m., in route at 1:02 a.m., arrived at scene at 1:04 a.m., at patient at 1:12 a.m., and depart at 2:38 a.m. EMS waited outside approximately 6 to 8 minutes before being found by aide and taken to patient room. Approximately 10-minute delay of care to patient was noted due to not having someone to guide EMS to patient. Aide informed EMS the patient had COVID, had been complaining of increased pain all over, increasingly got worse by her perspective, and appeared to be declining. No mention of CPR being performed. Upon arrival to patient room, it was noted the patient laid supine flat on bed with a CPAP face mask running, fixed gaze, no pupillary reaction noted, extremities and trunk were cold to the touch, skin pale cyanosis around cheeks and lips. Police officer on scene stated staff member noted a carotid pulse. EMS felt carotid for pulse and noted no pulse and asystole on monitor. R1 was lifted off bed onto the floor and CPR was initiated at 1:12 a.m. EMS was informed by facility staff the patient was just fine prior to their arrival. CPR continued and medications administered, no carotid pulse was noted, and efforts were terminated at 1:43 a.m. A progress note dated [DATE] at 4:38 a.m. and written after R1's death identified nurse was notified R1 was diaphoretic and in pain. Blood sugars checked 139 and 167. Requested to sit up and wanted to go to the emergency room. Nurse went and called 911 and trained medical assistant (TMA)-A completed vital signs blood pressure 142/109, heart rate 52, respirations 18 then laid R1 back down. The police officers and emergency medical technician (EMT) arrived, entered R1's room and she had no pulse, they began CPR and administered medications for about half an hour. Family and on call doctor notified and ok was given to stop CPR. Time of death was 1:42 a.m. During an interview on [DATE] at 10:00 PO-A stated the 911 call came into dispatch at 12:59 a.m., EMS was dispatched at 1:00 33 seconds., and PO were dispatched at 1:00 54 seconds. PO-A was in the neighborhood, had taken 45 seconds to drive to facility, and arrived on scene at 1:01 43 seconds. EMS showed up at 1:05 26 seconds. CPR began at 1:13 55 seconds. She was pronounced dead at 1:42 a.m. p.m. When he arrived at the facility, had a hard time with access to the door and staff which delayed his response time, up to seven minutes, before he arrived at R1's room. He entered R1's room and she laid on her back in bed flat with a mask over her face with difficult/labored/anginal (gasping for air usually due to lack of oxygen to the brain and caused by either cardiac arrest or stroke and a sign a person is near death) breathing and unresponsive. TMA-A was in the room alone with R1 and informed him she had been in pain, was sweating with possible blood sugar (BS) concerns (BS was 139 and 167), unable to detect an oxygen level, R1 sat up on side of bed for 5 minutes, then collapsed onto bed, tried sternum rub, and unable to arouse her. TMA-A was calm, relaxed, and seemed to be unaware of how emergent the situation was and/or unaware of what measures to have taken. TMA-A updated him as to medications she had received. He noted right away R1's breathing had changed within seconds, became more difficult, fewer, and spaced out. TMA-A was able to get a carotid pulse but did not indicate what it was. He was unable to get a radial pulse, and her hand/arm skin was cold to the touch. EMS arrived and started CPR manually. Licensed practical nurse (LPN)-A sat at the nurse's station desk approximately 20 feet away from R1's room and from the time he arrived on scene and when EMS arrived, she did not take part in the assessment or any interventions. PO-A stated R1 was full code and it seemed like staff could have taken further measures prior to his arrival. A full code meant CPR was in progress and the facility had taken life saving measures, one he arrived on scene that was not the case, CPR had not been started. During an interview on [DATE] at 12:30 a.m. trained medication assistant (TMA)-A stated R1 was COVID-19 positive. On [DATE] at 12:46 a.m. a nursing assistant (NA)-A answered R1's call light, opened the door and told her R1 was hollering out, and NA-A yelled for assistance. TMA-A applied personal protective equipment (PPE) while R1 yelled out and she entered the room. R1 laid on her back in bed with head of bed (HOB) up at 15 degrees with on an oxygen mask over her face, and said she was having a hard time breathing. R1 was soaked in sweat and still talking. She asked NA-B to call LPN-A and tell her to come down to R1's room. R1's blood sugar was 160 and 139, blood pressure 140/109 and heart rate 54. She was unable find a SaO2 level, fingers and hands were cold. R1 informed her she could not breath and was gasping for air taking deeper breaths. She sat R1 up on the side of the bed with legs hanging down, seemed to have helped, and then LPN-A entered the room. She knew it was an emergency, seemed like LPN-A recognized the same when she arrived, asked R1 if she wanted to go to ER, and left room to call 911. LPN-A did not complete an assessment prior to leaving R1's room, was usually completed mid-shift. There was a crash cart on the floor but was not brought to R1's room. TMA-A assisted R1 back to laying position on her bed, police officer arrived, and she was unable to get an SaO2 reading on R1. R1's fingers were cold and iridescent. She did not contact the nurse, stated she was more concerned about staying with the R1. PO-A made a comment R1 was not responding, had shallow breathing, and then massaged her chest /sternal rub with no response. R1's breathing then stopped, and EMS entered R1's room. R1 was lifted onto the floor and EMS started CPR manually. R1's body and hair were saturated with sweat. During an interview on [DATE] at 1:30 p.m. nursing assistant (NA)-A stated she cared for R1 on [DATE] on the day shift. R1 laid in bed on oxygen, very groggy like when you first wake up from a deep sleep like she was not there with a low energy level and sleepier than she should have been. She attempted to check R1's incontinent brief, R1 refused, said no more, which was not normal for her. She informed the nurse who responded, R1 was sick. During an interview on [DATE] at 3:43 p.m. nursing assistant (NA)-B stated on [DATE] R1 had placed her call light on before 1:00 a.m. and she had answered it. She went into the room and R1 laid on her back with a mask on her face. R1 grabbed onto her arm, pulled her closer, did not want to let go, and tried to speak. R1 pulled the mask off to one side and said come, come, come, and held onto her arm. She could not understand what R1 needed, exited her room, and informed the TMA R1 needed help. TMA-A entered R1's room right away. During an interview [DATE] at 4:00 p.m. licensed practical nurse (LPN)-A stated she was the only nurse working on night shift on [DATE]. The TMA called and informed her R1 was in a lot of pain around 1:00 a.m., she immediately went down to R1's room and noted she was having a hard time breathing and knew she was not doing well. The TMA sat R1 up on side of bed and stayed with her. She asked R1 if she wanted to go to ER, and she said yes. LPN-A left the room and called 911 for a transport and started on the paperwork. The TMA was in the room with R1 and did not feel the need to be in there. She did not complete an assessment or check her vital signs. The TMA did not ask for my help once she left the room, and she stayed at the nurse's station preparing the paperwork to send R1 out to the hospital. R1 was a full code. She went back to R1's room after EMS arrived, R1 was unresponsive, assisted with lowering her to the floor and CPR was started by EMS. CPR was not started prior to EMS arriving and would have been if she had been aware R1 had no heartbeat. During an interview on [DATE] at 11:00 a.m. emergency medical technician (EMT) stated EMS was contacted by dispatch to respond to a resident at the nursing home that needed to be transferred to ER and was a full code. She arrived at the facility with the paramedic and PO-B opened the door, no staff was available and walked down the wrong hallway. We stood in the hallway, unfamiliar with the facility for at least 3 to 5 minutes, and no staff were seen anywhere. Finally, we saw a female staff walking towards us slowly, in a calm manner not rushed, and informed us 911 call was made due to R1's increased pain. The CPR equipment was not brought into the facility, unaware it was a code situation. She was informed by the female staff R1 was breathing when she had walked PO-A to her room earlier. We arrived at R1's room [ROOM NUMBER] to 13 minutes after they arrived at the facility and while at R1's bedside noted she was unresponsive, no pulse, diaphoretic, cyanotic around her mouth (usually 8 to 10 minutes for this to occur), and cold without blood flow. R1 was not on oxygen when they arrived. The TMA-A informed her R1 had a pulse when PO-A arrived. We were not made aware of the seriousness of this situation until arrival to the facility and unaware CPR would be needed. She ran outside to the ambulance with PO-A and PO-B and grabbed the equipment for CPR. Communication was very poor with nurse, lacked knowledge, and the TMA was left alone to manage R1's situation alone. LPN-A did not come into R1's room and assist when moved from bed to the floor. After CPR was started LPN-A came to R1's doorway, left right away, and called family, 10 minutes of CPR was completed. LPN-A came back to the doorway and informed us as to what family had said. EMT stated once the pulse was weak enough starting CPR would have been beneficial and the outcome could have been different if the staff would have noticed how critical R1 was. During an interview on [DATE] at 2:45 p.m. registered nurse (RN)-A stated when a resident was in respiratory distress the nurse would be expected to get a crash cart into the room, checked code status, stay with the resident, and carry a facility provided cell phone. When 911 was called a staff nurse would be expected to identify resident room number, location of the room and staff would be expected to wait at the facility doors especially if locked and let them in for easier access. TMA and NA were allowed to gather vitals and should have provided them immediately if abnormal to the nurse by either phone or locating her, due to the possibility to intervene. The nurse would be expected to be the one with the resident during respiratory distress she is trained on how the situation should have been addressed, take whatever measure were needed, and act upon the resident wishes. The nurse would be responsible to have completed an assessment, determined if breathing and/or vitals were abnormal, kept a timeline, and documented as soon as possible. RN-A stated she covered the first part of the evening shift on [DATE] from 2:00 p.m. to 6:00 p.m. and completed R1's respiratory assessment. R1's assessment was abnormal, she had crackles in the lungs, SOB, a productive cough. She passed this information onto the oncoming shift LPN-A, and a provider was not contacted. She should have notified the provider, made her aware R1's condition had changed, may have wanted to do something different. During an interview on [DATE] at 2:46 p.m. nurse practitioner (NP) stated she had seen R1 on [DATE] in the morning around 8 a.m. and no SOB noted, vitals stable, and no concerns. R1 had very poor respiratory status to start with, poor lung function, not uncommon to have wheezes or rhonchi that may have cleared with deep breathing, cough, or nebulizer treatments. She would have expected a call from the nurse with a drop in oxygen levels, noted respiratory distress, change in heart rate, respirations, or temperature, not necessarily for only a change in lungs. When respiratory problems are a known problem within a resident's history nursing were expected have tried interventions first. The TMA and NA's would be expected have notified the nurse with a change in condition and should be a standard process for them. We have been taught to use the chain of command and starts with the TMA and NA's, they spend more time with the residents, changes are recognized earlier, and that information should have been given to the nurse. The nurse would be expected to have completed an assessment and notified the provider using their nursing judgement to have kept them updated. During an interview on [DATE] at 3:22 p.m. floor manager, RN-B, stated the nurse would be expected to complete the initial assessment on a resident in respiratory distress, from that point would be acceptable to delegate to TMA or NA. She expected TMA or NA to have communicated with the nurse right away/as soon as possible if any change occurred or noted so that the nurse had all the data, whole picture of the situation, and could have intervened if needed. She stated the PO had a key to enter the facility building, unsure if EMS had one. Staff would be expected to have provided room and lane number to have directed PO and EMS to the right area. She was unsure whether it would have been a courtesy or policy for staff to have been at the door and waited for them, would be possible if staffing allowed but not completely necessary, they were only two units in the facility. During an interview on [DATE] at 3:38 p.m. director of nursing (DON) stated R1 had an extensive respiratory/breathing history, and her status would fluctuate and was expected. Staff nurses were expected to follow the policy and orders and indicated a provider should have been contacted. She would have probably called a provider with R1's changed on [DATE] on the evening shift so that the NP would have been made aware there were changes. She was not aware if a provider was contacted. She identified the timeline that occurred on [DATE]: NA-B answered call light, notified TMA-A, and entered room, R1 was cold clammy and unsure if NA-B informed LPN-A about unable to get an oxygen level reading. NA-A called LPN-A and came to R1's room, TMA-A had collected R1's blood sugar (BS) prior to her arrival. LPN-A talked to R1 and asked if she wanted to go to ER, R1 requested ER, LPN-A left room, and called 911. LPN-A gathered R1's paperwork together, should have taken up to 10 minutes to have completed this. She was unsure as to what LPN-A did after that and the resident should have been the number one priority. The nurse would have been expected to make a nursing judgment call on what R1 needed after completion of a respiratory visual and physical assessment that should have included lung sounds, recheck vital signs, and oxygen levels. LPN-A could have delegated the 911 call to another staff, did not have to be a nurse. She would have expected LPN-A to return to R1's room as soon as possible to check on R1 sooner, so that she would have known the situation, and assisted with what was needed. NA-A was not able to leave R1's room but could have called LPN-A if she had a cell phone, was unsure whether she had one with her, placed call light on, or yelled down the hallway from the doorway. She stated there was a lack of communication with staff. There was not a facility policy that identified what the process was when emergency services required access to the facility building when doors were locked so that they are able to respond quickly. There was a key in a locked box located outside the facility door and the PO should have had a key to open it. She did not have a specific procedure/policy staff should have used as a resource when calling 911. There will be changes made to help guide staff such as policies reviewed, what information should be provided to EMS to get the proper assistance, and review change in condition policies so that the nurse would have known the resident's situation and assist with what was needed. TMA job description dated [DATE], identified TMA was responsible for providing direct care and medication administration to residents consistent with the individual plan of care and under the direction of licensed staff. TMA administers medication to residents under the direction of licensed nurse, responds to resident call lights, and requests and notifies nurse of any resident care needs or changes in condition. LPN job description dated [DATE], identified LPN was responsible for providing nursing care to residents including medication and treatment administration, documentation, and other therapeutic interventions under the direction of the DON/clinical director. The position was responsible for providing direction to NA's, resident assistants, TMA's, and other clinical staff on unit/shift. The LPN was responsible to provide nursing care to residents within the scope of practice, assists RN with completion of assessments, documentation, and data collection, acting timely on findings, administers medications, completes treatments as ordered, observes and monitors resident's condition and reports changes as appropriate. Facility policy Transfer or Discharge, Facility-Initiated dated 10/2022, identified for an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures: a. Call 911 if resident met clinical/behavioral criteria per facility policy or assist in obtaining transportation. b. Notify the resident's attending physician. c. Orient/prepare the resident for transfer. d. Prepare for medial record transfer. Information conveyed to receiving provider should include: a. Basis for the transfer/discharge. b. Contact information of the practitioner responsible for the care of the resident. c. Resident representative information including contact information. d. Advance directive information. e. All special instructions or precautions for ongoing care, as appropriate such as: treatments and devices (O2, implants, IV's, tubes/catheters), transmission-based precautions. f. Special risks such as falls, elopement, bleeding, or pressure injury, and/or aspiration precautions. g. Comprehensive care plan goals and all other information necessary to meet the resident's needs, including but not limited to: resident status, including baseline and current mental, behavioral and functional status, recent vital signs, diagnoses and allergies, medications (when received last), most recent relevant labs, other diagnostic tests, and recent immunizations, copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. Facility policy Resident Examination and assessment dated 2/2014, identified a physical exam of a resident should have included: 1. Vital signs - blood pressure, pulse (carotid), respirations and temperature 2. Cardiovascular - heart rhythm, peripheral pulses, capillary refill 3. Respiratory - lung sounds (upper and lower lobes) for wheezing, rales, rhonchi, or crackles), irregular or labored respirations, cough (productive or nonproductive) and consistency and color of sputum. 4. Neurological - alertness and orientation, speech clarity, drooping eye lids, facial paralysis, asymmetry, strength and equality of the hand grasp, and numbness or tingling of extremities. 5. Pain - description, location, duration, severity, factors that worsen/relieve pain, how pain affects them, current medication and treatments for pain. The assessment should be recorded in the resident's medical record. Physician would be notified of any abnormalities such as, but not limited to abnormal vital signs, labored breathing, breath sounds that are not clear, or cough, productive or nonproductive, change in cognition, behavioral or neurological status from baseline, and worsening pain. Facility policy requested emergent access to the locked facility and staff process for a 911 call and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review, the facility failed to ensure residents were assessed to safely operate or provide necessary supervision to keep residents safe while utilizing an electric recliner for 2 of 6 residents (R3, R6) reviewed, who utilized an electric recliner. This resulted in actual harm when R3 lifted self in electric recliner using the remote causing a fall which resulted in a fracture. Findings include: R3's quarterly Minumum Data Set (MDS) dated [DATE], included a diagnosis of Parkinson's disease and had severely impaired cognition. R3 required extensive assistance by staff with transfers and ambulation. R3 had three falls since previous assessment 8/02/22, two of which resulted in injuries. R3's care plan dated 1/27/22, identified R3 was at risk for falls related to confusion, deconditioning, gait and balance deficits, and unaware of safety needs. On 6/12/22, R3's care plan was revised and directed staff not to leave R3 unsupervised in his room unless in bed. On 1/22/23, R3's care plan was revised and directed staff not to place R3 in the recliner in the commons area and to utilize a wheelchair. Incident report number 2026 dated 1/19/23, indicated at 4:30 p.m. R3 was observed sitting in recliner in lounge next to the nurses' station. R3 raised the recliner up into a high sitting position by utilizing the remote. R3 attempted to stand independently which resulted in an unwitnessed fall. R3's progress notes revealed the following: -On 1/19/23, at 4:30 p.m. R3 was observed in the recliner at the nurses' station when R3 raised the recliner up into high sitting position and attempted to stand which resulted in a fall. R3 was assessed and noted to have injuries which included: bruising to forehead and eye, hip and back pain, skin scrape to left elbow 2 centimeters (cm) by 2 cm, and skin scrape to left lower knee. -On 1/20/23, R3 was noted to be restless and attempted to climb out of recliner using the remote to raise the chair. R3 was noted to show signs of pain. -On 1/21/23, R3 was noted to be yelling out in pain during morning cares. R3's family was visiting and opted to send to emergency room due to change in condition. -On 1/22/23, R3 was admitted to the hospital -On 1/27/23, R3 re-admitted to the facility with hospice services. R3 would require the use of a mechanical Hoyer lift with assistance of two staff members for transfers due to being non-weight bearing to left lower extremity. Review of R3's hospital History and Physical dated 1/23/23, indicated R3 sustained a non-displaced bimalleolar left ankle fracture likely during his recurrent falls. Further review of document indicated R3 had frequent falls at the nursing home and approximately 3 to 4 days ago he fell and had been showing signs of discomfort and pain when moving left lower extremity. During observation on 1/31/23, at 3:20 p.m. R3 was resting in bed, which was in lowest position, in his room. R3 appeared comfortable. During an interview on 2/1/23, at 9:00 a.m. nursing assistant (NA)-A stated R3 required assistance from staff for activities of daily living (ADLs) such as transferring and ambulation. NA-A indicated R3's cognition was impaired and was at risk for falls. Further, NA-A stated R3 had a fall from the electric recliner and sustained an ankle fracture which was discovered in the hospital. NA-A stated R3 was unable to appropriately use the remote to control the electric recliner, so staff would often place the remote behind the recliner on the floor and out of R3's reach. In addition, NA-A stated on the memory care unit, there were three electric recliners next to the nursing station that any residents were able to utilize, and the recliners were always plugged in however, staff would hide the remotes to the recliners, so residents were unable to use the remotes independently. During an interview on 2/1/23, at 9:19 a.m. family member (FM)-A indicated R3 had impaired cognition and was transitioned to the facility's memory care unit. FM-A stated R3 had a fall from an electric recliner, which he was not safe to be in and R3 had used the recliner remote unsupervised to lift the chair, resulting in a fall and huge decline in R3's condition. FM-A brought R3 to the hospital a couple days later due to change in condition and that is when a fracture in R3's ankle was discovered. During an interview on 2/1/23, at 10:37 a.m. licensed practical nurse (LPN)-A stated R3 had impaired cognition and safety awareness which caused R3 to be at a high risk for falls. LPN-A stated R3 had a fall from an electric recliner by the nursing station which resulted in an ankle fracture and staff were directed not to place R3 in the electric recliners after the incident occurred. Further, LPN-A was unaware if a safety assessment was completed prior to allowing cognitively impaired residents to utilize the electric recliners. During an interview on 2/1/23, at 11:10 a.m. registered nurse (RN)-A indicated R3's cognition and safety awareness was impaired. RN-A indicated R3 had a history of self-transferring and staff would attempt to keep R3 in the commons area in an electric recliner by the nurses' station to keep him within staff's vision. Further, RN-A stated if R3 was sitting in an electric recliner staff would place the remote where R3 was not able to visually see it or reach it. RN-A indicated R3 would often search for the remote and if R3 was able to find it he would not appropriately use the remote and press the buttons causing the recliner to lift high and R3 would begin to slide out. In addition, RN-A was not aware of a safety assessment that would be completed prior to allowing cognitively impaired or otherwise identified unsafe residents to utilize the electric recliners. During an interview on 2/1/23, at 11:56 a.m. LPN-B indicated R3 had impaired cognition and was often restless, so staff would keep R3 in the commons area by the nurses' station to have him within vision due to being a high fall risk. LPN-B stated R3 had a recent fall from the electric recliner in the commons area next to the nurses' station when a nurse on duty left the area and R3 pressed the buttons on the remote which brought the recliner all the way up to a high position causing R3 to fall and sustained injuries. Further, LPN-B stated R3 was observed to mess with the remote to the electric recliners prior to the incident and added, R3 was not appropriate for the electric recliners due to safety concerns and impaired cognition. LPN-B stated after R3's fall from the recliner, R3 was hospitalized due to a change in condition and when he returned to the facility, then required the use of a Hoyer mechanical lift for transfers due to an ankle fracture. During an interview on 2/1/23, at 12:14 p.m. LPN-C stated R3 had impaired cognition, poor safety awareness and was at high risk for falls which meant he required close supervision by staff. LPN-C stated they were to ensure R3 was not left in his room alone unless in bed and directed to place R3 in the electric recliners at the nurses' station to have good visual watch of him. Further, LPN-C confirmed R3 could not appropriately and safely operate the remote for the electric recliners. LPN-C indicated there were three electric recliners, which were always plugged in, by the nurses' station that any residents in the memory care unit could utilize, however LPN-C stated if the residents were at high risk for falls the staff would hide the remotes to the electric chair due to some residents' being observed to press the buttons inappropriately. During an interview on 2/1/23, at 12:34 p.m. NA-B indicated R3 was noted to be very confused, restless, and at a high risk for falls. NA-B indicated staff would place R3 in an electric recliner in the commons area next to the nurses' station and staff would recline his chair back, put his feet up, and then place the remote out of R3's reach. Further, NA-B stated if R3 did find the remote to the electric chair he would press the buttons inappropriately which was what caused R3's fall prior to being sent to the hospital. During an interview on 2/1/23, at 12:50 p.m. NA-C indicated R3 had poor safety awareness and was at risk for falls due to poor balance. NA-C indicated R3 required staff supervision due to falls, so staff would place R3 in the electric recliners at the nurses' station. Further, NA-C indicated any residents could utilize the electric recliners at the nurses' station and they were always plugged in, however staff would not place a resident in the recliner if the resident was known to self-transfer or operate the remote inappropriately. NA-C confirmed R3 was known to self-transfer and operate the buttons on the recliner inappropriately and staff would still place R3 in the electric recliner as it was safer for him to be out in the commons area by the nurses' station for increased supervision rather than in his room. During an interview on 2/1/23, at 1:02 p.m. LPN-D indicated R3 had poor short-term memory and safety awareness and would often self-transfer which indicated he was at a high risk for falls. LPN-D indicated as a fall intervention, R3 was not allowed to be in his room alone unless R3 was in bed, so staff were directed to keep R3 in either his wheelchair or the electric recliners at the nurses' station. Further, LPN-D confirmed R3 could not appropriately operate the buttons on the electric chair, but staff would keep the chair plugged in, recline R3 back and elevate feet then leave the remote either on the floor behind the chair or place the remote in the pocket on the side of the recliner. LPN-D indicated on 1/19/23, at approximately 2:00 p.m. R3 was observed sitting in the electric recliner and appeared to be resting reclined and feet were elevated. LPN-D could not recall where the remote for the electric recliner was at that time but stated it was either in the pocket on the side of the chair or behind the recliner on the floor. LPN-D stated she was not R3's nurse that day but was the only staff in the area at that time. LPN-D stated she stepped away and when returning to the area heard what sounded like a resident falling and when LPN-D came around the corner R3 was observed to be laying on the floor next to the recliner, the recliner was raised up. LPN-D indicated at that time R3 was not able to clearly verbalize where he was having pain but did point to left pelvis area. During an interview on 2/1/23, at 1:35 p.m. RN-B indicated prior to R3 being admitted to the hospital he required assistance by staff for ADLs and was able to ambulate with staff to and from destinations utilizing a walker and gait belt. RN-B indicated R3 had impaired cognition and safety awareness and was also noted to be impulsive which put him at a high risk for falls. RN-B indicated R3 always required visual supervision by staff unless R3 was in bed sleeping, however RN-B confirmed visual supervision was not in R3's care plan but RN-B stated she would expect staff to have visual contact on R3. RN-B stated there are three electric recliners at the nurses' station, which are always plugged in, that staff would place R3 in and ensure the remote was out of R3's reach. RN-B confirmed a safety assessment was not completed to determine if a resident is safe to operate the remote appropriately prior to residents utilizing the electric recliners and RN-B was not aware of a procedure to ensure residents can safely use the electric recliners. Further, RN-B stated on 1/19/23, R3 was observed to be laying on the floor next to the electric recliner at the nurses' station, the recliner was noted to be lifted enough for R3 to slide out. R3 was noted to have pain to his left side but was unable to communicate exactly where the pain was located. On 1/21/23, R3 transferred to the hospital related to change in mental status, and facility staff were made aware of R3's ankle fracture on 1/24/23, when reviewing R3's hospital paperwork. RN-B stated R3 re-admitted to the facility on [DATE], and began hospice services and would now require the use of a full body Hoyer lift due to being non-weight bearing on left leg. During an interview on 2/1/23, at 2:20 p.m. LPN-E indicated R3 had impaired cognition and safety awareness. LPN-E indicated R3 required staff supervision and would often sit in the electric recliners at the nurses' station. LPN-E confirmed R3 would not operate the remote appropriately and staff would hide the remote for R3's safety. During an interview on 2/1/23, at 4:08 p.m. director of nursing (DON) indicated R3 had severely impaired cognition and safety awareness prior to being admitted to the hospital. DON indicated R3 required increased monitoring by staff and would often sit in the electric recliner for comfort and staff would place the remote in the side pocket of the chair. DON indicated on 1/19/23, R3 was in the electric recliner and used the remote to lift the chair, and was found on the floor next to the recliner. DON stated R3 was complaining of back and hip pain at that time, but when hospitalized a couple days later x-rays revealed an ankle fracture from the fall on 1/19/23. In addition, DON confirmed safety assessments were not part of the facility's procedure to determine safety of cognitively impaired residents utilizing the electric recliners. DON also confirmed the facility did not address the safety concern of the electric recliners following R3's fall on 1/19/22, which resulted in a fracture but would have been important to ensure residents who are cognitively impaired are safe to utilize the electric recliners which could have potentially prevented R3's fall. DON indicated staff have now been directed to unplug all three electric recliners at the nurses' station until further notice. R6's significant change MDS dated [DATE], included a diagnosis of dementia and R6 had severely impaired cognition. R6 had one fall with no injury since previous MDS assessment. On 2/1/23, at 5:09 p.m. R6 was observed sitting in an upright position with feet flat on the floor in an electric recliner at the nurses' station, the remote was on the floor behind R6's recliner and a green light was noted to be on indicating the recliner was receiving power. LPN-F grabbed the remote from the floor and operated the buttons, and R6's chair began to recline, and feet began to elevate which revealed the electric recliner was plugged in. During an interview on 2/1/23, at approximately 5:09 p.m. LPN-F stated R6 had severely impaired cognition and safety awareness and R6 was not able to appropriately use the remote for the electric recliner appropriately. The facility policy Safety and Supervision of Residents dated 7/17, indicated facility's individualized resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary team would analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. Further policy direct facility to implement target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to evaluate and develop potential interventions to prevent further coffee burns for 1 of 1 resident (R27) who experienced two instances of coffee burns. This deficient practice resulted in actual harm to R27 who suffered a second degree burn (partial thickness burn, involving the epidermis (top layers of skin) and part of the dermis (underneath the epidermis) layer of skin, appears red, blistered, and may be swollen and painful) from spilt hot coffee. Findings include: R27's Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS) dated [DATE], identified R27 had diagnoses which included Alzheimer's disease, diabetes, anemia and above the knee amputation of the left leg. The MDS indicated R27 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's) of bed mobility, transfers and dressing. The MDS identified R27 was independent with eating after set up assistance from staff. The MDS indicated R27 had clear speech, was able to make himself understood and was able to understand others. Review of R27's SCSA Care Area Assessment (CAA's) dated 6/25/22, identified R27 had moderately impaired cognition, was able to voice his needs, concerns, preferences, and make daily choices. The CAA indicated R27 had poor safety awareness and judgement related to Alzheimer's Disease. The CAA identified R27 required assistance with ADL's related to medical conditions which included left above the knee amputation. The CAA indicated R27 was able to eat independently with set up assistance and staff were to anticipate his needs as needed. Review of R27's progress note dated 8/8/22, identified R27 spilled hot coffee on himself before lunch. The note indicated R27 had a red mark, a blistered area, a clear Tegaderm (transparent dressings can be used to cover and protect wounds,) had been applied and the burn would be observed daily until resolved. The note lacked identification of where R27 had sustained the burn on his body, what he was doing when the burn happened, other causative factors, characteristics of the burn to include measurements of the burn or interventions implemented to prevent further burns. R27's progress note dated 8/15/22, identified he was seated at the dining room table, fell asleep and spilt coffee on his stump and leg again. The note indicated the author removed R27's clothing which covered the burn, assisted him to his room and changed his clothing. The note identified the nurse manager (NM) assessed R27's previous burn area present on his stump, applied Bacitracin and a non-adherent pad to the burn. R27's care plan revised 7/11/22, identified R27 had memory loss, was mostly understood and mostly understood what was communicated to him. The care plan indicated R27 was independent in eating and drinking after set up assistance from staff, had limited physical mobility and had an amputation of left lower extremity. R27's care plan lacked any documentation of his second degree burn. Additionally, the care plan lacked identification of any interventions to prevent further coffee burns. Review of R27's Treatment Administration Record (TAR) for August 2022, identified an order dated 8/8/22, to observe left leg burn/blister from spilled coffee. The TAR instructed staff to cover the area with a Tegaderm patch; if the patch came off, reapply or reassess treatment options, document changes in progress notes, discontinue when resolved, twice daily. Review of R27's Order Summary Report dated 8/17/22, identified an order to observe left leg burn/blister from spilled coffee, cleanse area, apply Bacitracin (anti-bacterial cream) and non-adherent pad. Staff were to document any signs or symptoms of infection in progress note and update medical doctor / nurse practioner (MD/NP) as needed, every day and evening shift. On 8/15/22, at 3:10 p.m. R27 was observed seated in his wheelchair and was wheeled down the hallway by nursing assistant (NA)-A towards his room. R27 had a brown spot on his t-shirt approximately the size of a softball. NA-A indicated R27 had spilled some coffee on himself and NA-A would assist him to change his shirt. On 8/15/22, at 5:18 p.m. R27 was observed seated on the edge of his bed with his right foot on the floor. R27 was not wearing any pants, his left stump was exposed and a bright red open area (burn) was noted on the top of his stump which measured approximately 10 centimeters (cm) in length and six (6) cm in width with flayed layers of skin around the edges of the burn. At that time, R27 stated he had been burned by hot coffee when he spilled it on himself approximately a week ago and again that day. R27 stated the burn hurt a lot, especially when touched. On 8/17/22, at 8:03 a.m. R27 was observed seated in a wheelchair in the dining room at a table with another resident. R27 held a two handled covered cup with brown liquid in his left hand and took a long drink. At that time, R27 indicated the two handled, covered cup held his coffee. R27 indicated the two handled covered cup was used to help prevent further coffee spills. -at 8:30 a.m. R27 was observed to wheel himself away from the table, at that time, he reached down, fidgeted with the fabric of his pants on over his left stump, winced and was approached by registered nurse manager (NM)-A who proceeded to ask him several questions about his left stump burn. R27 then proceeded to propel himself towards his room. During an interview on 8/16/22, at 9:52 a.m. NA-B indicated the unit's coffee machine was located behind a locked door for resident safety. NA-B stated staff obtained resident's hot beverages for them and indicated R27 had recently spilled hot coffee on his left stump and had burned himself. NA-B stated she was unaware of any changes in how R27 was served his coffee and indicated he continued to use a regular coffee mug. During an interview on 8/16/22, at 2:25 p.m. NA-E stated R27 was alert, able to verbalize his needs and wishes. NA-E stated R27 was independent in eating and drinking after set up assistance was provided. NA-E indicated R27 was recently burned when he spilled a cup full of hot coffee on his left stump approximately a week before and again the day prior. NA-E indicated R27 had been a bit sleepy the day prior and had fallen asleep when he was holding the coffee. NA-E stated residents were unable to get their own coffee on the unit, as it was behind a locked door in the kitchenette area. NA-E stated there had been no changes with how R27 received or drank his coffee since he was burned. NA-E indicated R27 continued to use a regular coffee mug to drink his coffee. During an interview on 8/16/22, at 2:37 p.m. the dietary manager (DM) stated he felt a safe water temperature for hot coffee was between 160-165 degrees Fahrenheit (F). At that time, the DM was asked to check the temperature of the coffee dispenser for the memory care unit (where R27 resided.) The DM used a key which was affixed to the door frame to open the locked door to enter the kitchenette area. On the countertop was a Folgers coffee dispenser with three spouts that were labeled as follows; left spout for decaffeinated coffee, middle spout for hot water and right spout was for caffeinated coffee. The DM proceeded to check the temperature of each hot fluid with a gauged thermometer. The temperatures registered as follows; -decaffeinated coffee reached a temperature of 171 degrees F -hot water reached a temperature of 170 degrees F -caffeine coffee reached a temperature of 171 degrees F. During an interview on 8/16/22, at 2:42 p.m the DM indicated he was not aware of what temperature the water in the coffee machines was supposed to be set at. The DM stated he was not aware of any concerns with hot fluids, or any residents having been burned from hot water/coffee. During an interview on 8/17/22, at 8:40 a.m. a life enrichment aid (LE)-A indicated she often helped as a dietary aid when needed and had assisted preparing and passing resident meals in the dining room of the unit where R27 resided. LE-A indicated prior to that morning, R27 had received his coffee in a regular coffee cup for breakfast and other meals if he requested. LE-A stated she was notified by the dietary departments report board, R27 was to use a two handled cup with a cover for hot beverages, such as coffee that morning, 8/17/22. During an interview on 8/17/22, at 9:01 a.m. NA-A stated R27 needed assistance with most of his cares, used a wheelchair for mobility and was able to freely move about the unit. NA-A indicated R27 was able to voice his needs and was alert most of the time. NA-A stated R27 was able to eat and drink independently with set up assistance from staff. She indicated R27 had spilled coffee on himself twice in the last week, which resulted burns to his left stump. NA-A stated when R27 had spilled the coffee, both times he had been tired and dozed off. She indicated when R27 spilled the coffee the second time, it landed directly on the original burn which covered the top portion of his left stump. NA-A stated R27 had complained of pain at the time of the burn and when the burn was touched. NA-A stated R27 had continued to use a regular coffee mug for his hot coffee up until that morning when he started to use a covered, two handled cup for safety. During an interview on 8/17/22, at 9:43 a.m. the director of nursing (DON) stated she had been notified on 8/16/22, R27 had spilled hot coffee and had sustained a burn which blistered on his left stump. The DON stated she had been unaware R27 had sustained a burn from spilt coffee on 8/8/22, until yesterday afternoon. The DON confirmed R27's second degree burn had not been measured, or assessed following either incident, on 8/8/22, and 8/15/22. The DON confirmed neither incident had been assessed for causative factors, nor had any interventions been implemented to help prevent reoccurrence. The DON indicated R27's second degree burn had been monitored for signs and symptoms of infection since 8/8/22, and treatment had been implemented by the NM. The DON stated she would have expected R27's burn to have been assessed, and both incidents to undergo a thorough assessment to include identification of causative factors, nor had any interventions been implemented to help prevent reoccurrence. The DON stated she was unaware if R27's second degree burn had worsened following the second burn. During an interview on 8/17/22, at 10:03 a.m. NM-A stated she had been present during both incidents when R27 had spilled his coffee, on 8/8/22, and on 8/15/22. NM-A stated on 8/8/22, R27 had a scheduled blood transfusion due to low hemoglobin level, and had been drinking a cup of hot coffee in the dining room. NM-A indicated she believed R27 had dozed off, the coffee mug had slipped from his hand and spilled on his left stump. NM-A stated she had removed his pants and observed the burn to immediately blister. NM-A confirmed she had not completed an assessment of the burn, such as measurements, or identification of any characteristics of the burn. NM-A indicated she covered the burn with a Tegaderm dressing and sent R27 to his scheduled appointment. NM-A indicated the burn almost covered the entire top of his left stump. NM-A stated she felt the incident was isolated and confirmed there had been no new interventions implemented to prevent reoccurrence. NM-A indicated after lunch on 8/15/22, R27 had been in the dining room with a coffee mug of hot coffee, appeared to doze off and spilled the hot coffee over his left stump again. NM-A stated she had not noticed any worsening of his burn, and confirmed she had not completed an assessment of the burn, such as measurements, or any characteristics of the burn until that morning. NM-A indicated she had contacted the NP on 8/16/22, notified her of his burns and received an order for dressing changes. NM-A stated following the second incident, R27's plan of care had been updated for R27 to use two handled, covered cups for coffee. NM-A indicated she had completed an assessment of R27's burn earlier that morning and had applied a Tegaderm dressing. NM-A confirmed she had completed the following skin assessment after the second burn which revealed the following; -Skin and Wound Evaluation form dated 8/17/22, identified R27 had a second degree burn on his left stump, acquired in house on 8/8/22. The burn measured 10.2 cm in length by 6.4 cm in width, covered a surface area of 45.2 cm squared. The wound bed consisted of 70% granulation (red tissue with cobblestone or bumpy appearance, bleeds easily with injured) tissue, pink/red in color and had a ruptured fluid filled blister, moderate amount of serous (various body fluids resembling serum, that are typically pale yellow and transparent and of a benign nature,) drainage. On 8/17/22, at 11:35 a.m. a telephone call was placed to R27's Nurse Practitioner (NP), a message was left for a return call. During a telephone interview on 8/18/22, at 12:37 p.m. registered nurse (RN)-B indicated she had been present when R27 had spilled a cup of hot coffee on 8/15/22. RN-B stated R27 had been in the dining room at approximately 2:30 p.m. to 3:00 p.m., when she had heard him swear and found a regular coffee mug with spilled coffee on the floor. RN-B indicated the hot coffee had spilled directly over the burn R27 had sustained on 8/8/22. RN-B indicated she had not assessed R27's left stump and confirmed no immediate interventions had been implemented to prevent hot coffee from spilling on R27. During a telephone interview on 8/18/22, at 2:39 p.m. RN-A stated she had been present during both incidents when R27 had spilled hot coffee and sustained a burn to his left stump. RN-A stated during both incidents R27 had dozed off and the coffee mug had slipped from his hand. RN-A stated she had not completed a skin assessment or an analysis of the incidents which caused the burns. RN-A confirmed following R27's first burn, there had been no new interventions implemented as they felt the incident was isolated. RN-A stated following the second burn, R27 used a two handled cup with a secure cover for his coffee to help prevent further burns. During a telephone interview on 8/22/22, at 9:20 a.m. R27's NP stated she had been covering the facility since 8/15/22, and had been made aware R27 had sustained a burn on 8/18/22. NP-A confirmed she had no awareness prior to that day and there was no record of the clinic having been notified prior to that time. NP-A indicated R27's primary NP had been out for a couple of weeks and the facility had contacted her to ask about dressing changes for R27. NP-A stated she had not seen R27's burn and stated she would have wanted to see the burn after it happened, both times. NP-A confirmed based on the verbal description of the woud blistering, it would have been determined to be a second degree burn, no question. NP-A stated she would have expected when R27 was burned the first time, (8/8/22,) she should have been notified. NP-A indicated she would have expected R27's burn to be assessed by a nurse to include measurements, characteristics to include coloring, tissue type, pain, possible cause, and definitely should have looked to see if an intervention would have been appropriate. NP-A indicated she had not been aware R27 had actually been burned twice, and confirmed R27 had definitely sustained harm from the coffee spill. NP-A stated the second time the hot coffee hit the pre-existing burn, it likely could have deepened the wound and impaired healing. Review of a facility policy titled, Accidents and Incidents- Investigating and Reporting revised July 2017, revealed all accidents or incidents involving residents would have been investigated and reported to the administrator. The policy revealed the nurse supervisor/charge nurse would promptly initiate and document investigation of the accident or incident, which would include the following data; date, time of the incident, nature of the injury, circumstances surrounding the incident, where it took place, witnessed or the residents account of the incident, time the persons physician was notified, time residents family member was notified and condition of the injured person.