Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to implement interventions to prevent falls for 3 (Residents 1, 2, and 3) of 4 sampled residents. The facility census was 82. Findings are: A record review of the facility's Fall Risk Assessment dated 8/2023 revealed it was the policy of the facility to provide an environment that was free from accident hazards over which the facility had control and provide supervision and assistive devices to prevent avoidable accidents. The falls care plan would include interventions, to include supervision, in order to reduce the risk of an accident. A. A record review of Resident 1's Clinical Census dated 03/03/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 03/03/2025 revealed the resident had diagnoses of Unspecified Fracture Of Left Femur (left hip), Muscle Weakness, Other Abnormalities Of Gait and Mobility (walking and moving disorders), History of Falling, Muscle Wasting And Atrophy (loss of muscle tissue), Unspecified Dementia (confusion), Cerebral Infarction (stroke), Bipolar Disorder (mental condition), Unspecified Dementia (confusion), and Schizophrenia (mental condition). A record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 12/20/2024 revealed the resident had a BIMS of 00 which indicated the resident was unable to complete the interview. The resident required supervision or touching assistance with eating, substantial/maximal assistance for upper body dressing and personal and oral hygiene (cleaning), a was dependent on staff for toileting, bathing, lower body dressing, and footwear. Functional abilities of sit to stand and chair/bed-to-chair transfer was not attempted due to medical or safety concerns. The resident had not fallen since admission, re-entry, or the prior assessment. A record review of Resident 1's Progress Notes (PN) dated 03/03/2025 revealed: -12/13/2024 - the resident fell in the resident's restroom, the resident was transferred to the hospital and had surgery for a left hip fracture. -01/27/2025 - a late entry was put in that the resident had a fall in the dining room, but did not have injuries. Monitoring was to be continued per the care plan. -01/30/2025 - Interdisciplinary Team (IDT) fall meeting. Resident fell 01/27/2025 with no injury. The care plan was reviewed, and an intervention was added to not leave the resident alone in the small dining room. -01/31/2025 - the resident was seen laying in the dining room on the resident's right side. When the staff rolled the resident, the resident grabbed the right hip/leg and moaned, and it was noted to be internally rotated (rotated inward). The resident was sent to the hospital -02/04/2025 - the resident was discharged to another type of facility on 041/31/2025 A record review of the facility's unwitnessed Fall without Injury report dated 01/27/2025 revealed the resident fell but did not have injuries. The resident was oriented (knew) person, situation, and the time. There was nothing marked under Mental Status, no Predisposing Environmental Factors (causes from furniture, lighting, wet floor, or other), no Predisposing Physiological Factors (confusion, weakness, gait imbalance, impaired memory, or other), no Predisposing Situation Factors (ambulating with or without assist, during transfer, not using walker), and no Other Information (Info) was completed. A record review of Resident 1's Care Plan with an admission date of 08/09/2024 revealed the resident had the potential for falls related to muscle wasting, deconditioning (decline in physical function), psychotropic (medications for mental diagnoses) drug use, and cognitive deficit (impairment in thinking). The Care Plan interventions included: -Transfers: sit to stand lift as needed. 1-2 staff assist for stand pivot transfer using grab bar in bathroom, Date Initiated 01/28/2025, Revision on: 02/10/2025 -Video monitoring to help prevent falls, Date Initiated 12/31/2024, Revision on: 02/10/2025 -Do not leave resident alone in the dining room, Date Initiated 01/28/2025, Revision on: 02/10/2025 A record review of Resident 1's AS- Post Fall Assessment dated 02/05/2025 for the 01/31/2025 fall revealed an immediate intervention to prevent further falls was to lay down between meals. The cause of the fall was the resident was left alone in the dining room. An intervention or system change was don't leave alone in the dining room. A record review of the facility's Accidents investigation report form dated 02/06/2025 completed by the Administrator revealed Resident 1 fell on [DATE] while attempting use the restroom. The resident complained that the right hip was painful and that the resident hit their head. The resident had a Comminuted, Intertrochanteric Right Hip Fracture with Impaction (break in the right hip's thighbone and the bone is shattered into multiple pieces). The resident was transferred to the hospital where it (right hip) was surgically repaired. In an interview on 03/03/2025 at 4:01 PM, Licensed Practical Nurse (LPN)-D confirmed LPN-D was the nurse on duty when Resident 1 fell, and the Activities Director (AD) was the staff member that found the resident after the fall in the small dining room. LPN-D confirmed the small dining room is a highly visible area were to put the resident so the staff could watch the resident. LPN-D reported following the fall LPN-D could tell right away the resident had a broken right hip. LPN-D confirmed the only interventions LPN-D was aware of prior to the fall was to make sure to offer the restroom after meals and offer snacks. LPN-D confirmed the resident was in the small dining room, LPN-D went to the restroom, and there were no other staff members in the small dining room at the time when Resident 1 fell. In an interview on 03/04/2025 at 11:57 AM, the facility's AD confirmed the AD was in the small dining room putting items away from an earlier activity in the main dining room. The AD confirmed when the AD entered the small dining room Resident 1 was sitting in the wheelchair unattended and had just finished eating. The AD had the AD's back to the resident and happened to turn around and see Resident 1 slide out of the wheelchair. The wheelchair brakes were not locked and the wheelchair slid out from behind the resident and the resident hit the floor. The AD stayed with the resident until the nursing staff arrived and the resident was transferred to the hospital. The AD confirmed the that when the AD entered the small dining room, the resident was in there and there were no staff in the area. In an interview on 03/04/2025 at 10:00 AM, Physical Therapist Assistant (PTA)-C confirmed Therapy had been working with Resident 1 and that the resident was struggling with rehab. PTA-C confirmed that the resident had been released for staff to do a 1-2 staff assist with grab bar transfer or sit to stand transfer. PTA-C confirmed Resident 1 was very impulsive and was not safe to be in the dining room alone. In an interview on 03/04/2025 at 2:25 PM, the Director of Nursing (DON) confirm Resident 1 should not have been left in the dining room alone. In an interview on 03/05/2025 at 2:58 PM, the AD confirmed Resident 1 was in the dining room without other staff in the area when the AD entered. The AD confirmed that the AD was not asked to monitor or keep an eye on Resident 1. B. A record review of Resident 2's Clinical Census dated 03/03/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 2's Medical Diagnosis dated 03/03/2025 revealed the resident had diagnoses of Bimalleolar Fracture of the Left Lower Leg (both lower leg bones in the ankle), History of Falling, Unspecified Dementia (confusion), Cerebral Infarction (stroke), Muscle Weakness, Need For Assistance With Personal Care, Unilateral Osteoarthritis Diffuse (worsening joint condition on one side), and Morbid Obesity (severely overweight). A record review of Resident 2's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 11 which indicated the resident was moderately cognitively impaired. The resident required supervision or touching assistance with eating and oral hygiene (cleaning), substantial/maximal assistance for upper body dressing, and was dependent on staff for toileting, bathing, lower body dressing, and footwear. Functional abilities of sit to stand and chair/bed-to-chair transfer was not attempted due to medical or safety concerns. The resident had not fallen since the prior assessment. A record review of Resident 2's Care Plan with an admission date of 02/13/2025 revealed the resident was at risk of falls related to impaired mobility and other disease processes with a revision date of 9/19/2024. The resident had increased risk for actual/potential limitations in the ability to perform Activities of Daily Living (ADLs) related to the resident diagnoses. The Care Plan interventions identified the following information: -For toilet use Resident 2 was dependent, with an initiation date 10/29/2024 and revised on 10/29/2024 -Resident 2 was dependent for transfers and used a Hoyer lift with a initiation date of 10/29/2024 and revised on 02/14/2025. -Resident 2 was dependent for transfers and used a sit stand lift. The initiation date was 10/29/2024 and revised on 10/29/2024. A record review of Resident 2's Progress Notes(PN) dated 02/07/2025 at 10:26 AM revealed the resident was a 2 person staff assist with transfers and 1 person assist with ADLs. A record review of the facility's AS-Admission/readmission Assessment - V 3 dated 01/27/2025 revealed the fall risk assessment section indicated Resident 2 had not fallen in the last 6 months, the resident was incontinent of urine (lack of bladder control), had intact safety awareness, and required assistance or supervision for mobility or transfers. A record review of the facility's AS- Post Fall Assessment dated 02/09/2025 completed by the Charge Nurse, Registered Nurse (RN)-A revealed Resident 2 was alert, standing upright, was transferring, had limited range of motion, and had not fallen in the last 6 months. The identified root cause of the fall was the resident needed to toilet and the Nursing Assistants (NA) were busy, so the resident tried to self-transfer. The intervention was to remind the resident to wait for help. A record review of Resident 2's PN dated 02/09/2025 at 1:46 PM revealed Resident 2 was attempting to self-transfer from the wheelchair to the toilet. According to Resident 2's PN dated 2/09/2025, NA-B went in to assist Resident 2, however, Resident 2, could not pivot and was lowered to the bathroom floor. Further review of Resident 2's PN dated 2/09/2025 revealed RN-A responded to a call for help from the roommate, and Resident 2 was found sitting on the floor. NA-B was bent over Resident 2, supporting the resident from falling. Resident 2's PN dated 2/09/2025 revealed 3 more NAs came to help and lowered the resident completely to the floor. Further review of Resident 2's PN dated 2/09/2025 revealed a Hoyer lift was used to lift the resident off the floor and in the process, the resident's left foot appeared to twist against the wall and with Resident 2 reporting pain. RN-A assessed the situation and had the staff proceed with caution of the ankle and transferred Resident 2 into bed. The doctor was notified with an order for an X-ray to the left foot. A record review of the facility's Fall sheet dated 2/9/2025 prepared by RN-A revealed Resident 2 was attempting to pivot transfer (move someone from one surface to another by spinning while bearing weight on one or both legs) onto the toilet when a NA went in to assist Resident 2. According to the Fall sheet dated 2/09/2025 Resident 2 reported to the NA that Resident 2 was a pivot transfer. Further review of the Fall sheet dated 2/09/2025, while trying to get the resident onto the toilet, the resident's legs gave out and the resident was lowered to the floor resting on the resident's buttocks with feet outstretched in front. When 3 NAs tried to assist Resident 2 off the floor with the Hoyer lift (a full body lift), the resident's ankle was against the wall and looked like it was twisted. A record review of Resident 2's PN dated 02/09/2025 at 8:06 PM revealed the left ankle was swollen, had a black bruise, and was painful and were waiting on X-ray to arrive. A record review of Resident 2's PN dated 02/09/2025 at 11:45 PM revealed the resident's left ankle was swollen and bruised, and the resident was informed the X-ray would not be until 02/10/2025. According to Resident 2's PN dated 2/09/2025, Resident 2 refused to go to the Emergency Department (ED). A record review of Resident 2's PN dated 02/10/2025 at 10:28 PM revealed the X-ray had been completed and sent to the provider who ordered the resident to be sent to the ED. Further review of Resident 2's PN dated 2/10/2025 revealed Resident 2 was sent to the hospital. A record review of Resident 2's PN dated 2/11/2025 revealed the resident had a fall with fracture, an X-ray was ordered, and the resident was sent to the hospital on [DATE]. A record review of Resident 2's PN dated 02/16/2025 at 4:11 PM revealed Resident 2 was re-admitted from the hospital with a left ankle fracture that was surgically repaired. An observation on 03/04/2025 at 7:50 AM revealed Resident 2 was lying in bed with a large cast on the left lower leg wrapped with a brown elastic wrap. An observation on 03/04/2025 at 9:51 AM revealed Resident 2 was lying in bed with a large cast on the left lower leg wrapped with a brown elastic wrap. In an interview on 03/04/2025 at 7:50 AM, Resident 2 confirmed that on 02/09/25, the resident had to use the restroom, so the resident used the call light to get staff. A NA entered the room and followed the resident to the restroom. The resident confirmed that the resident thought the resident could get up and use the toilet, the wheelchair moved, and down the resident went. The resident confirmed the NA was in the room, followed the resident to the restroom to help with a pivot transfer, but it didn't work, and the resident fell. During the interview Resident 2 reported the NA did not attempt to stop the resident from transferring. The resident did not recall having a gait belt (a belt used to steady a resident when transferring). In an interview on 03/04/2025 at 9:51 AM, Resident 2 confirmed that on 02/09/25, there was a NA in the room to assist with a pivot transfer to the toilet, the resident fell, and the wheelchair went sliding with the brakes on. The resident confirmed that it was not a normal transfer, usually the staff used a sit to stand lift, but the resident had been practicing pivot disk transfers. The resident confirmed there was not a pivot disk in the room at the time of the fall and the NA did not try and stop the resident and get a pivot disk. Therapy was teaching the staff for to transfer the resident with the pivot disk, and everyone had lessons on it. The resident confirmed that before Therapy started working with the resident on the pivot disk, the resident rarely went to the restroom. The resident confirmed the NA was with the resident the whole time and knew what the resident was going to do, and did not try to stop the resident. The resident did not remember if the NA had a gait belt on the resident or if the NA was touching the resident because it happened so fast. In a telephone interview on 03/04/2025 at 10:25 AM, RN-A confirmed RN-A was the charge nurse that was on at the time of the fall. RN-A confirmed that RN-A was not in the room at the time of the fall, but NA-B was in the room at the time of the transfer to help the Resident 2. RN-A reported Resident 2 fell because the resident was trying to pivot transfer. RN-A confirmed 3 other staff entered the room to assist with the Hoyer lift transfer following the fall and that was when Resident 2's ankle got caught against the wall and broke. RN-A confirmed the resident complained of pain when the ankle was touched or moved and progressively swelled and bruised before an X-ray was performed and the resident transferred to the hospital. In a follow up interview on 03/04/2025 at 11:02 AM, Resident 2 confirmed the resident thought the fractures happened when the resident fell due to the extreme pain when the resident hit the floor. In an interview on 03/04/2025 at 2:25 PM, the DON confirmed that Resident 2 was a sit to stand transfer at the time of the fall. The DON confirmed the staff should not have transferred or allowed Resident 2 to self-transfer and the staff should have stopped the resident from attempting to stand from the wheelchair. C. A record review of Resident 3's Clinical Census dated 03/03/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 3's Medical Diagnosis dated 03/03/2025 revealed the resident had diagnoses of Muscle Weakness, Other Abnormalities Of Gait and Mobility, History of Falling, Muscle Wasting And Atrophy, Generalized Anxiety Disorder, and Adjustment Disorder (strong emotional and behavioral reaction to a stressful event) With Depressed Mood. A record review of Resident 3's MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively aware. The resident required supervision or touching assistance with eating, partial/moderate assistance with oral and personal hygiene, substantial/maximal assistance for upper body dressing, a was dependent on staff for toileting, bathing, and footwear. Functional abilities of sit to stand and chair/bed-to-chair transfer was not attempted due to medical or safety concerns. The resident had 1 fall with injury since admission, re-entry, or the prior assessment. A record review of the facility's un-named, incident log report dated 09/06/2024 - 02/17/2025 revealed that Resident 3 had a fallen on: -09/28/2024,11/04/2024,12/16/2024,01/24/2025 and 02/14/2025. A record review of Resident 3's PN dated 03/03/2025 revealed the following: -09/28/2024 - The resident fell in the resident's room without injury. -10/03/2024 - IDT (interdisciplinary team) meeting for 9/28/2024 fall and intervention of visual cues to use call light and ask for assistance. -11/04/2024 - the resident was found on the floor, resident sent to the hospital, no IDT meeting note. -12/16/2024 - Resident was found on floor wrapped with bedding and call light on. Resident said the resident was trying to reach the urinal, no injury. Resident was repositioned with call light in reach and surrounding was clutter free with adequate lighting. -12/19/2024 - IDT fall meeting. Resident fell 12/15/2024 with no injury. Intervention was offering assistance with urinal at rounds. -01/24/2025 - the resident was found lying on the floor in the room. The resident was picking the remote up off the floor. The resident had a laceration (cut) to the left eye and facial bruising. Resident was sent to the hospital. -01/25/2025 - The hospital called the facility, and the hospital placed sutures above the left eye. -01/30/2025 - IDT fall meeting for 1/24/2024 fall with minor injury. Care plan was reviewed and an intervention added to get a basket for resident to store the television (TV) remote in. -02/14/2025 - the resident was found on the floor and stated the resident was getting out of bed to use the phone at the nurse's station. -02/20/2025 - IDT meeting to discuss fall, and intervention added to have phone charged and near the resident. A record review of Resident 3's Care Plan with an admission date of 04/04/2024 revealed the resident had the potential for falls related to generalized weakness, muscle wasting and atrophy, history of falls, pain to left knee, use of psychotropic (medications for mental diagnoses) medications, and hypertension (high blood pressure). The Care Plan interventions included: -Adhere basket to bedside table for TV remote -Anticipate and meet the resident's needs. Place items frequently used by the resident within easy reach when in the room -Pancake call light (flat, easy to push call light) attached to bed -Place the resident's call light within reach and encourage the resident to use it for assistance as needed. An observation on 03/04/2025 at 8:10 AM revealed Resident 3 was sleeping in bed with the bed in the lowest position. The call light was on the floor at the foot of the bed on the resident's left side and was not a pancake call light. The overbed table had a basket mounted without TV remote in the basket. The overbed table was positioned where the basket was on the opposite side and out of reach of the resident. The urinal was hanging on a basket that had been mounted on the vertical post of the bedside table and out of reach of the resident. An observation on 03/04/2025 at 8:21 AM with the DON revealed the resident was sleeping in bed, the bed was in the lowest position. The call light was on the floor at the foot of the bed on the resident's left side. The call light was not a pancake call light. The overbed table had a basket mounted on it but the TV remote was not in it and the resident would not have been able to reach the basket because it was on the opposite side of the overbed table. The urinal was hanging on a basket that had been mounted on the vertical post of the bedside table and the resident would not have been able to reach it because it was on the opposite side of the table from the resident. In an interview on 03/04/2025 at 8:21 AM, the DON confirmed the call light was on the floor at the foot of the bed on the resident's left side and the resident would not have been able to reach it. The call light was not a pancake call light. The basket on the overbed table, did not have the TV remote in it, and the resident would not have been able to reach the basket because it was on the opposite side of the overbed table. The urinal was hanging on a basket that had been mounted on the vertical post of the bedside table and the resident would not have been able to reach it because it was on the opposite side of the table from the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D7 Based on observation, interview, and record review, the facility failed to implement interventions to protect 2 [Residents 1 and 2] of 3 sampled residents from potential burns. The facility had a total census of 88 residents. Findings are: A. A review of Resident 1's admission information in electronic medical record revealed Resident 1 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, C5-C7 incomplete [a form of paralysis that affects all four limbs, plus the torso]. A review of Resident 1's quarterly MDS [Minimum Data Set, a comprehensive assessment used for care planning] with assessment reference date of 6/14/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. Resident 1 was identified as requiring extensive assist of 2 plus persons for bed mobility and dressing, having total dependence with assist of 1 for toilet use and personal hygiene, and requiring extensive assist of 1 for eating. Resident 1 was identified as having almost constant pain and receiving scheduled and as needed pain medications with no non-medication intervention for pain. A review of Resident 1's care plan revealed a focus area initiated on 3/26/2018 and revised on 3/22/2021 of alteration in comfort related to pain in bilateral upper extremities, contractures, and decreased mobility with a goal of reduction in my pain or be pain free within 1 hour of receiving pain medication or a lower acceptable pain rating or show less sign/symptoms of pain. Interventions were listed as follows: -Administer pain medications per orders -Anticipate the resident's need for pain relief and respond timely to any complaint of pain -If as needed pain medication is used, monitor and document effectiveness after administration -New order for routine hydromorphone for better pain control -Resident has been ordered Fentanyl patch for pain control -Staff will encourage me to participate in activities that I enjoy and help me with pain management prior to the activity -Staff will encourage me to participate in therapy as ordered and help me with pain management prior to therapy to increase my participation -Non pharmaceutical techniques that work for me to decrease my pain are repositioning and rest. -Medications ordered -A licensed nurse or medication aide will assess and document response to each as needed dose of analgesic -A licensed nurse will document and monitor the effects of my analgesics -Pain assessment on admission to achieve baseline then as needed per protocol -Notify my medical doctor promptly if my analgesic is ineffective or pain rating increases -Pain medication is an effective way to provide me pain relief -Repositioning improves my pain -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain -Observe and report any changes in my usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care, limitation in day-to-day activities possible due to pain -Provide me my pain medication as ordered, document and evaluate the effectiveness of my pain medication. Coordinate with my medical doctor, physician assistant, or nurse practitioner to manage pain medication for optimum pain control A review of facility investigation dated 9/6/23 revealed the following information: 9/2/23 at 2 AM, charge nurse smelled smoke and noted smoke down at the end of the hallway. Charge Nurse entered Resident 1's room and observed flames on the top right side of Resident 1's bed. Charge Nurse removed the top linen, placed on floor, and stomped out the fire. Another sheet on the bed was smoking and it was also removed. Right handrail was noted to be hot and charred. A pillow and the hot pack with burn marks was removed. Resident 1 reported falling asleep with hot pack under right posterior shoulder and arm. The police and the fire department arrived as the fire alarm system activated and 911 was called. Resident 1 had burns on right posterior arm and shoulder. Resident 1 was transferred to the hospital burn center. The Fire Marshall investigated the fire and determined the cause of the fire was the hot pack. The causal factors were determined to be re-warming a hot pack consisting of towels in bag in the microwave. The towels were not re-wet prior to being heated. Staff education was provided to include nurse aides are not authorized to place warm compresses or warm packs on residents, linen items should never be placed in a microwave for any reason, and heat sources should never be placed in bed with a resident. A review of Resident 1's hospital medical record dated 9/2/23 revealed Resident 1 right upper extremity has a full thickness burn on the lateral aspect. The Assessment section of hospital record identified a 6% total body surface area burn most of which is full thickness. According to John Hopkins Medicine found at hopkinsmedicine.org revealed the following information: -A third-degree (full thickness) burns destroy the epidermis (top layer of skin) and dermis (middle layer of skin). Third-degree burns may also damage the underlying bones, muscles, and tendons. In an interview on 9/12/23 between 9:40-9:42 AM, Resident 1 reported using a hot pack on right shoulder that has been a long term treatment. Resident 1 report a wet towel was placed in a trash bag with a pillowcase over it and then placed over Resident 1's covers. Resident 1 reported the aides would get it for Resident 1 and Resident 1 would ask them to reheat it. Resident 1 reported that the towel had gotten too dry which resulted in the spontaneous combustion. A review of Order Listing Report dated 9/12/23 that included all discontinued orders for Resident 1 revealed the following discontinued orders for hot packs: -Hot pack as need to right shoulder to help with pain order dated 11/16/18 and discontinued 1/8/19 -Ok for ice pack or heat pack to right shoulder for 20 minutes every 1 hour as needed for pain order dated 6/9/19 and discontinued 12/19/19 A review of Resident 1's Medication Administration Record for 9/2023 revealed no orders for a hot pack. In an interview on 9/12/23 at 12:13 PM, Nurse Aide (NA) A reported reheating Resident 1's hot pack. Nurse Aide A reported never making a hot pack for Resident 1 only reheating. Nurse Aide A reported never being trained on how to make the pack and was not aware that towel had to be wet. In an interview on 9/12/23 at 2:13 PM, NA C reported that Resident 1 used the hot pack frequently and would request when Resident 1 wanted it. NA C reported a wet towel was heated in the microwave for 1 minute placed in a trash bag and then in a pillowcase. Hot pack would be reheated at Resident 1's request. In an interview on 9/12/23 at 2:20 PM, NA D reported making hot packs for Resident 1 for years and was not aware that order had been discontinued. NA D reported heating a wet towel in the microwave for 1 minute putting it in bag and then in a pillowcase. In an interview on 9/12/23 on 2:59 PM, NA E reported reheating Resident 1's hot pack but never making one for Resident 1. In an interview on 9/12/23 at 2:35 PM, Licensed Practical Nurse (LPN)/Charge Nurse B reported entering Resident 1's room and discovering the fire. LPN B reported pulling covers off of Resident 1's bed and stomping on the bed covers to put out the fire. LPN B reported being unaware that staff were providing hot packs to Resident 1. In an interview on 9/12/23 at 10:07 AM, LPN/Charge Nurse G reported that LPN/Charge Nurse G had never made a hot pack for Resident 1 and that there was no order for hot packs. In an interview of on 9/12/23 at 3:08 PM, LPN Manager F reported having no knowledge that hot packs were being used on Resident 1. In an interview on 9/12/23 between 11-11:18 AM, the facility Administrator reported the facility does not have a policy on use of hot packs for residents as this is not a facility practice. The Administrator acknowledged the facility investigation had revealed that staff were providing hot packs to Resident 1 based on a discontinued order. B. A review of Resident 2's admission information in electronic medical record revealed Resident 2 admitted to the facility on [DATE] with diagnoses unspecified lack of coordination, cognitive communication deficit, unspecified macular degeneration, and Alzheimer's disease. A review of Resident 2's quarterly MDS with assessment reference date of 8/9/2023 revealed a BIMS score of 12. According to the MDS [NAME] a score of 8 to 12 indicates a person has moderately impaired cognition. In addition, Resident 2 was identified as requiring supervision and set up help with eating. A review of Resident 2's care plan revealed a focus area dated 9/21/20 of having potential risk for sustaining injury while consuming foods/fluids due to my functional limitation to balance or grip steadily cups, utensils and/or plates with a goal of decreased risk for injury associated with spilling and/or dropping my flood fluids on me. Interventions are listed as follows: -If I do spill a hot fluid and/or food items on me, please clean immediately and provide appropriate treatment to minimize complications initiated 9/21/20 -Occupational Therapy to evaluate for adaptive feeding equipment dated 8/23/23. Resident 2 has agreed to add ice to coffee and allow staff to prepare it for him,initiated 8/23/23 and revised 9/12/23. -Provide clothing protector when consuming hot liquids initiated on 3/5/21 and revised on 8/23/23. A review of facility investigation dated 8/25/23 identified that on 8/23/23 Resident 2 poured a fresh cup of coffee and then hit arm against the table and the coffee poured on Resident 2's stomach from coffee cup. Resident was noted to have a 6 cm [centimeter] x 2.5 cm burn. According to investigation, the following interventions were to be implemented for Resident 2 to prevent a reoccurrence: -Educate nurse to apply a cool cloth to area until area is no longer reddened instead of applying ice -Staff to add ice to Resident 2's coffee -Staff will pour Resident 2's coffee for Resident 2 -Occupational Therapy to evaluate for adaptive feeding equipment A review of email dated 9/12/23 regarding Occupational Therapy evaluation revealed Resident 2 was aware that that staff are to pour Resident 2's coffee and bring it to Resident 2's table. Resident 2 indicated that Resident 2 would not use lid on coffee cup but was accepting of cooling down coffee with ice. In an interview on 9/12/23 at 1:40 PM, Resident 2 reported spilling coffee on abdomen resulting in a row of blisters. Resident 2 reported staff do not allow Resident 2 to pour own coffee. Resident 2 reported not using a lid on coffee or wanting any ice in Resident 2's coffee. Observations on 9/12/23 at 11:34 AM revealed Resident 2 wheeling (gender) wheelchair to table with coffee carafe and cups. Activities Assistant (AA) H poured coffee from the carafe into a cup and took the cup to the table that Resident 2 would be eating at. No ice was observed being put in coffee before Resident 2 drank the coffee. In an interview on 9/12/23 at 12:46 PM, AA H reported that AA H only filled the cup halfway to decrease risk of spills. AA H reported being unaware of direction to put ice in coffee. Observation on 9-12-2023 at 11:40 AM revealed the Dietary Director (DD) I utilizing the facility thermometer measured the temperature of the coffee poured from the carafe with a resulting coffee temperature of 140.1 F (Fahrenheit). In an interview on 9/12/23 at 11:40 AM, DD I reported that all coffee is brewed in the kitchen and placed in a carafe. The carafe is filled and not brought out to the dining room until the temperature has dropped to 150 F or below. DD I reported that ice is only added to resident coffee at their request. DD I reported coffee temperatures are to be documented on food temperature logs completed by dietary staff. A review of food temperature logs for 9/1/23 to 9/12/23 revealed coffee temperatures were documented for 9 of 34 meals served during that time. The food temperature log dated 9/1-2023 to 9/12/2023 identified coffee temperatures had dropped below 150 F for 8 of 9 meals recorded. In an interview on 9/12/23 at 4:00 PM, the Administrator reported expected the ice in coffee intervention to be in place directed by the care plan. C. A review of undated Hot Beverage Safety policy revealed the following: -All residents should be evaluated for Hot Beverage Safety on admission, with any change of condition and annual assessment using the Hot Liquid Safety Evaluation. If an OT evaluation is required the therapist will determine if special strategies/equipment are needed due to vision, physical status and cognitive status. The rehab therapist however, should not make a formal recommendation as to the safety for hot liquids in isolation. This must be an interdisciplinary team decision, documented in the resident's medical record and care planned. -If a resident is at risk for spills consider the following: -Allow the hot beverage to cool -Add milk or ice if resident allows -Provide a cup with a secure lid -If resident does not accept a cup with a lid consider a china mug (wit cooled beverage) since they absorb the heat and allow for more rapid cooling -Supervise resident at all times when drinking a hot beverage -Offer cold beverage as an alternative