**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated surveys (NY00269612 and NY00272726) conducted on 6/1/21- 6/9/21, the facility did not ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents for 2 of 4 residents (Residents #93 and #141) reviewed. Specifically, - Resident #93, who had intact cognition and a diagnosis of quadriplegia (paralysis), sustained burns from food/beverages on multiple occasions. On 1/2/21, the resident microwaved soup and spilled it on their leg causing a 9.5 by 5.5 centimeter second-degree burn, which is currently a non-healing wound. On 1/9/21, Resident #93 microwaved a beverage and spilled it, sustaining a cluster of blisters on their abdomen. On 4/27/21, staff microwaved soup and provided it to Resident #93, who was lying in bed; the resident spilled the soup on their abdomen, sustaining a 12 by 26 centimeter second-degree burn. The facility did not have a policy addressing safely re-heating foods. Staff interviewed were not able to state a policy for ensuring food was re-heated to safe temperatures. Two staff members were observed microwaving foods/beverages for residents. Thermometers are not available on the units for staff to monitor the temperatures of the food. The provider's failure to prevent burns caused by foods and drinks microwaved to unsafe temperatures placing 144 residents at immediate risk to their health and safety. This resulted in actual harm that was Immediate Jeopardy/Substandard Quality of Care to resident Health and Safety for Resident #93 and Immediate Jeopardy to the facility's other 144 resident (including Resident #141). Findings include: The facility's Microwave Oven - Operational Procedures (undated) documented a procedure for operating a microwave and documented microwaves could be used by both residents and staff. The policy did not address temperatures that food should be heated to or how long to microwave food/beverages. 1) Resident #93 had diagnoses including quadriplegia due to C6-C7 spinal fracture (paralysis). The 1/16/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance from 1 person for most activities of daily living (ADL), required supervision and physical assistance from one person for eating, had no functional limitation in range of motion in either upper extremity (shoulder, elbow, wrist, hand), had functional limitation in range of motion in both lower extremities and used a wheelchair. The comprehensive care plan (CCP), initiated 2/22/19 and revised on 5/7/19, documented the resident had nutrition/hydration problems and an ADL self-care deficit related to quadriplegia. Interventions included occupational therapy (OT) to screen and provide adaptive equipment for feeding as needed. The CCP did not include specific recommendations for adaptive eating equipment. The resident required the assistance of 1 person for personal hygiene and oral care and the resident's eating ability was not addressed in the CCP. The resident was hospitalized [DATE]-[DATE] with a diagnosis of a closed left hip fracture. The 12/23/20 Admission/re-admission assessment documented the resident returned from the hospital at 4 PM and the following skin findings/conditions were noted: a healing burn to the chest that measured 2.5 centimeters (cm) X 0.6 cm, and a healing burn to the abdomen measuring 4 cm x 2.8 cm. The OT Evaluation and Plan of Treatment with a start of care date of 12/24/20 documented the resident required set-up assistance with feeding. The resident's range of motion in both upper extremities was impaired due to quadriplegia. The resident had impairments in fine and gross motor coordination resulting in limitations and/or participation restrictions in the area of self-care, mobility and general tasks and demands. Due to physical impairments and associated functional deficits, the resident was at risk for further decline in function and increased dependency upon caregivers. There was no documentation of the resident's requirement for adaptive feeding equipment. The 12/30/20 [NAME] (care instruction) documented staff were to inspect the resident's skin weekly, the resident needed set-up by staff for meals, received a regular diet, and used a lipped plate and sip cup. The 1/2/21 at 9:29 PM, RN #25's progress note documented they were called to the resident's room to evaluate the resident's left ankle because it looked burned. The resident stated they spilled their soup they had heated in the microwave. The plan was to have the skin team evaluate the resident. There was no documented evidence of a skin assessment completed by the RN. The 1/2/21 Accident and Incident report documented while staff were providing care to the resident, they noticed a large intact blister to the inner left ankle. The resident stated they spilled soup on their pant leg and due to lack of sensation they were not aware of the burn. The resident was to be evaluated by OT for microwave safety, dietary was to provide lidded cups, and the resident was educated about requesting assistance from staff for all microwave use. OT #23's progress note dated 1/6/21 did not address the resident's ability to safely use a microwave. The 1/9/21 at 10:02 PM RN #25's progress note documented the RN was asked to go the resident's room. Upon entering the resident was at the sink and asked the nurse to look at their stomach and mid-abdomen, there was a burn mark with peeling skin. The resident stated the spout to their teacup spilled. The resident noted their shirt was wet but did not think anything happened. The DON (Director of Nursing) was made aware and medical and family were notified. OT #23's progress note dated 1/13/21 documented the resident was educated on the risks of carrying hot liquids and ways to improve safety with task and was encouraged to wear clothing protectors provided by staff and ask for assistance to transport hot mugs to prevent burns. There was no documentation the resident's CCP was revised to include lidded cups or microwave use. There was no documented evidence the CCP was reviewed or revised with a plan of care to prevent further burns following the identification of the burn on 1/9/21. The 4/6/21 Braden Scale for predicting pressure ulcer risk documented the resident's sensory perception was slightly limited which limited the resident's ability to feel pain or discomfort. The resident was at high risk for pressure ulcers. The 4/27/21 Accident/Incident Investigation and Root Cause- Injury of Unknown Origin and Initial Wound Assessment documented the resident sustained a burn that was a cluster of blisters and redness on the chest and abdomen measuring 26 cm x 12 cm. The physician was notified and ordered bacitracin (antibiotic ointment) and dry dressing cover twice daily to the wound. The resident stated they were eating soup while lying down. Interventions included to encourage the resident to wear a clothing protector while eating, position upright when eating, and provide lidded tops to all hot beverages and foods. The 4/29/21 OT progress note documented the OT was asked to discuss the resident's recent burn from spilling hot soup. The resident used a plastic microwavable mug with lock lid. Staff microwaved for the resident according to directions. The resident was agreeable to have staff microwave the food for less time so that soup was still hot but not scalding. The resident was not able to lift the mug with the lid to drink due to poor grip and decreased dexterity. The resident was to utilize clothing protectors and staff were to microwave for less time to prevent burns. There was no documented evidence the CCP was revised to include the OT recommendations from 4/29/21. On 5/21/21, the CCP was revised to include the resident may not use the microwave. The 5/22/21 at 9:45 PM licensed practical nurse (LPN) #37 nursing progress note documented the resident asked staff to warm up soup in the microwave. Resident #93 then proceeded to remove the hot liquid from the microwave without waiting for staff to assist. The resident was educated on the importance of waiting for assistance. During an interview on 6/1/21 at 10:30 AM, Resident #93 stated they sustained a burn to the chest and upper abdomen from tomato soup. They stated the burn happened because of a late return to the facility from an appointment. The resident returned after dinner and was hungry, so they asked the CNA to warm up some soup. The resident refused the clothing protector because they were eager to eat. They explained they were a quadriplegic and very shaky at times. When they put the soup up to their mouth, the hot soup dripped on their abdomen. During an interview on 6/2/21 at 11:40 AM, while observing lunch tray pass, CNA#34 stated staff were not trained in reheating food. CNA #34 stated they microwave food 30 seconds to one minute. There were no probe thermometers available for use. The [NAME], dated 6/3/21, documented the resident required set-up only to eat and received a regular diet with thin liquids and a lipped plate. There was no documentation the resident required any adaptive feeding equipment (cup or bowl) or assistance with the microwave. During an interview on 6/3/21 at 9:15 AM, CNA #27 stated they were usually assigned to the resident in the evening and they recalled the resident went to the hospital for a test or procedure in 4/2021 and when the resident returned, they were hungry. The resident had a lot of canned food in their room. CNA #27 heated up a can of soup for the resident in a container that clicked locked on both sides. CNA #27 stated it was the resident's personal container which was a cup with a handle on the side. CNA #27 followed the heating instructions on the soup can and warmed it for about 2-3 minutes. CNA #27 stated they were not trained on how to heat food to safe temperatures. That night, the resident ate in their room sitting up in bed. The resident had a shirt on but refused a clothing protector. CNA #27 stated they often microwaved food for residents when it arrived cold from the kitchen. During an interview on 6/03/21 at 9:45 AM, with CNA #28, they stated food was warmed in the microwave all the time and they were not sure how to tell if the temperature was safe. The CNA stated they could not recall warming up food for any residents, but there were microwaves available on all units. During an interview on 6/03/21 at 11:37 AM with RN Manager #22 they stated they thought the burns the resident sustained to the abdomen in 12/2020 were from spilling hot tea on themselves. On 1/2/21, the resident sustained a burn to the left ankle and thought it was from soup or tea. RN Manager #22 stated the resident had been using the microwave independently. The resident refused clothing protectors, would not allow staff to apply lids to soup containers and/or hot drinks and the resident would remove the lids. The 6/3/21 lunch meal ticket for Resident #93 documented a Lip Plate and a regular diet. There was no documentation that the resident required covered mugs, or covered soup bowls or any adaptive feeding equipment. During an interview on 6/03/21 at 12:59 PM, Resident #93 stated the night they burned their chest (4/29/21) they were not wearing a shirt because they asked to be helped into bed after their outside appointment. The resident stated at the time the facility dishwasher was broken and they were given a plastic spoon which did not work well with their palm assistant because the plastic spoon was too short. The resident stated the soup must have dripped on their stomach. The resident explained they also warmed up tea in the microwave and when placing the hot tea on the wheelchair footrest, it spilled, and they burned themself. On 06/03/21 at 7:17 PM Resident #93 was observed with an empty green soup cup/mug on their lap. They stated this was not the mug they used all the time. They explained the cover on the mug was really clamped down and used for soup because it had a vent in it, and they had ordered it online. They stated they could use the facility mug. They stated when they used the mug for soup, they did not use the lid and they sustained the burns when using the soup mug without a lid. They were not wearing a shirt or clothing protector and the soup dripped off the spoon when using the facility mug and they were burned. During an interview on 6/03/21 at 2:57 PM with OT #23, they stated the resident used to use the wheelchair footrest to carry things between their feet when going back and forth to the microwave. OT #23 stated in 12/20, the resident had a blue cup and would put it on their la or rest it on the footrest and the cup tipped and spilled. The interdisciplinary team determined the resident was unable to safely manage use of the microwave therefore staff were going to heat foods up for the resident. Routinely, staff would heat the food up for the resident. The resident bought their own large mug with a handle and locked top containers for soup and drinks. OT #23 stated they thought the resident was using these. The OT recalled it was recommended the staff not heat foods up to burning hot. They stated they had not recommended any adaptive equipment, as the resident already uses the universal cuff (gives persons with limited grip or dexterity controlled use of items such as eating utensils and writing tools). The OT did recommend the resident not transport the hot food items and should be at a table or sitting up in a chair because the resident had a poor grip. The OT stated they recommend a clothing protector if eating in bed and to wear a shirt because the resident was prone to spilling what they were consuming. The resident bought the bowl and the cup, the OT did not recommend them, but stated they thought the items were safe. The OT stated it was safe for the resident to eat in their room alone. The resident was cognitively intact but needed to be in the best position and use adaptive equipment such as the blue mug for hot tea at night. The OT stated they were asked to do a microwave safety assessment for the resident in April 2021, and recommended the resident not warm up foods independently because of the lack of sensation and lack of grip. The OT stated the resident's current meal ticket did not document anything about the bowl or mug. There was no documentation for the nursing staff to know how to transfer the hot liquids into the large handled mug with the lid, or the shallow bowl with the lock top. The resident had cans of soup in their room that they had staff warm the soup up at night. The OT stated the care plan should be updated with OT recommendations. When these details are on the care plan, the aides will see it on the [NAME] and would need to check that task off as part of their care. The OT stated the resident care plan should have documented no use of the microwave by the resident. During an interview on 6/03/21 at 3:55 PM RN Manager #22 stated the resident came back from the hospital on [DATE]. When the readmission assessment was completed it was noted the resident had burns to the abdomen and chest. There was no documentation the burns had been previously reported. RN Manager #22 and the DON were not aware the resident had burns prior to the hospitalization because there was no documentation about the burns on the abdomen and chest. They recalled an incident on 1/2/21 when the resident burned their left foot with hot soup. The resident warmed up soup in the microwave in the kitchenette at around 9:00 PM and spilled the soup on themself when getting the soup out of the microwave. The resident had their own personal cup with a lid and had a big handle mug they would pour the can of soup into and warm up. An incident report was completed on 1/2/21 and it was immediately decided the resident needed to be educated about not using the microwave without supervision. The RN stated the microwave was still on the unit. On 1/9/21, the resident burned their abdomen heating up a drink in the microwave after being told not do so without assistance. On 4/29/21 the resident sustained a burn to the chest and abdomen from hot soup that a staff member microwaved for the resident in the unit dining room/ kitchen area. The RN Manager #22 confirmed the resident's care plan did not include the resident's personal dishes and/or personal food and it should have. They stated the care plan updates the [NAME] for the care and tasks to be completed by the CNA. Food that needs to be warmed up should be sent to the kitchen. The RN Manager #22 stated the CNAs did not have a way to check temperatures of microwaved items. The resident currently had a locked lid shallow bowl and a blue big handle mug. The RN Manager #22 stated the resident was able to remove the lids and did not use the bowl and mug in a safe or appropriate manner. During a telephone interview on 6/03/21 at 5:59 PM, attending physician #26 stated they were not familiar with the resident, as they started as their provider in the beginning of 4/21. After review of the burn incident, they stated it seemed as if the resident was not doing well with the hot liquids and may need to be reevaluated to ensure that the resident is safe Physician #26 stated the resident did not appear to be capable of feeding themself safely. Staff needed to know how to check food temperatures for safety with hot food. During an interview on 6/3/21 at 6:30 PM, RN Manager #22 stated they talk to the resident in the past about their safety concerns, but the resident refused to use a clothing protector. The resident did not feel the burns were significant. The care plan documented their noncompliance but did not include the resident's need for adaptive dishes and assistance with microwaving foods. During an interview with the DON on 6/3/21 at 4:10 PM they stated the resident had spilled coffee and soup on themself and all incidents had been investigated. They offered clothing protectors and heat resistant pads and the resident refused those items. They stated safety lids and containers were also attempted but the resident had taken the lids off. The resident received extensive education on different occasions about food preparation safety. The resident purchased their own type of lids because they preferred the way the lid went on and came off. Assistive devices should be listed under the dietary care plan. The microwave was removed temporarily when the resident had first spilled hot liquid, but other residents also used it, so it was returned, and the resident had not been using it when it was returned. The 6/4/21 electronic communication from the facility Administrator documented there was no investigation related to the burn observed in December 2020 when the resident returned from the hospital. 2) Resident #141 had diagnoses including chronic obstructive pulmonary disease (COPD), oxygen dependence, and anxiety. The 2/5/21 Minimum Data set (MDS) assessment documented the resident was cognitively intact and independent with activities of daily living (ADL). The resident required set-up assistance for eating. The 6/4/19 physician's order documented a regular diet, regular texture, thin liquids. The 2/26/18 comprehensive care plan (CCP) updated 3/5/21 documented the resident had potential/actual skin impairment to left third finger related to a self-inflicted burn from a hot microwave meal. Interventions included identify cause of skin impairment and eliminate, follow facility protocols for treatment of injury, monitor size, location, document, notify the physician of failure to heal, signs and symptoms of infection, resident agrees to ask for assistance when heating food in the microwave, verbalizes complete understanding (safety), Silvadene treatment until healed. The 4/14/20 [NAME] (care instructions) documented the resident required set-up help for eating. The 3/4/21 at 1:06 AM, licensed practical nurse (LPN) #42's progress note documented they were told by the resident at 12:55 AM, the resident had a fluid filled blister on their left third finger. The blister measured 3.6 centimeters (cm) X 1.0 cm. The resident reported they had a CNA (not identified) heat up noodles in a Styrofoam cup in the microwave. When the resident grabbed the cup, some of the water got on their finger. The resident put cold water on it right away. The Supervisor was notified. Skin prep (a clear protective liquid film) was applied. The 3/4/21 Accident and Incident report completed at 1:14 AM by LPN #42, documented the resident sustained a 3.6 cm x 1.0 cm burn to their third left finger. Skin prep was applied. The CCP documented staff would heat items in the microwave. The resident accidentally spilled hot water on their finger and was educated to wait to let the food cool. The probable cause of the accident was identified as accidental, education provided to allow items to cool. The CNA assigned was CNA #43. The 3/5/21 at 12:32 PM registered nurse (RN) Manager #40's progress note documented that per nurse practitioner (NP) #12, start treatment with Silvadene cream and monitor until healed, care plan involved staff heating food in microwave to avoid injury, resident agrees. The progress note did not document what was to be treated with Silvadene cream. The CCP initiated 3/5/21 documented the resident had impairment in skin integrity of the left hand 3rd finger related to a burn from a hot microwave meal accidentally self-inflicted. The CCP was updated on 3/9/21 to include the resident agreed to ask for assistance when heating up items in the microwave. The wound assessment, effective 3/9/21, documented the resident had a self-inflicted burn on the left third finger measuring 3.6 x 1 x 0 cm, no odor, slight inflammation. The wound was discovered on 3/4/21 and the provider and family were notified on 3/5/21. Treatment was for Silvadene cream with dry sterile dressing (DSD); wound team to see, care plan updated to ask for help with microwave. The 3/9/21 at 3:41 PM RN Manager #40 progress note documented the resident's wound was healed, Silvadene treatment discontinued. The 3/9/21 Director of Nursing (DON) accident summary (for the 3/4/21 incident) documented the resident was independent once in their electric wheelchair and made their own decisions. The resident went to the kitchenette in their wheelchair and heated up a container of noodles. When they returned to their room, they opened the lid and drops of water spilled onto their finger. The resident immediately ran cold water on it. Initially there was nothing there, then at 12:00 AM, the resident noticed the blister and notified the LPN. The resident had no prior known concerns with the microwave. The resident was educated to let the staff microwave and open the food items to prevent reoccurrence and the resident understood. When interviewed on 6/8/21 at 2:41 PM, RN Manager #40 stated they recalled the resident's burn. They treated the burn with Silvadene cream, and it healed within a week. At that time, the resident was alert. They warmed up something in the microwave and it was common for the resident to go in the kitchen and heat up food. The microwave sat on the counter at the height of the resident's chest. Prior to the burn, there had been no second thoughts regarding the resident using the microwave. The resident was then care planned to ask for assistance when heating food in the microwave and verbalized understanding. When interviewed on 6/9/21 at 8:56 AM, LPN #42 stated Resident #141 was alert and had no difficulty using their hands or manipulating their wheelchair. The resident used the kitchenette often and LPN #42 never questioned their ability to use the microwave. The resident notified staff if they needed help but would take hot foods back to their room. The resident placed their cup of noodles in a bowl and held the bowl with one hand on the outer part of the armrest and used their other hand to drive their electric wheelchair. They stated the resident did not tell LPN #42 if the burn happened in the kitchenette or in their room, or if a CNA had cooked the noodles for them. The blister was fluid filled but the skin was intact. LPN #42 was not sure if the facility went over any staff training about hot foods. Dietary used to check the temperature of the hot coffee, but LPN #42 had not seen them do that recently. LPN #42 stated there used to be a thermometer on the unit but did not know what happened to it. When interviewed on 6/9/21 at 9:16 AM, CNA #43 stated the resident was self-sufficient and would ring if they needed anything. CNA #43 stated it was not common for the resident to use the microwave themself. The resident kept food in their room and asked if they needed something warmed up but had never asked the CNA to heat anything. CNA #43 stated, they did not recall the resident getting burned. ------------------------------------------------------------------------------------------------------------ The Immediate Jeopardy was removed on 6/4/21 based upon the following: - All microwaves were removed from each units and staff breakrooms. The ability to warm food up was prohibited until dietary staff arrive in the AM. There was not hot food available from 9:00 PM until 5:00 AM. - Eighty percent of staff were educated regarding the removal of microwaves and all food would be heated up by food service staff only until all nursing staff and dietary employees have been educated on safe food heating methods. 10 NYCRR 415.12(h)(1)(2)