**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, record review and interview, the facility failed to provide adequate care and services to prevent a second degree burn on the Resident #68's right hand. Actual Harm occurred on 12/03/24 when Resident #68 sustained a second degree burn to her right dorsal hand after spilling hot noodle soup onto her right hand. The soup had been heated in a microwave by nursing staff at an unknown hot temperature and then handed to the resident who was standing in the area. This affected one resident (#68) of three residents reviewed for accidents/hazards. Findings include: Review of Resident #68's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, essential hypertension and bipolar disorder. Review of Resident #68's physician orders revealed an order dated 06/28/24 for a regular diet, regular texture with regular consistency. Review of Resident #68's Hot Liquid Evaluation form dated 09/26/24 revealed the resident did not have indicators for severe cognitive impairment, poor safety awareness, tremors, contractures, weakness or posture concerns. The assessment revealed there were no other indicators not listed above. Review of Resident #68's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. The resident resided on the secured memory care unit on the second floor. Review of a facility Occurrence Form #1223725 dated 12/03/24 at 4:11 P.M. revealed the nurse was sitting at the nursing station charting and the resident was handed a cooked noodle cup by the Certified Nursing Assistant (CNA). The resident sat the noodle cup on her roller walker and took a step backwards and lost her balance falling onto the floor. The incident was witnessed by staff. Review of Resident #68's Acute Visit Nurse Practitioner (NP) note dated 12/03/24 authored by NP #815 revealed the resident had a past medical history (PMH) of hypertension, diabetes, bipolar fell onto the floor in the secured unit. This was a witnessed fall. She hit her head to the floor with no bleeding, no hematoma and neurological checks were initiated. Her mental status was per the baseline and range of motion was per the baseline. The resident stood up with assistance and started walking with the walker. She also had spilled hot soup on her right hand and complained of burning. No blisters and an ice pack was applied. Review of Resident #68's Skin Grid Non-Pressure form dated 12/03/24 at 4:12 P.M. revealed the resident had right hand (back) redness which was classified as a burn. The wound measured one cm (centimeter) length by 2.0 cm width with no depth. The wound was red, moist grainy, with optimal granulation color and pain. Review of Resident #68's progress note dated 12/03/24 at 8:31 P.M. authored by Licensed Practical Nurse (LPN) #810 revealed while the nurse was sitting at the nursing station charting, the resident was handed a cooked noodle cup by the CNA. The resident sat the noodle cup on the roller walker and took a step backwards. She lost her balance and fell onto the floor. The resident was observed hitting her head but denied pain due to the recent fall. The skin was intact, and no injury was noted. The resident complained of pain to the right hand and stated the noodle cup got on her hand. The NP was made aware and assessed the resident. An ice pack to the right hand was ordered and neurological checks were ordered. The power of attorney (POA) was made aware, and urine was sent to the lab this morning. Review of Resident #68's progress note dated 12/04/24 at 1:00 A.M. authored by NP #815 revealed the encounter was a follow up post fall and burns to the right hand. The resident was seen in the hallway sitting in the walker seat. The resident denied a new headache, mental status at baseline and neurological checks continued. The resident complained of right elbow pain post fall and elbow redness was found on the bony area. No dislocation was identified and burns to the right hand. Bacitracin external ointment twice daily was ordered. Review of Resident #68's physician orders revealed an order dated 12/04/24 at 5:00 P.M. authored by NP #815 for bacitracin external ointment 500 units/gram apply to right hand/wrist two times a day. Review of Resident #68's physician orders revealed an order dated 12/04/24 to apply an ice pack to the right hand due to complaints of pain as tolerated by the resident; an order dated 12/04/24 for bacitracin external ointment 500 units/gram apply to right hand/wrist topically two times a day for seven days for a burn; and an order dated 12/12/24 to cleanse the right dorsal hand second degree burn with wound cleanser, apply Silvadene cream 1% (silver Sulfadiazine) to base of the wound, leave open to air and complete twice daily and as needed. Review of Resident #68's medication administration records (MARS) and treatment administration records (TARS) from 12/03/24 to 12/17/24 revealed treatments were completed as ordered. Review of Resident #68's Skin and Wound Note dated 12/13/24 at 3:30 P.M. revealed the visit was for a new skin and wound consult. Resident #68 presented with a burn to the dorsal right hand. The wound was new and was 1.5 cm length by one cm width with 0.1 cm depth with dryness to the peri wound and scant amount of serous exudate. The wound was classified as a right dorsal hand second degree burn. The order was to cleanse the right hand with Silvadene cream 1% to the base of the wound and leave open to air twice daily. Interview on 12/17/24 at 6:57 A.M. with CNA #808 revealed Resident #68 did not like the facility food and the resident's daughter would bring in ramen noodle cups for the resident. She revealed on 12/03/24 at approximately 8:25 P.M. she heated up a ramen noodle cup for Resident #68 at (approximately) one minute and 30 seconds in the microwave. The CNA stated the resident said it was not hot enough and she heated it for another 60 seconds in the microwave and then handed it to the resident. She revealed Resident #68 put the soup down on her walker and some of the soup splashed onto her hand. CNA #808 revealed the resident became startled and took a step back falling to the floor and hitting her elbow and head. CNA #808 revealed she was aware the facility policy indicated not to heat foods for residents, but she stated she had always heated Resident #68's noodle soup. She confirmed the resident had cognitive impairment and resided on the secured memory care unit. Interview on 12/17/24 at 7:26 A.M. with LPN #810 revealed he was sitting at the nursing station on 12/03/24 when CNA #808 handed Resident #68 her soup. LPN #810 confirmed the resident's family does bring in food for the resident. He revealed at the time of the incident, the resident stepped back and fell backwards to the floor striking her elbow and head on the floor. He revealed he did not see injuries to her hand but was more concerned about the injuries to her elbow and head. He confirmed staff were not supposed to be heating soup up for the residents and he stated he called the resident's daughter and NP following the incident with the resident. An attempted interview on 12/17/24 at 10:47 A.M. with Resident #68 revealed she was not able to answer interview questions. Observation of Resident #68's right hand at the time of the interview revealed she had a healing burn on the right hand between the thumb and first finger which appeared shiny pink and it had a scabbed area in the middle of the shiny pink area which appeared to be a healing blister. Interview on 12/17/24 at 12:22 P.M. with NP #815 revealed on 12/03/24 Resident #68 had soup on the seat of her walker) and burned her hand on it which caused her to fall backwards to the floor and hit her head. NP #815 revealed she had assessed the resident while she was still on the floor because she was in the building. She revealed Resident #68 did not have injuries to her shoulder and had a bruise to the right elbow and a burn to the right hand. She revealed at the time of the observation the resident's hand was just reddened, and she ordered an ice pack to be applied to the area. NP #815 revealed she assessed the resident on 12/04/24 and noted the resident's top layer of skin on the resident's right hand was peeling. She denied the resident had blisters at this time. Interview on 12/17/24 at 12:50 P.M. with the Interim Director of Nursing (DON) revealed Resident #68 developed a blister on 12/06/24 between the thumb and pointer finger (top uppermost part) as a result of the burn on 12/03/24. Review of the undated Storage of Resident Food policy indicated dietary services would provide any re-heating of foods but in the event dietary staff were not available, a trained staff member may re-heat foods brought in from outside sources. Foods must be re-heated in 15 second increments until the temperature reaches 165 degrees Fahrenheit. Allow the food to cool prior to serving for resident preference and palatability. The deficiency was corrected on 12/04/24 when the facility implemented the following corrective actions: • On 12/03/24 at 4:08 P.M., LPN Unit Manager (UM) #825 completed a skin assessment on Resident #68 and noted redness to the right hand measuring one cm length by two cm width with no depth. The resident's skin was intact at this time. • On 12/03/24 at 4:20 P.M. LPN UM #825 completed interviews with unit staff. The staff reported Resident #68 lost her balance due to being distracted and talking to other residents. • On 12/03/24 at 4:30 P.M., the Interim DON was notified of the incident by LPN UM #825. • On 12/03/24 at 4:31 P.M. the Interim DON reviewed Resident #68's diet order. The order was for a regular/regular/regular diet with no devices. • On 12/03/24 at 4:45 P.M., the Interim DON reviewed Resident #68's MDS and Care Plans and no diet modifications were noted. • On 12/03/24 at 4:45 P.M. the Interim DON completed an audit by assessing all residents in house for potential for risk of injury due to hot food items/liquids. No abnormal findings were identified. • On 12/03/24 at 6:05 P.M. LPN UM #825 educated all facility staff on Hot Liquids and initiated an in-service. • On 12/03/24 at 6:38 P.M., NP #815 ordered an ice pack to Resident #68's right hand twice daily as tolerated, and the ice pack was added to the resident order list. • Review of the Outside Food policy by the Administrator and DON on 12/4/2024 revealed no changes were made. • On 12/04/24 at 4:15 P.M. NP #815 assessed Resident #68. No swelling to the head was observed. Redness to the right hand was observed with intact skin. Neurological checks were within normal limits (WNL) and range of motion (ROM) was WNL. A verbal order for an ice pack was received and initiated. • On 12/04/24 at 9:50 A.M., an interdisciplinary team meeting was held regarding the incident which included the Administrator, Interim DON, LPN UM #832, LPN UM #825, LPN MDS #861, Therapy #602, Licensed Social Worker (LSW) #603. • On 12/04/24 at 2:30 P.M., NP #815 followed up with Resident #68 and treatment orders were obtained and implemented. On 12/04/24 at 3:00 P.M., NP #815 ordered bacitracin ointment to the right hand twice daily. • On 12/04/24 at 4:00 P.M. the Interim DON initiated ongoing monitoring audits three times a week for four weeks related to monitoring residents for risk for injury related to hot liquids/foods. The audits were being monitored for compliance by the DON in conjunction with the Administrator daily during the clinical meeting and weekly during the nursing risk meeting. • On 12/04/24 at 5:00 P.M. LPN UM #825 completed Storage of Resident Food Hot policy in-service with focus on hot liquids/foods to all facility staff. • On 12/05/24 at 11:46 A.M., Speech Therapy evaluation was completed by Speech Therapist #604 and an order received for ST services three times a week for four weeks for cognitive skills development • On 12/06/24 at 10:33 A.M., a skin evaluation was completed on Resident #68's right hand burn. The resident was added to wound care rounds with Wound NP #985 (routine). The burn to the right hand measured one cm length by two cm width with no depth and was red in color with no exudate and no pain. The physician orders were to continue the treatment of Bacitracin topically twice daily. The resident's right hand had an intact blister which was noted to the center of the burn. • On 12/12/24 at 4:00 P.M. a wound assessment was completed with the facility wound nurse LPN UM #825 and Wound NP #985. The burn to the right hand measured at 1.5 cm length by one cm width with 0.1 cm depth. Dryness was noted to the periwound with scant serous exudate. The treatment orders was changed to Silverdene cream 1% twice daily and as needed. On 12/12/24 at 8:04 P.M. the treatment order for Resident #68 was changed to Silvadene twice daily and as needed by Wound NP #985. This deficiency represents non-compliance investigated under Complaint Number OH00160640.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, resident and staff interview, review of medial imaging results, review of staff statements, and review of facility corrective action, the facility failed to provide adequate and sufficient assistance during personal care to prevent a fall with major injury for Resident #30. Actual harm occurred on 05/28/24 when Resident #30, who required staff assistance (care planned to require two-person assistance and/or substantial to maximal assistance with activities of daily living (ADLs)) sustained a fall out of bed resulting in a fractured left hip. At the time of the incident, one (1) staff member was providing care to the resident. This affected one (#30) of three residents reviewed for falls. The census was 99. Findings Include: Review of Resident #30's medical record revealed an admission date of 06/25/21 with diagnoses including anemia, orthostatic hypotension, retention of urine, muscle weakness, chronic kidney disease, congestive heart failure, anxiety, and major depression. Review of a fall risk care plan dated 04/17/24 revealed Resident #30 was placed at risk for falls related to incontinence, weakness, anemia, end stage renal disease, diabetes mellitus, wounds, and immobility. Appropriate interventions were implemented to include use of non-skid footwear, maintain the resident's room free of accidents and hazards, ensure bed locks are engaged, place the call light in reach, and move the resident's room closer to the nurses' station. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was assessed with intact cognition with no range of motion impairments to the upper or lower extremities. Review of Resident #30's plan of care revised 05/16/24 revealed the resident had an ADL self-care deficit and the resident required assistance with ADLs related to incontinence, diabetes mellitus, weakness, and immobility. Interventions included the resident was totally dependent on staff for toilet hygiene, showers/bathing, and chair to bed transfers requiring two (2) or more helpers to do all of the work. An intervention included the resident required substantial/maximal assistance where helpers do more than half the effort to complete upper body dressing, personal hygiene, and rolling left and right. An intervention was also implemented which indicated the resident's assistance level with ADLs may vary based on the time of day, pain, mood, or fatigue and staff should document and adjust as indicated. Review of a late entry nursing progress note dated 05/28/24 at 7:45 P.M. revealed staff were alerted to Resident #30's room by a State Tested Nursing Assistant (STNA) and Resident #30 yelling out for help. As the writer of the progress note entered the room, Resident #30 was observed rolling out of bed from behind a privacy curtain. The resident was mechanical (Hoyer) lifted from the floor using four (4) staff members to get the resident into bed. Resident #30 was noted with abrasions to his head, a skin tear to the top of the right hand, an abrasion to the front of the right shin, and bruising to the left arm. The resident was to be assisted by two staff for hygiene care, repositioning in bed, etc. The physician was notified, and x-ray imaging was ordered for the resident's hips and pelvis as the resident complained of pain while moving back to bed. The resident was able to move all 4 extremities. Review of a post-fall evaluation document dated 05/28/24 at 7:45 P.M. revealed Resident #30 sustained a fall in his room from bed which was in normal position. The resident was wearing non-skid socks and was not using any assistive devices. It was noted the last time the resident was toileted was on 05/28/24 at 7:45 P.M. and STNA #114 was the only witness to the fall. Vital signs were within normal limits, and the resident was complaining of pain in both hips and the left antecubital. The pain was described as achy and tender. Resident #30 was assessed with three (3) small abrasions on the top of his scalp, a skin tear on the back of the right hand, and an abrasion to the front of the right lower leg. Notification was made to the physician and resident's responsible party at 8:00 P.M. When the resident was asked what he was doing prior to the fall the resident responded that he was being changed and rolled off the side of the bed. The suspected root cause of the fall was the resident was holding onto a grab bar and started rolling off the edge of the bed. STNA #114 was not able to get to the other side of the bed fast enough to stop the resident from falling. It was also noted the resident was on an air mattress as a suspected root cause. Following the incident, staff identified the resident required two staff members to provide care at all times. Review of a written statement dated 05/28/24 given by STNA #114 revealed at approximately 7:45 P.M. he was doing a bed change on Resident #30. STNA #114 documented he rolled the resident over to face the door and the resident was grabbing the side rail holding himself over. As STNA #114 was putting the corners of the sheet on the bed, Resident #30 started to roll off the bed. STNA #114 reached to grab for the resident and yelled for help. STNA #114 documented Resident #30 slipped from his grip and rolled off the bed just as staff members entered the room. Review of a typed statement dated 05/29/24 at 2:25 P.M. given by Licensed Practical Nurse (LPN) #132 revealed she just had finished shift report and was at the nurses' station charting when she heard a yell for help and a thud. LPN #132 observed Resident #30 laying on the floor between the two beds in his bedroom and his nurse aide was on the opposite side of the bed moving toward the resident. LPN #132 stated the resident was alert and oriented and indicated he rolled out of bed when the nurse aide was providing care and was not sure how it happened as it happened so quickly. LPN #132 documented the resident was assessed and was able to move his hands and arms with no issues. The resident indicated he had discomfort in both hips and he was able to move his right left more than his left leg. There was no obvious external rotation or significant length differences when comparing the resident's legs. Review of a nursing progress note dated 05/29/24 at 5:22 P.M. revealed Resident #30 complained of severe left arm pain in the morning and an order for x-ray imaging of the left arm from shoulder to fingertips was ordered. The resident was medicated with narcotic pain medications; however, the medication was not effective. Results of the resident's x-rays revealed a possible fracture of the left hip and the resident was sent out to the hospital. Review of a subsequent nursing progress note on 05/29/24 at 11:40 P.M. revealed Resident #30 was being admitted to the hospital due to a left hip fracture from a fall. Review of x-ray imagine results dated 05/29/24 revealed Resident #30 was found with irregularity of the left intratrochanteric region and may represent a nondisplaced fracture. The femoral heads showed no concerns, and the surrounding soft tissue was normal. X-rays of the left hand to shoulder revealed no acute fractures and the surrounding tissue was normal. Interview with the Administrator on 06/04/24 at 3:30 P.M. verified Resident #30 rolled out of bed approximately at 7:45 P.M. on 05/28/24. At the time of the incident, Resident #30 was holding the upper assist rail and his legs started going off the bariatric low air loss mattress with bolsters mattress. The Administrator revealed prior to the incident, the resident could hold the rail once assisted to roll onto his side, but stated the resident did not have the upper arm strength to roll himself over. The Administrator stated STNA #114 was providing incontinence care for the resident at the time of the incident. The Administrator indicated the facility notified the family, an x-ray was ordered, and the x-ray showed a possible fracture of the resident's left hip. Observation of Resident #30 on 06/06/24 at 7:57 A.M. revealed the resident was laying in bed with no obvious concerns noted. An interview was attempted with the resident; however, no information was able to be provided regarding the fall on 05/28/24 from the resident. Interview on 06/06/24 at 3:53 P.M. with STNA #114 via telephone revealed (on 05/28/24) he had to do a full bed change on Resident #30. While providing care, STNA #114 indicated he turned the resident to wipe his back side, and the resident was fine. STNA #114 stated Resident #30 was holding on to the upper side rail while he went to fit the corner of the sheet on the corner of the bed. STNA #114 stated, out of the corner of his eye, he could see Resident #30 started to slip. STNA #114 stated he got a little hold of Resident #30, but the resident slipped from his grasp. STNA #114 stated he called for help and Resident #30 fell off the bed as 2 staff members were coming in. As a results of the incident, the facility implemented the following corrective actions to correct the deficient practice on 06/03/24: • On 05/29/24, Resident #30 was sent out to the hospital for evaluation and treatment of a suspected left hip fracture. The resident was readmitted to the facility on [DATE]. • On 05/31/24, an audit was completed on all residents with air mattress to ensure there were not issues with the mattresses and application of the mattresses was appropriate. There were no concerns noted. • On 05/31/24, all resident care plans were reviewed and updated to ensure proper interventions were in place for assistance with care with no concerns noted. • On 05/31/24, all staff members were educated that all residents utilizing an air mattress required a 2-persons assistance with care and to check the resident's [NAME] for updates to the resident's tasks. • On 06/03/24, audits were initiated to ensure 2-person assistance with utilized for residents with low air loss mattress. The audits were of three residents weekly for three weeks to ensure compliance. Review of the audits completed for the weeks of 06/03/24 and 06/10/24 revealed no concerns were identified. This deficiency represents noncompliance investigated under Complaint Number OH00154514.