**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility neglected to provide the appropriate staff assistance of one person physical assist for eating, which resulted in physical harm in the form of second degree burns of left thigh and left hip for one of three residents (Resident R1) and failed to ensure resident was free from mental abuse resulting in resident feeling emotionally distressed for one of three (Resident R2). Findings include: Review of facility policy Abuse - Prevention, Identification, Investigating and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property dated 1/5/22, indicated that Neglect is defined as a failure of a facility, it's employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or mental illness. Review of facility policy Feeding Residents dated 1/5/22, indicated residents will receive meals in a timely and orderly fashion and will be provided with the appropriate level of assistance. Review of Resident R1's admission record indicated admission to the facility on 7/10/19. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/16/22, indicated that Resident R1 required extensive assistance for eating with assist of one physical person. Review of care plan dated 9/28/22, indicated Resident R1 will have two or less behaviors per week of grabbing and receive necessary assistance with meals. Interdisciplinary Department Team (IDT) form dated 10/21/22, indicated Nursing Assistant (NA) Employee E1 went into the room at 12:20 p.m. to pick up lunch tray after meal service and noted hot chocolate on Resident R1's lap with blisters and redness. Review of Quality Peer Review Committee form dated 10/21/22, indicated the NA Employee E1 noticed Resident R1 was attempting to climb out of bed most of the daylight shift and legs were out of the bed. Review of NA Employee E1's interview signed statement dated 10/21/22, indicated she walked into the room, noticed hot chocolate on blanket, noticed leg was red, and that Resident R1 was climbing all day, legs were off the bed at the time, and it looked as if Resident R1 pulled the table to get out. Review of NA Employee E2's interview signed statement dated 10/21/22, indicated she walked in room to help with Resident R1 and there was hot chocolate on the blanket and upper left leg was red. Interview on 11/14/22, at 11:10 a.m. Director of Rehab Employee E3 indicated Resident R1 was extensive assist of one person physical assist for eating, and that she would have needed help to eat as resident historically positions herself onto her side in a fetal position. Interview on 11/14/22, at 12:24 p.m. Registered Nurse (RN) unit manager Employee E4 indicated it was reported that Resident R1 spilled her hot chocolate, lid was still on, with burns to left thigh and hip. The burns were pink at first and then blistered and confirmed the tray should not have been left unattended with Resident R1's behaviors that morning because she required assistance of one staff for eating. Review of signed Licensed Practical Nurse (LPN) Employee E5's interview dated 10/21/22, and progress note dated 10/21/22, at 3:19 p.m. indicated NA Employee E1 noted hot chocolate on Resident R1's lap with injury of blisters to left hip and thigh: area one measured 11.5 cm x 8 cm (centimeters) with three blisters and area two measured 6 cm x 5cm with one blister. Interview on 11/14/22, at 12:28 p.m. with Director of Dietary Employee E7 and Registered Dietary Tech Employee E8 indicated a vendor came out and calibrated their hot water to dispense at 185 degrees Fahrenheit so meal time temperature would range around 155 - 160. Review of temperature logs dated 10/16/22 - 10/29/22, of tray line indicated a hot beverage result of 185 for the lunch meal on 10/21/22. Review of random test tray audit dated 10/17/22, indicated a hot beverage temperature of 155 degrees at the time Resident R1 was served. Review of facility policy Abuse - Prevention, Identification, Investigating and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property dated 1/5/22, indicated Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment, deprivation or abuse. Review of facility policy Concern/Grievance dated 1/5/22, indicated a grievance is defined as an official statement of a complaint over something believed to be wrong or unfair and requiring the assistance of facility management to seek resolution when possible and that concerns of abuse, neglect, exploitation and misappropriation of property are addressed in the Abuse Policy. Review of Resident R2's admission record indicated admission to the facility on 8/13/22. Review of MDS dated [DATE], indicated diagnoses of heart failure (chronic condition where the heart doesn't pump blood as well as it should), hypertension (high blood pressure), and cerebral vascular accident (CVA stroke) and review of the Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment for Resident R2 the score was 15 - cognitively intact. Review of care plan dated 9/5/22, indicated an intervention to monitor for signs of bladder dysfunction and signs of urinary tract infection due to history of stroke. Review of Resident R2's September 2022 Medication Administration Record indicated the medication of Lasix (a water pill to help prevent fluid in the lungs) twice daily at 8:00 a.m. and 6:00 p.m. for treatment of heart failure. Review of Grievance dated 9/11/22, on 11/14/22, at 1:36 p.m. indicated R2 stated NA Employee E9 was very rude and short with her and told her that she pees too much and made her feel badly and like a burden. The form failed to have any signatures of Social Worker, Director of Nursing, or Administrator indicating the status of the grievance. Review of Resident R2's interview with Social Services Employee E10 on 9/12/22, indicated Resident R2 is alert and orientated and was sitting up in bed. Reported that on Saturday night there was an aide assigned to her that she described as really mean, Resident R2 could not identify the staff member by name. Resident R2 could provide a description of her race and gender. This aide never had this staff provide her care before but she made Resident R2 not wanting to ask for any help because this staff member made her feel emotionally distressed and talked to her like she was a bother because she had to go to the bathroom. The aide did help her but Resident R2 did not want to be a bother and was apprehensive to ask for anymore help that evening. Interview on 11/14/22, at 12:13 p.m. with the Director of Nursing and Assistant Director of Nursing Employee E6 confirmed that NA Employee E1 should not have left the tray unattended since Resident R1 demonstrated behaviors and required extensive assistance of one person physical assistance to eat. Also, confirmed that NA Employee E1 neglecting to assist Resident R1 with eating resulted in harm causing second degree burns of left thigh and left hip for Resident R1. Assistant Director of Nursing Employee E6 and Director of Nursing confirmed that NA Employee E9 caused Resident R2 to endure mental abuse resulting in resident feeling emotionally distressed and apprehensive to request help. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.28(c) Nursing services 28 Pa. Code 211.28(d)(1)(5) Nursing services 28 Pa. Code 211.28(d)(3) Nursing services.

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to make certain each resident receives adequate supervision and assistance to prevent accidents for one of three residents. (Resident R1). Findings include: Review of facility policy Abuse - Prevention, Identification, Investigating and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property dated 1/5/22, indicated that Neglect is defined as a failure of a facility, it's employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or mental illness. Review of facility policy Feeding Residents dated 1/5/22, indicated residents will receive meals in a timely and orderly fashion and will be provided with the appropriate level of assistance. Review of Resident R1's admission record indicated admission to the facility on 7/10/19. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/16/22, indicated that Resident R1 required extensive assistance for eating with assist of one physical person. Review of care plan dated 9/28/22, indicated Resident R1 will have two or less behaviors per week of grabbing and receive necessary assistance with meals. Interdisciplinary Department Team (IDT) form dated 10/21/22, indicated Nursing Assistant (NA) Employee E1 went into the room at 12:20 p.m. to pick up lunch tray after meal service and noted hot chocolate on Resident R1's lap with blisters and redness. Review of Quality Peer Review Committee form dated 10/21/22, indicated the NA Employee E1 noticed Resident R1 was attempting to climb out of bed most of the daylight shift and legs were out of the bed. Review of NA Employee E1's interview signed statement dated 10/21/22, indicated she walked into the room, noticed hot chocolate on blanket, noticed leg was red, and that Resident R1 was climbing all day, legs were off the bed at the time, and it looked as if Resident R1 pulled the table to get out. Review of NA Employee E2's interview signed statement dated 10/21/22, indicated she walked in room to help with Resident R1 and there was hot chocolate on the blanket and upper left leg was red. Interview on 11/14/22, at 11:10 a.m. Director of Rehab Employee E3 indicated Resident R1 was extensive assist of one person physical assist for eating, and that she would have needed help to eat as resident historically positions herself onto her side in a fetal position. Interview on 11/14/22, at 12:24 p.m. Registered Nurse (RN) unit manager Employee E4 indicated it was reported that Resident R1 spilled her hot chocolate, lid was still on, with burns to left thigh and hip. The burns were pink at first and then blistered and confirmed the tray should not have been left unattended with Resident R1's behaviors that morning because she required assistance of one staff for eating. Review of signed Licensed Practical Nurse (LPN) Employee E5's interview dated 10/21/22, and progress note dated 10/21/22, at 3:19 p.m. indicated NA Employee E1 noted hot chocolate on Resident R1's lap with injury of blisters to left hip and thigh: area one measured 11.5 cm x 8 cm (centimeters) with three blisters and area two measured 6 cm x 5cm with one blister. Interview on 11/14/22, at 12:28 p.m. with Director of Dietary Employee E7 and Registered Dietary Tech Employee E8 indicated a vendor came out and calibrated their hot water to dispense at 185 degrees Fahrenheit so meal time temperature would range around 155 - 160. Review of temperature logs dated 10/16/22 - 10/29/22, of tray line indicated a hot beverage result of 185 for the lunch meal on 10/21/22. Review of random test tray audit dated 10/17/22, indicated a hot beverage temperature of 155 degrees at the time Resident R1 was served. Interview on 11/14/22, at 12:13 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) Employee E6 confirmed that NA Employee E1 should not have left the tray unattended since Resident R1 demonstrated behaviors and required extensive assistance of one person physical assistance to eat. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.28(c) Nursing services 28 Pa. Code 211.28(d)(1)(5) Nursing services 28 Pa. Code 211.28(d)(3) Nursing services.