Health inspection·February 25, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview, and record review the facility failed to monitor temperatures of coffee to prevent burns for 1 (R1) of 3 residents reviewed for accidents in the sample of 4. Residents Affected - Few The findings include: An incident description report sent to the Illinois Department of Public Health document that on 1/29/25 R1 was in the dining room getting coffee from container when she spilled a small amount of coffee on her inner thigh causing .5cm (centimeter) blister to right inner thigh. A final incident description documented, After a thorough investigation the patient was with a nurse manager when she pushed back in her chair to talk to another resident while holding her coffee cup. The coffee spilled on resident's inner thigh causing a red mark that later turned into a blister. Doctor notified of resident burn area is now open. Orders to cleanse with wound cleaner and apply dry dressing. Resident is now using a coffee cup with a lid to prevent other incidents from happening. Care plan has been updated and coffee temperature logs kept and an audit of all coffee/hot beverage drinkers preventing all residents who could be affected. R1's Resident Face Sheet documents an initial admission date of the facility of 06/03/2021 with diagnosis including neuroleptic induced parkinsonism, bipolar disorder, schizophrenia, chronic obstructive pulmonary disease, major depressive disorder, peripheral vascular disease, polyosteoarthritis, restless leg syndrome, gastro - esophageal reflux disease, other anxiety disorders, urinary incontinence, anemia, constipation, dementia, presence of intraocular lens, insomnia, delusional disorder, and hyperlipidemia. R1's MDS (Minimum Data Set) section C, dated 01/10/2025, documents that R1 has a BIMS (Brief Interview of Mental Status) of 10 indicating that R1 has moderate cognitively impairment. R1's Care Plan with a date of 06/16/2021 documented a focus area of Pressure Ulcer / Injury. She is at risk for breakdown. She has a history of breakdown; she will scratch self until she bleeds. Factors that may affect the breakdown: diabetes with insulin, chronic obstructive pulmonary disease, overactive bladder, peripheral vascular disease with stent in legs, psychotic symptoms, anxiety/depression, schizophrenia, Bipolar, dementia, hypertension, neuroleptic induce Parkinson, anemia, clopidogrel, and age. 1/29/2025 dropped coffee on right inner thigh. 01/29/2025 ordered spill proof lids for cups. 01/30/2025 lids arrived and in service done. Documented interventions include cleanse right inner thigh with wound cleanser and apply dry dressing, make sure spill proof silicone lids are on the cup that contains hot liquids. R1's Progress Note authored by V6 (Registered Nurse) dated 01/29/2025 with a time of 1:57 P.M., Page 1 of 3 145388 145388 02/25/2025 Helia Healthcare of Olney 410 East Mack Olney, IL 62450

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented V7 (Medical Doctor) was notified of 0.5 centimeter blister to right inner thigh obtained from resident spilling coffee on herself today at meal time. R1's Progress Note authored by V5 (Registered Nurse) dated 01/31/2025 with a time of 10:22 A.M. documented V7 was notified of resident burn area is now open. New order to cleanse with wound cleanser and apply a dry dressing daily. R1's Event Report dated 01/29/2025 documented R1 received a burn to right inner thigh measuring 0.5 centimeters. Intervention listed new lid has been ordered to help reduce spills and burns. R1's Wound Management Detail Report with a print date of 02/25/2025 documented the date the area was identified as 01/29/2025 and measurements of 0.5 centimeters by 0.5 centimeters. On 02/21/2025 the wound to the right inner thigh measured 0.3 centimeters by 0.3 centimeters. In the comment section it is noted the area has no signs and symptoms of infection, continue the treatment per the medical doctor. Facility Coffee Temperature Log documented temperatures were obtained on 01/31/2025 - 02/06/2025 and 02/15/2025 - 02/25/2025. There were no temperatures documented for 02/07/2025 - 02/14/2025. The temperatures that were documented ranged from 185 - 130 degrees Fahrenheit. On 02/25/2025 at 10:02 A.M. R1 stated she dumped a whole cup of coffee on her leg. R1 stated she was at the table, and she just dropped the cup. R1 stated that my leg is healing. R1 stated that since the incident the facility has placed lids on the coffee cups to prevent spilling. R1 stated she was ok with the lid on her coffee cup. On 02/25/2025 at 10:09 A.M. V3 (Dietary Manager) stated when the coffee comes out of the machine it is 205 degrees Fahrenheit. V3 stated it then goes in the carafe. At that time coffee was poured out of the carafe V3 temped it at 122 degrees Fahrenheit. V3 stated that after the incident with R1 spilling coffee and burning her leg, the dietary staff are now temping coffee three times a day. V3 stated that the log has extra temps on it because someone wasn't paying attention and just wrote them down. On 02/25/2025 at 10:38 A.M. V3 stated he is not sure why there are no temps documented from 02/07-02/14. V3 stated there was some confusion when we started doing the temps. V3 stated that the coffee is made roughly around 530-545 am and is allowed to cool for at least 30 minutes before capping it. V3 stated they do this to ensure it is not over the temperature it is supposed to be. On 02/25/2025 at 10:43 A.M. V3 stated after reviewing his schedule, he realized the week that there were no temperatures checked, he had 3 staff members out with various illnesses. V3 stated the staff who covered the shifts were not aware to check the coffee temperatures. On 02/25/2025 at 10:26 A.M. V5 (Registered Nurse / MDS) stated she was passing out coffee like she normally does for breakfast and lunch. V5 stated she gave R1 coffee and was giving other residents coffee when she heard R1 yell, Ouch. V5 stated R1 explained to her that she just dropped her coffee cup. V5 stated she has done observations of all residents who drink coffee to ensure that they are safe to do so. V5 stated there are a few residents who refuse to use coffee lids on their coffee. V5 stated she is not sure how long the coffee had been placed on the carafe. V5 stated she educated the residents who refuse to use lids and documented it. 145388 Page 2 of 3 145388 02/25/2025 Helia Healthcare of Olney 410 East Mack Olney, IL 62450

F 0689 Level of Harm - Minimal harm or potential for actual harm On 02/25/2025 at 10:30 A.M. V2 (Director of Nursing) stated that once the incident was discovered, the kitchen staff were educated on keeping temperatures of the coffee. V2 stated V5 did an audit of all residents who drink coffee to ensure they are safe to do so or if they need any assistive devices. V2 stated no one else has had a burn related to coffee being spilled on themselves. V2 stated the staff have been educated about R1 using lids on her coffee. Residents Affected - Few On 02/25/2025 at 11:00 A.M. V1 (Administrator) stated prior to this incident they believed that R1 was on too much medication for her psych diagnoses. V1 stated R1 was noted to be sleeping more than normal. V1 stated R1 is either manic or sleeping and adjusting her medications to get the right dose for her is tricky. V1 stated R1's Klonopin had been reduced after the incident. V1 stated V5 was in the dining room giving out coffee. V1 was told that R1 was kind of drowsy but pushed herself back in her wheelchair to talk to another resident and spilled the coffee on her leg at that point. V1 stated the doctor was notified and treatment orders were obtained. V1 stated the facility completed a new BIMS (Brief Interview for Mental Status) and R1's went up from a 10 to a 14 with the medication reduction. V1 stated in order to prevent another occurrence, the facility removed the coffee carafes from the common areas and replaced them with Keurig's. V1 stated they ordered a silicone cover for R1's coffee cup. V1 stated that R1 was ok with the silicone cover going over the cup. V1 stated the facility has completed an audit of all residents who drink coffee to see if they are at risk for a similar event. V1 stated she did not speak to any of the dietary staff the day of the incident to see if they had a temperature on the coffee prior to the incident. 145388 Page 3 of 3