Health inspection·May 23, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to adequately supervise 1 of 1 resident (R5), reviewed for accidents and incidents, in a sample of 5. This failure resulted in R5 spilling coffee on herself and sustaining second degree burns. This past non-compliance occurred between 4/28/24 and 4/30/24. Findings Include: Facility reported incident, dated 4/30/2024, documented, [AGE] year-old female with Dementia, Atrial Fibrillation, Hypertension, Anxiety, Severely Cognitively Impaired. On 4/28/2024 at 10:16AM R5 was in room with breakfast tray. R5 attempted to stand and used the bedside table to stand up and the coffee that was on the breakfast tray spilled onto R5's lap. R5 was immediately assessed and R5 noted to have redness to right upper thigh. Medical Doctor, MD, and Power of Attorney, POA, were updated and R5 put on follow up to monitor area. No complaints of pain or discomfort to the site. On 4/30/2024 small clusters of blisters were noted to the right and left upper thigh. Call placed to update MD and orders given to apply Silvadene to the area three times daily. POA updated on orders as well. Environmental checks performed and care plan was updated to reflect update interventions. R5's progress notes, dated 4/28/2024 at 10:16AM, documented, (R5) spilled her coffee on her lap at breakfast, caused a raised red area measuring 9 (centimeter) x4 (centimeter) on her right upper leg. Complains of pain to touch. Cool cloth applied and R5 states it feels better. Update faxed to (Medical Doctor) and (Power of Attorney) aware. R5's progress notes, dated 4/29/2024 at 9:35AM, documented, Reddened area to upper right thigh noted from spilled coffee. No complaints of pain or discomfort. Resting in recliner, call light within reach. (R5) has not displayed any behaviors so far this shift. R5's progress notes, dated 4/30/2024 at 9:25AM, documented, Call placed to MD (physician) regarding treatment for areas to right upper/inner thigh and left inner thigh. Order received for Silvadene 85gram cream apply topically to right upper/inner thigh and left inner thigh three times daily. Call placed to POA updated and notified of new order. R5's Minimum Data Set, MDS, dated [DATE] documented that R5 was severely cognitively impaired and required set up for eating. R5's Care Plan, updated 4/25/2024, documented, (Activities of Daily Living), (R5) Requires Limited to Extensive Staff Assist with ADL's, To Extensive Staff Assist with ADL's related to her alteration in mobility/confusion (Dementia). Interventions include provide all tools/equipment needed for Page 1 of 3 145483 145483 05/23/2024 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0689 ADL's, setting up as necessary, but allowing and encouraging R5 to do as much as possible, providing both physical and verbal cues. Level of Harm - Actual harm Residents Affected - Few R5's order sheets, dated 4/30/2024, documented, Silvadene (silver sulfadiazine) cream 1%, 1 application topical. Special instructions: Apply topically to areas on right upper/Inner thigh and left inner thigh three times daily every shift. Open ended. R5's wound notes dated 4/28/2024 documents right thigh, length 15.5 centimeters, cm, x 18cm. Partial thickness: redness, blistered, moist, painful, stable. 5/22/2024 right thigh 6.7cm x 2cm. Left thigh dated 4/30/2024 3.5cm x 3cm. 5/22/2024 left thigh resolved. On 5/23/2024 at 10:00AM, V13, Dietary Manager, stated, We always label which coffee was brewed first, so we let it cool down and serve it first. We always check the temps. Coffee pot showed label cool down first. On 5/23/2024 at 9:00AM, V2, Director of Nursing, (DON), stated, (R5) likes to sometimes eat in her room and is independent. We allowed her to eat in her room at times, but after the incident with the coffee we now require her to eat in the dining room. We reported the incident, did in-services, Quality Assurance, temperature logs, and resident interviews. On 5/23/2024 at 10:30AM, V10, Licensed Practical Nurse (LPN), provided wound care to R5. Wound to left inner thigh closed. Wound area to right inner thigh appears open with moderate amount of reddish-brown drainage to dressing. Wound care provided with no issues. V10 stated, I was not working the day R5 received the burn, but I am the one who called and got the order for treatment. On 5/23/2024 at 10:50AM, V12, Certified Nursing Assistant (CNA), stated, I was working the day (R5) spilled the coffee on her. (R5) likes to eat in her room. We gave (R5) her breakfast tray and when she pulled on the overbed table the tray with the coffee went in her lap. We cleaned her right up and that's when we saw the redness to her thighs. On 5/23/2024 at 12:00PM, V7, CNA, stated, We have been checking the temps ourselves since the incident with (R5). (R5) would not be able to know if a drink was too hot, because when she gets her food, she immediately starts eating fast. Now we are to check the temps and the drinks are to be 130 degrees or less. On 5/23/2024 at 11:55PM, V8, CNA, stated, The kitchen checks the temps on drinks. I don't think (R5) would know if something was too hot. On 5/23/2024 at 11:00AM, V14, Nurse Practitioner, stated, Residents have the right to eat in their rooms if they want that. I think it was appropriate for (R5) to eat in her room prior to the burns, but now I feel she needs to go to dining room. The facility's policy, undated, documented, Serving Hot Beverages and Soup. The Food service Department will monitor the temperature of all hot liquids being prepared to ensure that hot liquids are served at a temperature that will prevent burns if they should come into contact with skin. Prior to the Survey date, the facility took the following actions to correct the deficient practice: 145483 Page 2 of 3 145483 05/23/2024 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0689 1. Level of Harm - Actual harm A Quality Assurance and Performance Improvement meeting was held on 4/30/24. In attendance was V1, Administrator, V2, Director of Nurses, V16, Regional Director of Operations, V17, regional Director of clinical Services and V18, Regional director of Clinical Services. Residents Affected - Few 2. Measures put into place/systematic changes to ensure the deficient practice does not recur: Dietary staff/clinical staff educated on temping hot liquids to 130 degrees when leaving the kitchen. Completed: 4/30/24. Audit all resident bedside tables to ensure no concern. Completed: 4/30/24 3. Plan to monitor performance to ensure solutions are sustained: Administrator/designee to audit temp logs of hot liquids leaving the kitchen to ensure they are at 130 degrees twice weekly for 1 month and share results with QA committee. 145483 Page 3 of 3