Health inspection·August 25, 2023

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 Based on observation, interview, and record review, the facility failed to effectively supervise a cognitively and functionally impaired resident during a meal service. This failure resulted in R1 spilling hot coffee onto R1's leg and sustaining a second degree burn to the thigh requiring extended medical treatment. R1 is one of three residents reviewed for supervision in the sample of three. Findings include: R1's Medical Diagnosis sheet (8/25/2023) documents diagnoses including Cerebral Infarction (stroke), Speech and Language Deficit, Epilepsy (seizure disorder), Dysphagia (swallowing difficulty), Slurred Speech, Cognitive Communication Deficit, and Parkinson's Disease (neurodegenerative disorder). R1's Resident Assessment (8/8/2023) documents R1 has severely impaired cognition and is totally dependent on staff, including physical assistance, for eating and drinking. R1's Care Plan (8/2023) documents R1 has impaired cognitive function/dementia or impaired thought processes related to Cerebrovascular Accident (stroke) and Parkinson's Disease (neurodegenerative disorder). The same record documents R1 has a range of motion self-care performance deficit and wrist and elbow deficits. On 8/23/2023 at 10:25AM, R1 was seated in a reclining chair and had bilateral hand contractures. V3 (R1's family) was present and reported R1 is dependent on staff for drinking and has not been able to drink from a glass independently due to R1's hand contractures. R1 reported spilling coffee on R1's self on 8/14/2023. The facility Serious Incident Report (8/14/2023) documents R1 received a meal tray and beverage during supper on 8/14/2023, and when staff approached R1, R1's drink (coffee) was in a cup with a lid (sippy cup) and located upright on R1's lap. The report documents staff did not initially observe any injury from R1 spilling a drink onto R1's lap, but staff noted a reddened area with blister on R1's left upper thigh later in the evening on 8/14/2023. R1's nursing Progress Notes document on 8/14/2023 Resident (R1) noted to have a second degree burn to left upper thigh and on 8/16/2023 Large fluid filled blister noted to left upper thigh burn area. R1's medical Progress Note (8/18/2023) documents R1 has a left anterior second-degree thigh burn and blister. Page 1 of 2 146030 146030 08/25/2023 Heartland Senior Living 101 Trowbridge Road Neoga, IL 62447

F 0689 R1's Skin and Wound Evaluation (8/19/2023) documents R1 has a new facility-acquired second degree burn to the front left thigh measuring 13.2 centimeters by 7.3 centimeters. Level of Harm - Actual harm Residents Affected - Few R1's Hot Liquids Risk Screen (8/15/2023) documents R1 has risk factors for injury from hot liquids, was dependent on assistance with eating prior to admission to the facility and has been injured by hot liquids. On 8/23/2023 at 2:29PM, V4 (Certified Nurse Aide/CNA) reported being the staff member assigned to assist R1 with the evening meal on 8/14/2023 and reported finding R1's coffee cup on R1's lap during supper on 8/14/2023. V4 reported R1 usually gets full staff assistance during meals, and R1 tries to drink and eat independently, but food doesn't make it to R1's mouth without staff assistance. V4 (CNA) reported R1 drinks coffee with every meal, and staff assist R1 with drinking coffee. V4 reported not serving any dependent resident hot liquids without staff supervision, but staff had already given R1 coffee prior to V4 getting R1's meal tray to assist R1 on 8/14/2023. V4 stated, Drinks are not normally served in front of (R1) until we (staff) were right there (at R1's dining table). On 8/25/2023 at 12:43PM, V9 (Physical Therapy Assistant) reported R1 required maximum staff assistance with drinking at the time of R1's burn on 8/14/2023. V7 defined maximum assistance as R1 requiring 75-100 percent assistance from staff to drink. V7 reported R1's cognition is in and out as related to R1's safety awareness. On 8/25/2023 at 12:48PM, V6 (R1's medical provider) stated, Correct (R1 should not have been left unsupervised with coffee on 8/14/2023). V6 reported expecting R1's thigh burn would take 30-45 days to convalesce and heal, and the shape or R1's thigh burn was consistent with a splash from a hot liquid. R1's Treatment Administration Record (August 2023) documents R1 has required daily treatment for R1's thigh burn since 8/15/2023. 146030 Page 2 of 2