Based on observations, interviews, record review, and facility policy review, the facility failed to follow a care plan and interventions regarding hot liquids, for a resident (Resident #60) with left side weakness of upper and lower extremities. The coffee had been microwaved by a facility staff member, and the temperature of the coffee was not checked prior to providing it to Resident #60, which resulted in burns to the resident's lip and chest. This failure to monitor the temperature of a hot liquid after being microwaved, placed Resident #60 at risk for serious harm, serious injury, serious impairment, or death. It was also determined the facility failed to safely transfer two residents (Resident #62 & #81) via mechanical lift to prevent falls, to ensure a gait belt was properly used for safe transfer to prevent falls for 1 resident (Resident #148), and to ensure a care planned intervention that indicated No Straws used was followed for 1 resident (Resident #300) to keep residents free from accidents and hazards. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 11/28/2024 at 5:12 PM when Certified Nursing Assistant (CNA) #1 heated up coffee in a microwave for Resident #60, then placed a lid and stirring straw on the cup. Resident #60 tipped the cup up and spilled coffee, causing a burn to the resident's lip and chest. The Administrator and Registered Nurse (RN) Consultant were notified of the IJ on 01/08/2025 at 11:42 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 01/08/2025 at 5:04 PM. The IJ was removed on 01/09/2025 at 10:00 AM after the survey team performed onsite verification that the Removal Plan had been implemented. The findings are: 1. Review of an admission Record indicated the facility admitted Resident #60 with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis that affect arms, legs and facial muscles) following cerebral infarction (stroke) affecting left non-dominant side and vascular dementia. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/2024 revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident was moderately cognitively impaired. Review of Resident #60's Care Plan, initiated 01/24/2023, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to CVA (Cerebrovascular Accident - damage to the brain from interruption of blood supply) affecting left non-dominant side; required assistance with meal set up; had cognitive functional impairment; and was at risk for burns from hot liquids due to left side weakness with interventions that included temperature of liquids were not to exceed 140 degrees. Review of the Admit Readmit Quarterly Assessment with CP, dated 10/29/2024, indicated Resident #60 scored a 5 out of 12 on the Hot Liquid Risk, indicating the resident was at risk for burns from hot liquids due to left side weakness. Interventions included to use a cup with lid, temperature of liquids were not to exceed 140 degrees. Review of a Progress Notes indicated on 11/28/2024 at 5:12 PM, an Incident and Accident (I&A) note revealed Resident #60 was drinking coffee and had a lid and straw in place and tipped the cup up high spilling coffee. The resident was assessed, and triple antibiotic ointment was applied. Review of an In-service dated 11/28/2024 discussed: Absolutely Do Not microwave any food or drink for any resident. If something needs warming, take it to dietary where they can temp it. The in-service was signed by 46 staff including CNAs, Licensed Practical Nurses (LPN) and Medication Assistant Certified (MA-C). Review of the Nursing (Nsg) Skin care plan and tasks, dated 11/28/2024 at 9:38 PM, indicated Resident #60 had a skin injury and specified a bump to the left arm on 12/27/2023. Goals included maintaining intact skin by the review date with interventions that included following protocols for injury treatment; identifying and documenting cause and elimination of cause; monitoring and treatment of injury; caution during transfers; and weekly treatment and documentation. There was no reference to the burn to Resident #60's chest and lip. Review of the Progress Notes, dated 11/28/2024 at 8:06PM, revealed a Nsg Hot Rack Note, Continues on hot rack charting for coffee spill earlier in day resulting in superficial burns to face and upper torso, areas healing without adverse reactions noted, will continue to monitor. Review of the Nursing (Nsg) Weekly Skin Audit, dated 11/29/2024 at 02:38 AM, indicated Resident #60 had a Small fluid filled blister to upper inner lip. Red spot noted to right upper chest area without blisters or abnormalities. Interventions included pressure reduction mattress, w/c (wheelchair) Geri (geriatric) chair cushion, skin protectant. The note section indicated skin was clean, dry and intact without abnormalities, with small fluid filled blister to upper/inner lip from coffee spill along with redness to upper right side of chest area. Review of the Progress Note Nsg-Order Note, dated 11/29/2024 at 5:02 PM, revealed order per NP (Nurse Practitioner) to start bacitracin (an antibiotic ointment used to treat bacterial skin infections or to prevent infection of minor burns, cuts, or scrapes.) to chest. Family member notified of new order. Review of Progress Notes Nsg I&A DON Follow Up, dated 11/29/2024 at 9:28 AM, indicated During interview Resident #60 attempted to drink hot coffee through the stir straw and when realized it was too hot, spit coffee out causing a small blister to Resident #60's right lower lip and red area to right upper chest. Long Term Intervention: Staff immediately educated requiring heating food and drink for residents. Added to the Care Plan: yes, Ensure MD & Family Notification: aware. Review of Progress Notes Nsg-Hot Rack dated 11/30/2024 at 00:01 AM indicated Resident #60 continues on hot rack charting for the following: New orders for Bacitracin Ointment to right upper chest area, appropriate changes made and resident tolerating without adverse reactions noted. Review of Progress Notes Nsg-Hot Rack, dated 11/30/2024 at 12:53 PM, indicated Monitoring r/t recent incident that resulted in burns to R lower lip and small part on R chest. No blistering or increased redness noted to burns, no bleeding or warmth noted as well. Resident #60 complained that the burns were hurting, scheduled pain analgesics administered with no further complaints at this time. Treatments administered and in place as per TAR (Treatment Administration Record). Call light and fluids within reach. Review of the Nsg Weekly Skin Audit dated 11/30/2024 at 1:50 PM indicated Skin is clean, warm dry and intact. Reddened area noted to right chest from coffee spill with no increased redness, swelling or warmth. Crusting noted to bottom of R lip with no noted signs/symptoms of discharge or inflammation. Pain from burns treated with scheduled analgesics. Treatments in place for burns. No other complaints at this time. Review of Progress Notes Nsg-Hot Rack dated 12/01/2024 at 03:08 AM indicated Monitoring r/t recent incident that resulted in burns to R lower lip and small part on R chest. No blistering or increased redness noted to burns, no bleeding or warmth noted as well. Resident complained that the burns were hurting, scheduled pain analgesics administered with no further complaints at this time. Treatments administered and in place as per TAR. Call light and fluids within reach. Review of the Nsg Weekly Skin Audit dated 12/01/2024 at 10:12 AM indicated Skin clean, warm, and dry. Reddened area noted to right chest from coffee spill with no increased redness, swelling or warmth. Crusting noted to bottom of R lip with no noted s/sx of discharge or inflammation. Pain from burns treated with scheduled analgesics. Treatments in place for burns. No other complaints at this time. Review of Progress Notes Nsg-Hot Rack dated 12/01/2024 at 10:55 AM indicated Monitoring r/t recent incident that resulted in burns to lip and chest. No increased redness or blistering noted to burns. Resident denies acute pain or distress at this time. Treatments administered and in place as per TAR. Call light and fluids within reach. Review of the Nursing Weekly Skin Audit, dated 12/02/2024 at 12:30 AM, indicated a superficial red area to right side of chest. Skin clean, warm, and dry. Reddened area noted to right chest from coffee spill with no increased redness, swelling or warmth. Crusting noted to bottom of R lip with no noted signs or symptoms of discharge or inflammation. Pain from burns treated with scheduled analgesics. Treatments in place for burns. No other complaints at this time. Review of Progress Notes - Orders Administration Note, dated 12/02/2024 at 4:12 PM, revealed Bacitracin-Polymyxin External Ointment, apply to right chest burn topically every morning and at bedtime for Burn for 7 Days treatment changed. Review of Progress Notes Nsg-Hot Rack, dated 12/02/2024 at 10:27 PM, revealed Resident #60 was on Hot Rack monitoring for d/c (discontinued) of Bacitracin changed to skin prep to wound to chest from recent injury. No s/sx (signs/symptoms) infection, no c/o (compliant) discomfort at this time. Will continue to monitor and follow wound orders. Review of the Nursing Weekly Skin Audit, dated 12/09/2024 at 9:28 PM, indicated a superficial red area to right side of chest. Skin clean, warm, and dry. Reddened area noted to right chest from coffee spill with no increased redness, swelling or warmth. Crusting noted to bottom of R lip with no noted signs or symptoms of discharge or inflammation. Pain from burns treated with scheduled analgesics. Treatments in place for burns. No other complaints at this time. Review of the Nsg Weekly Skin Audit, dated 12/2/2024 at 03:16 AM, indicated Superficial red area to right side of chest. Resident had a coffee spill to lip and right upper chest no noted area to lip noted has redness to upper right side of chest area. No s/s of infection c/o (complaint of) or noted. Review of the ICP Multidisciplinary Care Conference, dated 12/19/2024, did not address hot liquids. During an interview on 01/06/2025 at 1:00 PM, Resident #60 said, I had some coffee that was brought in by my family, but it was cold. I asked (CNA #1) if she would warm it up for me. She took it and heated it up and brought it back. I took a big sip from the straw, but it was too hot, and I spit it out. It ran down my mouth and to my chest. The nurse looked at it and put some salve on it. It's all better now. During an interview on 01/08/2025 at 09:10 AM, the Administrator said, I was notified by the Director of Nursing (DON) that Resident #60 had a burn from coffee and the DON told me what happened. I went and asked the resident what happened and talked to the CNA #1. The CNA said that it was coffee that Resident #60's family had brought in, and resident had asked the CNA to heat it up. Resident #60 said that coffee was spilled and spit out causing a burn to resident's lip and upper right side of chest. I filed a report to The Office of Long Term Care (OLTC), immediately in-serviced staff to not heat up resident's items in microwave, a sign placed on the microwave in the employee breakroom and it is on agenda to be discussed in our QAPI Quality Assurance and Performance Improvement) meeting at the end of the month. During an interview on 01/09/2025 at 08:15 AM, CNA #1 said, I'm familiar with Resident #60. The resident asked me to heat up some coffee, so I took a cup to the breakroom and put it in the microwave. I put a lid on it and took a little stir straw in and put on Resident 60's bedside (bs) table. I told the resident that it was hot so to wait a few minutes before drinking it. Resident #60 started cussing me and told me to get out, that they could drink coffee whenever they wanted. Removal Plan: 1. After notification of Immediately Jeopardy on 01/08/2025 at 11:45 AM, the Administrator identified all microwaves in facility. Signage verified to still be in place above employee microwave that reads that no food/or drink to be heated for any residents using this microwave, must take to dietary where the food/drink will be temped before served. Other microwaves located in facility, one in activities which is not accessible by staff or residents and one in therapy that is also not accessible by staff or residents. 2. On 01/08/2025 at 12:45 PM, signs were posted as precaution on both microwaves located in Activity Room and Therapy Gym. Signs state that no food or drink to be heated in this microwave for any resident. All Food and Drink that needs heated must go to Dietary where it can be properly temped before served. Completed 01/08/2025. 3. On 01/08/2025, In-services initiated by Administrator/Designee, with all staff that no food or drink is to be microwaved, except for in dietary where the food/drink could be correctly temped prior to serving. To ensure compliance. All staff members will be in-serviced prior to their next scheduled workday. 4. Administrator will Monitor, all microwaves to ensure signage is in place and that no food/drink is being heated for any residents. Monitoring will be done 5x/week until compliance is verified by OLTC. All Corrections were completed on 01/09/2025 Onsite Verification: The IJ was removed on 01/09/2025 at 10:00 AM, after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 01/09/2025 at 08:00 AM when signage advising Do NOT heat food/or drink to for any residents using this microwave, must take to dietary where the food/drink will be temped before served was observed on the microwave in the employee breakroom, the microwave in the activity room and the therapy room. In-service advising of not heating Resident food/drink in microwave was initiated on 01/08/2025 with all staff members to be in-serviced prior to their next scheduled workday. On 01/09/2025 at 09:30 AM, staff working on the halls were interviewed, asking the question how do you heat up food/drinks for residents. A total of 20 staff interviews were conducted with staff from day shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants (CNA), MA-Cs, Licensed Practical Nurses (LPN), Registered Nurses, Housekeeping, Therapy, Dietary, Activity Director, Nurse Consultant. The staff interviewed verified they had been in-services on 01/08/2025 on Do NOT use microwaves to heat resident's food/drinks, must be done by Dietary so it can be temped. The following was cited at F689 at a lower severity: 2. A review of Resident # 62's diagnosis list indicated diagnoses of cachexia (wasting syndrome), pulmonary hypertension, anemia and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/04/2024 documented Resident #62 had a brief interview of mental status (BIMS) of 11, indicating a moderately impaired cognitive status, and was dependent on staff for toileting, bathing, turning, positioning, and transfers and was non-ambulatory. The MDS revealed one fall with a minor injury. Resident #62's care plan with a revision date of 06/11/2023 documented the resident required limited assistance of one staff to move between surfaces and was at risk for falls. An OLTC Incident and Accident Report (I&A), dated 12/03/2024, indicated Resident #62 had sustained a fall from a mechanical patient lift on 12/03/2024 at 3:04 PM when two certified nursing assistants (CNAs), when using the mechanical lift to weight the resident had failed to secure one of the lift sling loops to the mechanical lift, allowing resident to slide out. This fall resulted in 3 minor skin tear injuries On 01/07/2024 at 4:16 PM, Certified Nursing Assistant (CNA) #5 related how she and another CNA were using a mechanical patient lift to weigh Resident #62, and when they elevated resident and moved lift to get an accurate weight, one of the loops that secures lift pad was not secured and the resident slid out of lift pad. 3. A review of Resident #81's diagnosis list revealed diagnoses of metabolic encephalopathy, muscle weakness, and type 2 diabetes. A quarterly MDS with an ARD of 11/05/2024 indicated Resident #81 had a BIMS of 07, and resident was dependent on staff for bed mobility and transfers. Resident #81's care plan with a revision date of 07/08/2024 indicated the resident required a mechanical lift with assistance of two staff for transfers. On 11/12/2024. a facility incident reported to the office of long-term care indicated Resident #81 had sustained a fall when two CNAs attempted to transfer resident without use of a mechanical lift. Resident #81's closet care plan, included in the reportable, indicated resident required a mechanical lift with assistance of two staff for transfers. On 01/07/2024 at 8:51 AM, Resident #81 said at the time they fell, the two CNAs knew she didn't like to be transferred with the mechanical lift, so they attempted to transfer without it, after becoming weak she had fallen on her knees. 4. A review of the Order Summary indicated Resident #148 had diagnoses that included multiple falls, other abnormalities of gait and mobility, age related osteoporosis, and interstitial pulmonary disease. A review of a facility policy titled, Gait Belts, Use of, dated 05/01/2016 revealed, Policy: Gait Belts will be utilized for any resident transfers (sit to stand; stand to sit; sit to sit) or for resident ambulation that requires assistance. The discharge MDS with an ARD of 12/06/2024, revealed Resident #148 had a BIMS score of 15, indicating the resident was cognitively intact. Section GG is coded 04 (Supervision or touching assistance) for transfers. Section J reveals Resident #148 had one fall with no injury since admission/entry or reentry. Review of Resident #148's Care Plan, revised on 12/09/2024, revealed the resident had an activity of daily living performance deficit. A revision dated 12/09/2024 on the care plan revealed the resident is a high fall risk, and the resident had an actual fall with no injury on 11/13/2024 with an intervention of staff education. Review of a Morse Scale and Care Plan Tasks assessment done on 11/13/2024 revealed that Resident #148 scored a 40, which is a moderate fall risk. Review of a Nsg-Incident and Accident Note done by Administrator on 11/15/2024 revealed, Family Member reported that resident had a fall onto their bed while ambulating back from the bathroom. Family Member stated it was because the CNA was not using a gait belt. Review of a Witness Statement completed by Registered Nurse #4 on 11/13/2024 revealed, Went to investigate an allegation of reported neglect. Talked with [Resident #148] who stated that [CNA #5] helped them into the bathroom to use the toilet and they stated, the [CNA #5] is so big and strong, I always remind him that I am old and slow because he will just pick me up. Resident #148 continued stating that CNA #5 did not use a gait belt when he took them to the bathroom, and he did not use the gait belt when walking them back from the bathroom back to the wheelchair. Resident #148 stated that CNA #5 was watching television instead of paying attention to them and told them to go ahead and back up to the wheelchair. Resident then told the CNA #5 that they were losing balance and fell back into a seated position on the bed. Resident stated that they sat in a wash basin on the bed. Family Member and Resident #148 felt that CNA #5 was neglectful in care by not using a gait belt and not staying close to the resident. Family Member stated, if the resident fell the other direction, they could have had a head injury or a broken bone. Review of a Witness Statement done by CNA #5 on 11/13/2024 stated that I transferred the resident without the gait belt to the bathroom my first thought was to transfer the resident to the bathroom sitting on their wheelchair, but family refused. Family member insisted on using the walker instead. Resident walked fine to the bathroom on the way back to the wheelchair the resident got tired and sat on the side of the bed. They did not complain of pain. After the resident grasp their air, I stood the resident up and sat them in the wheelchair which was right next to the bed. Review of the Closet Care Plan reveals that Resident #148 was a one assist transfer with a gait belt for all transfers. Review of Competencies revealed that CNA #5 completed return demonstration of transfers and return demonstration of care plans on 07/22/2024. Review of Office of Long-Term Care (OLTC) Incidents and Accidents Report states Findings and Action Taken: Resident has interstitial pulmonary disorder and requires oxygen .becomes short of breath upon exertion .resident is medically stable without any acute distress and no injuries noted related to incident. The allegation is found on the basis that CNA #5 was not using a gait belt while assisting resident. Resident closet care plan required one person assisted. Review of an In-service on 11/13/2024 for Closet Care Plan, revealed, Closet care plans are in place for a reason and are to be always followed. If there is not a closet care plan in residents' closet notify the charge nurse or team lead immediately so it can be placed. Review of an In-service on 06/26/204 and 06/28 2024 on Transferring with a Gait Belt, states 9. Never chicken wing someone-gait belts should be used on all transfers whether one person or two person transfers. Review of an In-service on 09/18/2024 and 09/20/2024 on Abuse/Neglect, Transfers, Resident Rights/Dignity/Civil Rights and General, revealed the CNA #5 signed off for attending in-services. On 01/08/2025 at 1:47 PM, the Surveyor had a phone interview with Resident #148 who recounted the incident and stated that I want you to know that CNA #5 was a couple steps behind me watching television when fall occurred, they did not have a hold of me as they did not use a gait belt for transfer. On 01/08/2025 at 1:53 PM, the Surveyor attempted to call Registered Nurse #4 with no response. On 01/08/2025 at 1:55 PM, the Surveyor attempted to call CNA #4 with no response. 5. A review of Resident #300's admission Record revealed the resident had a diagnosis of dysphagia/oropharyngeal phase. On 01/06/2024 at 10:50am, straws were observed in Resident #300's drinks sitting on the over the bed table. In an interview with Resident 300's spouse, it was discussed that the closet care plan was not being followed by staff. The closet care plan was observed and indicated resident has difficulty swallowing and has orders for no straws. On 01/07/2024 at 8:42am, a drink was observed on Resident 300's over the bed table with a straw in it. On 01/07/2024 at 3:00pm, an observation was made of Resident 300's beverages on the over the bed table. All three cups had straws in them. On 01/08/2024 at 8:55am, CNA #2 stated that the closet care plan is their resource for knowing what type of care needs the resident requires. CNA #2 confirmed that Resident 300's closet care plan indicates no straws under the liquids portion of the closet care plan. CNA #2 confirmed that resident had straws in his drink on the over the bed table. CNA #2 confirmed that residents who are ordered no straws should not be given straws as it poses a choking hazard. On 01/08/2024 at 8:59am, CNA #3 confirmed that the CNA's are instructed to use the closet care plan as a resource guide to provide resident's care. CNA #3 confirmed that it's important not to give straws to residents with a diagnosis of dysphagia or difficulty swallowing, as it poses a choking hazard to them. CNA #3 stated that Resident #300 had difficulty swallowing and the speech therapist had ordered the resident to have no straws. On 01/08/2024 at 9:07am, the Assistant Dietary Manager (ADM) confirmed that the dietary staff are responsible for fixing the resident's beverages. The ADM stated that the kitchen staff provide straws, but the CNAs who assist in passing meal trays to residents are the ones that get the straws. A care plan, dated 12/26/2024, indicated that Resident #300 was ordered a pureed diet, has swallowing problems due to dysphagia, and do not use straws. Date initiated was 12/27/2024. A policy on Accidents and Hazards along with staff in-services were provided by the Administrator. It indicated that staff were educated on the importance of looking at closet care plans.