**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide supervision to prevent accidents for one of one resident (Resident (R) R1) reviewed for accidents out of a total sample of 3. This failure caused actual harm on 06/26/25 when Certified Nursing Assistant (CNA) AA served R1 a hot soup on a Styrofoam bowl and left the room with R1 attempting to pull the bowl closer when the bowl fell on R1's sternum and R1 sustained a second degree burn on her chest and was hospitalized .Findings include:Review of R 1's admission Record, located in the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to muscle weakness (generalized), unspecified abnormalities of gait and mobility, other reduced mobility, Muscle weakness (generalized), and difficulty in walking.Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/23/2025 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. It was recorded that R1 under section GG-under Eating /Oral hygiene/ Upper body dressing requires Setup or clean-up assistance,Review of R1 Progress Note dated 6/26/2025 at 5:58 pm indicated Resident requested soup for dinner. CNA fixed her some chicken soup. Soup was placed on the bedside table by CNA which advised resident soup was hot. NursingFurther review of R1's Progress Note dated 6/26/2025 at 06:00 pm [Recorded as Late Entry on 6/27/2025 11:23 am] revealed CNA heard resident yell for help. When CNA entered the room, the soup bowl noted to be on floor. The resident states she pulled soup to her and started feeding herself. The soup fell off bedside table on to resident sternum/Abd area. NP notified new order given. Nursing Review of Progress Note dated 6/26/2025 at 6:35 pm revealed Emergency Medical Service (EMS) here to take the resident to the emergency room (ER). Review of Facility Wound Summary Report for R1 indicated a burn on 6/26/2025 at 6 pm located in the mid-chest area with an initial size of 5x5 centimeters (cm). Review of R1's entire clinical record failed to indicate an assessment to determine the resident's ability to handle hot liquids had been completed for the resident prior to 6/26/2025.Review of hospital record revealed R1 was admitted to the local hospital on 6/26/2025 due to second degree burn after spilling hot soup while she was drinking it.During an observation and interview on 7/2/2025 at 1:05 pm with R1, she revealed that she requested soup from Certified Nursing Assistant (CNA), CNA AA because she did not like what was on the dinner tray. R1 stated that CNA AA brought the soup in a Styrofoam bowl and sat the soup on a bedside table across the bed. R1 stated that she tried to move the soup, and the bowl fell on her chest and hands. R1 stated that she pushed the bowl off her chest to the floor and started screaming for help. She stated that the soup was very hot. R1 further stated that CNA AA responded within five minutes and reported that she could not do anything because she has to call the nurse, which she did.During an interview on 7/2/2025 at 1:28 pm with Licensed Practical Nurse (LPN) CC she revealed that she was on call on the night of the incident. She stated that she received a call from LPN BB that R1 sustained a burn. She stated that she notified the Administrator and informed her of the burn incident for R1.During an interview on 7/2/2025 at 2:48 pm LPN BB revealed that she was at the nursing station when the CNA AA informed her that R1's soup fell on her chest. She stated that she went to R1's room and R1 informed her that the soup was on her bedside table and as she tried to pull the soup closer to her the bowl fell and landed on her chest. LPN BB stated that she notified the physician and LPN CC who was the nurse on call, and the family was notified. She stated that the physician gave her orders for Silvadene and later an order to send R1 to the hospitalDuring a telephone interview on 7/2/2025 at 7:35 pm with CNA AA she revealed that she served R1 her dinner tray and she did not like what was on the tray. She stated that R1 requested soup. She stated that R1 was in bed Head of the Bed (HOB) elevated at 45-degree angle, and legs slightly elevated. She stated that she warmed the soup for a minute in a Styrofoam bowl in the microwave. CNA AA stated that the soup was not steaming because she held the bowl in her hand. It was further reported that she gave R1 some crackers per R1 request to soak them in the soup and placed the bowl on the bedside table with a towel across R1's chest. CNA AA stated that she then went to another resident's room across from R1's room to assist that resident. While in the other resident's room CNA AA reported that she heard R1 calling her name. Upon returning to R1's room CNA AA reported observing the bowl was on the floor and the towel was no longer on the R1's chest. She stated that R1 told her that she was burned, and that is when she called the nurse to the room to evaluate R1. During an interview on 7/3/2025 at 1:41 pm with Minimum Data Status (MDS) Coordinator who revealed the Interdisciplinary Team (IDT) discussed to ensure that all residents are assessed to handle utensils, liquids, and bowls. However, she did not specify if residents were assessed for hot liquidsDuring an interview on 7/3/2025 at 1:59 pm with the Dietary Manager revealed that she does not know if residents were assessed for hot liquids. She stated that assessment is completed as a team (IDT). The Dietary Manager stated that she cannot specifically say there was an in-service on hot liquids prior to the burn incident on 6/26/2025.During an interview on 7/3/2025 at 2:33 pm with the Administrator, who revealed that she expected staff to check food temperature before serving, and if the food needs to be reheated to follow the in-service procedure on 6/27/2025 in service provided. During an interview on 7/3/2025 at 2:40 pm with Director of Nursing (DON) regarding resident assessment. She revealed that residents are assessed upon admission by rehabilitation services and determination and recommendation is communicated to the nursing staff, and if a resident is declining that a referral is made. She stated that all residents are assessed for safety overall and ability.The facility implemented the following:1. SBAR (situation, background, appearance, review and notify) form was completed on 6/26/2025 indicating a burn to the lower part of sternum and top of abdomen.2. Skin assessment completed on 6/26/2025 with treatments identified as nutrition or hydration intervention, pressure-reducing device for chair, and pressure-reducing device for bed.3. Order received for silver sulfadiazine cream, as needed, for burn.4. Transferred to local hospital on 6/26/2025 for evaluation of burn.5. Care plan intervention updated on 6/27/2025 for Occupational Therapy (OT) to evaluate and treat. In addition, a care plan was developed related to the burn to the chest.6. Inservice on 6/27/2025 titled, Food Temperature safety and follow diet. Detailing that when food items should be logged when microwaved. Further stating that once heated to 165 degrees Fahrenheit the food must then be cooled to a reasonable eatable temperature for the resident to eat it.