Based on observation, interview, and record review, the facility failed to ensure a resident's safety and prevent a resident from being burned by the heater (radiator) in her room. This failure resulted in R2 sustaining a deep partial-thickness burn to her right foot when she fell against the radiator mounted on the wall in her room. The facility failed to monitor temperatures of hot beverages prior to serving to residents. This failure resulted in R3 sustaining full thickness burns to her right thigh, left thigh, and buttock after spilling tea on her lap. These failures have the potential to affect all 160 residents in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/17/25 when R2 burnt her foot on the radiator in her room; sustaining a deep partial thickness burn to her right foot. The Immediate Jeopardy was identified on 2/13/25. V1 Administrator was notified of the Immediate Jeopardy on 2/13/25. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 2/13/25 and the deficient practice was corrected on 2/12/25 however noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The Facility Data Sheet, dated 2/11/25, showed a resident census of 160. On 2/11/25, V1, Administrator, stated every resident room in the facility had a wall mounted radiator. 1. R2's Post Occurrence Documentation note, dated 1/17/25 at 8:04 PM, showed R2 was found, by staff, on the floor of her room with her right leg stuck under the heater. The note showed R2 was found to have a burn to her dorsal area (top) of her foot. R2's Nurses Note, dated 1/17/25 at 8:33 PM, showed facility staff were notified of abnormal lab results on R2. R2 was sent to a local hospital for an evaluation due to her abnormal labs. R2's hospital records, dated 1/17/25-1/27/25, showed R2 was subsequently hospitalized with diagnoses of a high blood potassium level, Influenza A, urinary tract infection (UTI), and a second-degree burn to her right foot. The records showed R2's right foot burn required wound debridement during her hospitalization. R2 was discharged from the hospital on 1/27/25 and was readmitted to the facility. R2's readmission medical provider/nurse practitioner note, dated 2/3/25, showed R2 was seen today for readmission. She was recently hospitalized due to shortness of breath, cough, and a fall out of bed. She was admitted for sepsis due to UTI as well as bacterial . She was found to have a deep partial-thickness contact burn of the right dorsum of the foot and underwent bedside debridement . R2's wound note, dated 1/31/25, showed R2 was assessed by the facility's wound physician upon her readmission to the facility. The note showed, Report new wound to right foot. Burnt her foot via radiator . The note showed R2's burn covered the top (dorsal area) of her right foot and the first two toes of her right foot. The note showed R2's burn measured 9 cm (centimeters) x 5.5 cm x 0.1 cm. On 2/11/25 at 11:25 AM, R2 was in bed with her right foot propped up on a pillow. A large gauze dressing was noted around R2's right foot and ankle. When R2 was asked what happened to her foot, R2 stated, I got burned. I fell and my foot got stuck under the heater. My bed used to be over by the wall with the heater. I stuck in between there (between her bed and wall/radiator) when I fell. I couldn't get up. My foot was burning. On 2/11/25 at 9:52 AM, V14, Registered Nurse (RN), stated, That night (1/17/25), (R2) had a fall. I heard her calling for help. I found her on the floor of her room, stuck between the bed and the radiator on the wall. Her right foot had gotten stuck in the radiator. When I pulled her foot out from under the radiator, the top of her foot was bright red . On 2/11/25 at 1:55 PM, V12, Wound Physician, stated he was currently treating R2 for a second degree burn to her right foot caused by the radiator in her room. On 2/11/25 at 11:30 AM, V9, Maintenance Director, stated the facility currently did not have a process in place to monitor the temperatures heat produced by the wall radiators and/or the temperature of the radiator covers. V9 stated wall radiators were located in every resident room in the facility. V9 stated, We don't check the temperatures of the radiators. We can't control the wall radiators. They just kick in when the forced air heating system of the facility has trouble maintaining room temperatures. When it's colder outside and the forced air system has trouble keeping the temperatures up, the wall radiators will work longer and harder to help keep the room temperatures where they need to be. V9 also stated the facility did not monitor the outdoor daily temperatures. On 2/11/25, V1, Administrator, stated the facility did not have a policy or process on monitoring the temperatures of the wall mounted radiators. 2. A facility incident report, dated 1/23/25, showed R3 sustained burns to her right thigh, left thigh, and buttock area after spilling hot tea in her lap on 1/19/25. R3's wound note, dated 1/24/25, showed R3 was evaluated by V12 Wound Physician for burns to her bilateral thighs and buttocks caused by scalding of hot water. R3's right thigh burn measured 3.5 cm x 1.8 cm x 0.1 cm. R3's left thigh burn measured 6.0 cm x 4.0 cm x 0.1 cm. The note showed no measurements for R3's burn to her buttocks but showed the skin to R3's buttocks appeared red. On 2/11/25 at 2:34 PM, R3 was seated in bed. R3 stated on 1/19/25, the aide had just gotten a cup of hot water for my tea. I eat in my room. She put the cup on my table. I went to pick up the cup. My hand started shaking and spilled the whole cup all over my lap. It was hot. Not sure how hot it was but it burnt my legs. On 2/11/25 at 1:23 PM, V10, Dietary Manager ,stated it is the policy of the facility that no hot beverages leave the kitchen until the temperature of the beverage is at 120 degrees Fahrenheit (F) or below. V10 stated, We would get hot water for tea either by boiling tap water on the stove or getting it out of the coffee machine. We pour the hot water and/or coffee into separate insulated carafes and wait for the temperatures to drop before taking the carafes to the floor or dining room. The dietary aides are responsible for monitoring the beverage temperatures before beverages leave the kitchen. Once the temperatures are ok, the activity aides come down and get the drinks to pass out to residents while they are waiting for the food to come. On the day of the incident, I believe it was a Sunday, the activity aide ran out of hot water for tea. My understanding is that she came down and refilled the carafe with hot water by herself. I am not sure where she got the hot water from, but she did not check the temp of the water before she poured it for a resident . On 2/11/25 at 1:43 PM, V11, Activity Aide, stated on 1/19/25, I was serving coffee, cocoa, and tea to the residents before dinner. I ran out of the coffee and hot water I had in the containers I had gotten from the aides in the kitchen. I quick ran down to kitchen to refill my containers. I got the hot water for the tea out of the pot that was on the stove. The stove wasn't on, but the pot of hot water on the stove was steaming. I poured some of the hot water into my container and went back up to the floor. I have no idea what the temp of the water was. (R3) asked for a cup of hot water for her tea. I poured her a cup and put the cup on her table. We didn't put lids on the cups at that time. I was just walking out of her room when I heard her start yelling. She spilled her tea on her lap. On 2/11/25 at 1:55 PM, V12, Wound Physician, stated R3 had full thickness burns to her thighs from being scalded by water. The facility's AT RISK Hot Food and Beverage Temperature Service policy, dated 12/2024, showed, Food will be served at a temperature that is safe and palatable . Hot beverages to include coffee, tea, hot chocolate, hot water, cappuccino will be served at an ideal temperature of 120 degrees . The Immediate Jeopardy that began on 1/17/24 was removed 2/13/25, when the facility took the following actions to remove the immediacy: On 01/21/2025, education listed below was reinforced by the Administrator and Director of Nursing, with all staff that were working and those that were scheduled to work upcoming shifts thereafter. Education will continue to be conducted prior to the start of the next shift for each nursing, housekeeping, and dietary staff member and on an ongoing basis until all employees scheduled to work have been educated and demonstrate understanding of the education through pop quizzes and/or return demonstration of competency. Education will focus primarily on maintenance, nursing, dietary, and housekeeping staff with the potential to be impacted by non-compliance and not limited to staff involved in the actual incident. 1. All residents' heaters were reviewed for conditions that may make them unsafe. All resident beds were visually inspected to ensure they were not touching or within a close distance of the heaters. 2. All staff were educated on room safety checks and notifications to appropriate parties/vendors of equipment malfunction. Completed 01/21/2025 and ongoing for all incoming staff not on duty this day. 3. The [NAME] President of Facilities Environmental Services and Life Safety was called in on 01/21/2025 to verify that all resident's heaters are in good repair and functioning properly. 4. All staff were educated on updated hot beverage and temperature policy. Completed 1/23/2025 and ongoing for all incoming staff not on duty this day. 5. Coded door knobs were replaced on both kitchen doors to ensure only kitchen staff are to enter and exit from the kitchen, and have access to kitchen equipment and supplies. 6. A crowd control belt was added at the kitchen entrance at the elevator to remind any staff other than Dietary to ask for dietary's assistance. 7. Resident Council Meeting held on 2/12/25 to educate residents on the updated hot beverage policy 8. Resident Council Meeting held on 2/12/2025 to educate residents on room safety and keeping themselves away from thermal surfaces. 9. On 01/21/2025, the facility Administrator and IDT (interdisciplinary team) reviewed related policies and procedures. The following policies were reviewed: Incident/Accidents; Fall Management; Dietary Food and Beverage temperatures 10. The Administrator initiated a QA (Quality Assurance) audit tool for environmental safety checks to ensure that environmental hazards are resolved. Heaters in residents' rooms and common areas shall be maintained in a manner to prevent residents from prolonged contact with thermal surfaces. Weekly temperature checks of the radiator's thermal surface will be conducted with an Infrared Thermometer and placed on a log. Random room audits will be conducted 1 time per week for the duration of the heating season, and then on an as needed basis to ensure residents are safely placed away from the radiators. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Initiated 2/12/2025 and ongoing for QA monitoring. 11. The Administrator initiated a QA audit tool for hot beverage serving and temperature taking, to ensure that dietary staff are preparing hot liquids and taking temps of liquids as per the policy and ensure that hot beverages are served at the appropriate temperature. All resident wings will be reviewed 2 times a week for 30 days, then 1 time a week for 30 days, and then on an as needed basis until ongoing compliance is achieved The results of the QA audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Initiated 1/23/2025 and ongoing for QA monitoring. 12. An emergency QA meeting was held by the Administrator with the Interdisciplinary Care Team and Medical Director on 01/21/2025 and 2/12/25 to review the removal plan. The QA committee shall meet monthly thereafter and review the results of the QA audits. Changes to the policy and procedure shall be made as indicated by the QA results. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator. Completed 02/12/2025 and ongoing for QA monitoring.