Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents. The facility failed to ensure hot liquids were at a safe temperature and were served in an appropriate container for one (1) of three (3) sampled residents reviewed for accident hazards out of a total of twenty-seven (27) sampled residents (Resident #1). Resident #1, who the facility assessed as requiring supervision (oversight, encouragement, or cueing) and support from staff for set up help only with eating, was served a cup of coffee in a Styrofoam cup with a lid on 08/24/19; instead of the correct hot beverage plastic drinking cup. Subsequently, Resident #1 spilled hot coffee resulting in a second degree burn to the right thigh. The findings include: Review of the facility's Policy titled, Accidents and Supervision dated 11/01/18, revealed the resident environment should remain as free of accident hazards as possible and each resident should receive adequate supervision to prevent accidents. This includes identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks and communicating the interventions to all relevant staff; and monitoring for effectiveness and modifying interventions when necessary. Accident refers to an unexpected or unintentional incident which results in injury or illness to a resident. A Policy related to food/fluid temperatures at point of service was requested; however, not submitted for review. Interview with the Director of Nursing (DON), on 08/29/19 at 3:00 PM, revealed the facility did not have a policy related to resident safety with hot beverages, nor did the facility complete assessments/evaluations on residents related to resident safety with hot liquids prior to 08/24/19. Review of Resident #1's medical record revealed the facility admitted the resident on 09/29/17 with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. Review of Resident #1's Comprehensive Care Plan (CCP), revised 07/26/19, revealed the resident had a self-care deficit problem due to limited physical mobility related to general weakness. The goal stated the resident would maintain level of mobility. There were several interventions including extensive assist of one (1) staff for bed mobility, transfers, locomotion in wheelchair, toileting and personal hygiene. Further review revealed the resident fed self after tray prep with supervision as needed. Review of the Nutritional Assessment, dated 08/05/19, completed by the Registered Dietician, revealed the resident received a regular diet with thin liquids and had no problems with chewing or swallowing. Further review revealed the resident fed self after set up help. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/07/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a six (6) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring supervision (oversight, encouragement, or cueing) and support from staff for set up help only with eating. Review of the Incident Report, completed by Licensed Practical Nurse (LPN) #1, revealed on 08/24/19 at 10:30 AM, Resident #1 was served coffee in his/her room and spilled the coffee, sustaining a right thigh burn. Per the Report, there were no witnesses to the event. Further review of the Report, revealed the Physician was immediately notified and orders were received for Silvadene Cream. The family was notified on 08/24/19 at 3:36 PM. Review of the CCP initiated 08/24/19, revealed the resident sustained a burn to the right leg and was at risk for pain and infection with a goal stating the area to the right leg would heal without infection. There were several interventions including administer medications and treatments as ordered; air mattress; assess right leg for infection; and monitor nutritional status. Review of the Physician's Order dated 08/24/19 at 10:30 AM, revealed orders for Silvadene Cream 1% (sliver sulfadiazine) apply to right lateral thigh topically two (2) times a day to burn. Review of the Nurse's Note, dated 08/24/19 at 11:10 AM, written by the DON, revealed she spoke with Resident #1's Daughter and explained treatment was in place related to the burn and informed her the resident could be sent to the emergency room (ER) if she desired. Per the Note, the Daughter declined sending the resident to the ER. Review of the Nurse's Note, dated 08/24/19 at 3:47 PM, written by LPN #1, revealed the resident was served coffee from the kitchen, spilled coffee on his/her right thigh and sustained a burn. Per the Note, the DON and Administrator were notified. Additional review of the Note, revealed the Physician was notified and orders were received for Silvadene Cream to areas. The subsequent Nurse's Note dated 08/24/19 at 8:56 PM, revealed treatment was completed to the burn on the resident's right upper side of the leg and clear fluid was draining from large blisters. Per the Note, the resident denied pain. Review of the Doctor's Progress Notes, dated 08/26/19 at 4:00 PM, revealed Resident #1 sustained an accidental burn to the right thigh and had a large bullous blister and excoriation. Review of the Resident Investigation Form, signed by the Administrator on 08/26/19, revealed on 08/24/19 at 10:30 AM, Resident #1 received coffee from the kitchen and sustained a burn to the left thigh. The Physician was notified and an order was received for Silvadene twice a day. Per the Investigation Form, staff was educated on not serving hot beverages in Styrofoam cups and the need to serve hot beverage in regular coffee cups with lids. Further review of the Investigation Form, revealed temperatures were lowered on the coffee pot in the kitchen; and each unit would have a thermometer to test the temperatures of hot liquids. Review of the Long Term Care Facility-Self Reported Form Five (5) Day Follow Up/Final Report, signed by the DON, on 08/28/19, revealed per employee interviews, Resident #1 was served coffee from a Styrofoam cup with a lid. The employee placed the cup on the resident's tray and exited the room. The employee heard the resident yell out and entered the room at which time the resident stated, my pants are wet. Per the Report, the employee stated she removed the resident's pants and noted the resident spilled coffee, at which time she went to get the nurse. Additional review of the Report, revealed education was started on 08/24/19 regarding serving hot beverages; the facility devised the Hot Liquid Safety Policy and began education on Policy on 08/27/19; hot beverage audits on temperatures began on 08/24/19 and would continue in dietary department; and two (2) employees were terminated who were directly involved with the incident (State Registered Nurse Aide (SRNA) #1 and SRNA #2). Review of the Attached written Statement by SRNA #2, undated, revealed Resident #1 asked for a cup of coffee and she went to the kitchen to get the coffee. Per the Statement, a brand new girl handed her a cup of coffee in a Styrofoam cup with a plastic lid and the lid on the cup was sealed. Review of the Wound Physician's Note, dated 08/27/29, revealed the resident was seen at bedside at the facility for a burn to the right lateral thigh which measured 22 centimeters (cm) length x 5.5 cm width x not measurable depth with light serous exudate, 100 % percent dermis, and fluid filled blister. The Note stated the resident sustained a burn wound of the right lateral thigh from hot coffee which occurred three (3) days ago. and appeared to be at least a second degree burn. Per the Note, treatment options were discussed with resident and Daughter. According to the Note, the Wound Physician recommended sending the resident to the burn unit at the University Hospital for further evaluation, but the resident was palliative care and the resident and Daughter did not want this. Per the Note, the resident's and Daughter's wishes would be respected. Recommendations were to off load the wound, vitamin C 500 milligrams (mg) twice daily, multivitamin once daily, zinc sulfate 220 mg once daily, and silver sulfadiazine apply twice daily with Gauze Island for fourteen (14) days. Observation of meal service on 08/27/19 at 12:45 PM, revealed all residents were served in dining area with plastic cups with safety lids applied. There was no visual confirmation of Styrofoam cups being dispensed by the kitchen for hot soups or beverages. Observation of the Breakfast meal on the Wisteria Unit where Resident #1 resided, on 08/29/19 at 8:45 AM, revealed all resident trays were delivered with no presence of Styrofoam cups. Resident #1 was observed to have the meal tray set up by staff and his/her coffee was dispensed in a plastic cup with a lid. LPN #1 cued the resident to eat and supervised the resident while he/she was drinking coffee. Observation on 08/29/19 at 1:30 PM, of Resident #1's burn wound, and dressing change performed by LPN #2, revealed the wound to the resident's right thigh appeared as skin excoriation and decompressed blisters with redness of the entire area, with signs of new dermal formations present. The nurse cleansed the wound with Normal Saline and 4 x 4 gauze, and applied Silvadine cream to the entire burn area, and applied the dressing as per the Physician's Orders. Resident #1 denied any pain during the procedure. Interview was attempted with Resident #1, on 08/27/19 at 10:30 AM, and the resident stated he/she could not recall how he/she acquired the wound to his/her hip and upper thigh. He/she denied having any pain from the wound. Interview with Resident #1's Daughter, on 08/27/19 at 11:00 AM, revealed she received a telephone call on 08/24/19 from the facility explaining Resident #1 sustained a burn to his/her right leg from spilling a cup of coffee which had been given to the resident in a Syrofoam cup. Continued interview revealed she requested Resident #1 not be transferred to the ER and that all treatment be carried out at the facility as the family wanted to keep the resident comfortable and an extensive hospitalization may cause the resident to decline. Continued interview revealed Resident #1 did not remember the exact details of how the burn occurred when family inquired as to how the incident happened. Interview with SRNA #1, on 08/28/19 at 8:16 AM, revealed on 08/24/19 after breakfast between 9:00 AM and 10:00 AM, she witnessed Resident #1 ring the call bell and ask for coffee. SRNA #1 stated she walked to to the Kitchen with SRNA #2 who was new and on orientation. SRNA #1 stated SRNA #2 came out of the kitchen carrying a Styrofoam cup with a lid on the cup. Per interview, the temperature of the coffee was not checked at the time by the SRNAs because dietary staff checked coffee temperatures. Continued interview revealed she witnessed SRNA #2 set the coffee on the resident's table beside the chair where the resident was sitting, and then SRNA #1 and SRNA #2 continued resident care with other residents on the unit. Per interview, shortly thereafter, Resident #1 began to scream, and when she entered the resident's room, the resident had spilled the coffee and LPN #1 was notified. SRNA #1 could not recall if the coffee cup had lost its integrity or if the lid was still on the cup upon finding the resident had spilled his/her coffee. Further interview revealed after the incident she was informed by kitchen staff that coffee had to be delivered in plastic cups and not Styrofoam cups, but she had never been educated related to this prior to the incident with Resident #1. Per interview, SRNA #1 had seen residents being served hot drinks in Styrofoam cups in the past. Interview with SRNA #2, on 08/28/19 at 8:30 AM, revealed she was in the orientation period as she was a new hire and was assigned to Resident #1 on 08/24/19. SRNA #2 stated she was orienting with SRNA #1 when Resident #1 asked her for a cup of coffee. Per interview, she went to the dining room and informed kitchen staff and SRNA #3 handed her the cup of coffee in a Styrofoam cup with the lid from the kitchen door. She stated she took the coffee to the resident's room and placed the cup on the table by the chair where the resident was sitting. Continued interview revealed a short time later, while conducting rounds, Resident #1 was heard screaming out, and upon entering the resident's room Resident #1's pants were wet and the resident complained his/her leg was hurting. SRNA #2 stated the coffee had spilled on the resident's leg, but she could not recall if the cup had lost its integrity causing the coffee to spill out or if the lid was still on the cup. SRNA #2 stated at this point Resident #1's nurse, LPN #1 was called into the room along with the weekend Supervisor/Registered Nurse #1. Further interview revealed she had not been educated related to the need to use plastic cups and not Styrofoam cups for hot beverages, prior to the incident on 08/24/19. Interview with SRNA #3, on 08/28/19 at 9:45 AM, revealed SRNAs were not allowed to go into the kitchen and she did not recall going into the kitchen on 08/24/19 and obtaining a cup of coffee to hand SRNA #2. Per interview, she had been trained in the past that Styrofoam cups were not to be used to serve hot liquids. Interview with LPN #1, on 08/29/19 at 1:30 PM, revealed on 08/24/19 she was working on the Wisteria unit and was assigned to Resident #1. Per interview, on that date during midmorning she was called to Resident #1's room by SRNA #1 and SRNA #2 who stated the resident spilled coffee on himself/herself. She stated when she entered the room, she noted the Styrofoam cup was upright on the table by the chair and the cup had a safety lid in place, but the lid was loose. Further interview revealed she assessed the resident and noticed there was a red area on the resident's right thigh, and she immediately notified the Physician who ordered Silvadene treatment. LPN #1 stated she then notified the resident's Daughter of what happened, and the Daughter stated she did not want the resident sent to the Hospital ER as the resident had a recent referral for a palliative care consult. Further interview with LPN #1, revealed the weekend Supervisor/RN #1 went to the kitchen to investigate as to why the resident had been served coffee from the kitchen in a Styrofoam cup. Additional interview revealed Resident #1 was independent with eating and could drink hot beverages independently in plastic lids with cups. LPN #1 stated she felt the burn could have been prevented if staff had not served the resident coffee in a Styrofoam cup as the hot liquid plastic cups were better designed to be safe. LPN #1 stated she had been informed not to put hot liquids in Styrofoam prior to the incident, but did not know if it was a formal inservice. Interview with the Weekend Supervisor/RN #1, on 08/29/19 at 2:15 PM, revealed on 08/24/19, she responded to an incident where Resident #1 spilled hot coffee on himself/herself from a Styrofoam cup. She stated she and the DON immediately initiated an investigation and concluded Resident #1 was given a Styrofoam cup of coffee with a lid, and shortly afterward spilled coffee on his/her right leg. Per interview, the investigation revealed SRNA #2 gave the cup of coffee to the resident; however, it was not clear as to who prepared the coffee in the kitchen for the resident and handed the cup of coffee to SRNA #2. Continued Interview revealed Resident #1's family did not want the resident sent to the ER and the burn was treated in the facility with Silvadene. RN #1 stated education was provided to all staff after the incident related to hot coffee was not to be served in Styrofoam cups, and she further stated she had received education related to this prior to the incident. Interview with Dietary Aide # 1, on 08/29/19 at 10:30 AM, revealed even though only dietary staff was to be in the kitchen, certain SRNAs did not abide by that policy. Per interview, SRNA #3 was in the kitchen on 08/24/19 midmorning while kitchen staff was in the process of preparing lunch; however, she did not notice if SRNA #3 poured a cup of coffee during that time. She further stated she did not recall anyone asking dietary staff for a cup of coffee for Resident #1 on 08/24/19 during midmorning. Further interview revealed the Coffee temperature was 150 degrees Fahrenheit (F) in the pot on the morning of 08/24/19 when it was tested earlier at breakfast. Additional interview revealed dietary staff knew not to serve hot beverages in Styrofoam cups. Per interview, hot coffee was to be served in plastic cups with a lid and there was no shortage of plastic cups on 08/24/19. Review of the facility's Temperature Log, dated 08/24/19 at breakfast, revealed the coffee temperature was one hundred fifty (150) degrees Fahrenheit (F) for the morning serving. Interview with the Dietary Manager on 08/28/19 at 10:45, revealed 150 degrees F was an acceptable temperature for coffee in the pot and it would cool once poured into a cup. Further interview revealed hot coffee had to be served in plastic cups with a lid. She stated this was because the plastic hot liquid cups could not be eroded, warped, or broken. Further interview revealed the kitchen never ran out of the plastic hot liquid cups. Continued interview revealed all nursing and dietary staff was specifically trained on this facility practice. Further interview revealed she had witnessed SRNAs to come into the kitchen and help themselves; however, only dietary staff should be in the kitchen. Continued interview revealed accurate coffee temperatures were obtained and recorded on the morning of 08/24/19 with coffee temperatures consistent with normal preparation. Interview with SRNA #4, on 08/28/19 at 11:45 AM, revealed she was not working on 08/24/19; however, was frequently assigned to Resident #1. Per interview, Resident # 1 required meals to be set up, and some verbal cueing, but was capable of feeding self and capable of handling glasses and cups and drinking independently. Per interview, Resident #1 frequently drank coffee independently in his/her room. Further interview revealed she learned upon hire that in no circumstance was a resident to receive a hot liquid drink in a Styrofoam cup. Interview with LPN #2, on 08/29/19 at 2:00 PM, revealed she was frequently assigned to Resident #1 and the resident could feed himself/herself and often drank coffee independently in his/her room. LPN #2 stated all hot drinks were to be covered with safety lids. Further, she had been informed prior to and after 08/24/19, to not put hot drinks in Styrofoam cups as the plastic hot beverage cups were safer. Interview on 08/29/19 at 1:45 PM, with Unit Supervisor/RN #2, who was the Supervisor of the Wisteria Unit where Resident #1 resided, revealed Resident #1 required meal setup and cues to eat. Per interview, the resident liked to drink coffee independently and had never had an incident in the past to her knowledge until the incident on 08/24/19 when he/she spilled the coffee. Unit Supervisor/RN #2 stated under no circumstances was staff permitted to give hot liquids in Styrofoam cups as they were not as safe as the plastic cups that were to be used for hot beverages. Interview with the Staff Development Coordinator, on 08/29/19 at 2:30 PM, revealed she was new to the position and had been in her current role only a few months. She stated to her knowledge there had been no formal staff education in the past related to the need to use hot beverage plastic cups instead of Styrofoam cups for hot beverages. However, she stated after the incident on 08/24/19, with Resident #1 sustaining the burn from the hot coffee, education was being provided for all staff. The State Agency Representative phoned Resident #1's Attending Physician on 08/29/19 at 2:45 PM, and a message was left with no return phone call. Interview with the DON, on 08/29/19 at 3:00 PM, revealed on 08/24/19 she received a phone call related to the incident where Resident #1 spilled hot coffee and sustained a burn. Per interview, the Physician was immediately notified of the burn and orders were received for Silvadene treatment which the facility immediately retrieved from a nearby pharmacy. The DON stated the resident's family was asked several times if hospitalization was desired; however, the family was adamant they did not want the resident sent to the Hospital ER. Additional interview with the DON, revealed she initiated an investigation on 08/24/19 and started interviewing staff as to how the resident received a Styrofoam cup. Per interview, SRNA # 2 admitted to giving the resident the hot coffee in the Styrofoam cup; however, no staff member admitted to dispensing the coffee from the kitchen or giving SRNA #2 the cup of coffee for Resident #1 on the morning of 08/24/19. Continued interview revealed, it had always been a rule to not serve hot beverages in Styrofoam cups. She stated hot liquids were to be served in plastic hot liquid cups with a safety lid; however, she was unaware if staff had been educated during inservices related to this rule. Further, the DON stated new policies and education were being instituted in an attempt to prevent further accidents from hot beverages. Post survey phone interview with the Administrator, on 09/11/19 at 3:05 PM, revealed there was no written policy in effect related to serving hot beverages nor was there an assessment tool in place for screening residents at risk for burns related to hot beverages prior to 8/24/19 when Resident #1 sustained the burn. Per interview, staff had been informed in the past they needed to be sure to use the hot beverage plastic cups for hot liquids such as coffee instead of the Syrofoam cups because the safety lids worked better on the plastic cups. However, further interview revealed there was no documented evidence of formal education presented to staff related to this prior to 08/24/19. She stated this information was just passed along from staff members to other staff members in the past, but after the accident occurred related to Resident #1 sustaining a burn, formal education began in an attempt to prevent recurrence. The Administrator stated, Honestly, it feels like it was unfortunate accident, as the wrong style of cup was used.