**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to have a system in place to ensure coffee was served to residents at a safe temperature to prevent burn injuries for 1 (#72) of 1 (#72) sampled residents investigated for burns. This deficient practice resulted in an Immediate Jeopardy for Resident #72 on 01/14/2025 at approximately 7:20 p.m., when Resident #72 was served hot coffee from the evening snack/hydration cart that she spilled on herself. The resident was sent to the emergency room where it was determined she had second degree burns from the spilled coffee. The deficient practice had the likelihood to cause serious harm or death to 95 residents who were served hot liquids, as identified by S1Administrator. S1Administrator was notified of the Immediate Jeopardy on 05/22/2025 at 8:00 a.m. The Immediate Jeopardy was removed on 05/22/2025 at 4:45 p.m. after it was verified through observations, interviews, and record reviews that the provider implemented an acceptable Plan of Removal prior to the survey exit. The deficient practice remains at a potential for more than minimal harm for all of the 95 residents in the facility. Findings: Review of the American Burn Association Scald Injury Prevention Educator's Guide revealed in part: The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. Older adults, identified as a high risk group, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications .Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. Third degree burns can occur within 1 second with hot water temperatures at 155 degrees Fahrenheit (F), within 2 seconds at 148 degrees F, within 5 seconds at 140 degrees F, within 15 seconds at 133 degrees F, and within 1 minute at 127 degrees F. All facility policies related to scald prevention were requested of S1Administrator on 04/30/2025 at 4:55 p.m. None were provided. Review of Resident #72's record revealed an admit date of 07/30/2024 and diagnoses including: hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, iron deficiency anemia, seizures, myelodysplastic syndrome, folate deficiency anemia, and dependence on renal dialysis. Review of Resident #72's most recently completed comprehensive MDS (Minimum Data Set) assessments with ARD (Assessment Reference Date) of 02/25/2025 (quarterly) revealed the Resident had a BIMS (Brief Interview for Mental Status) score of 13 out of 15 indicating she was cognitively intact. Further review revealed Resident #72 required supervision with setup help only for eating. Review of Resident #72's comprehensive care plan revealed in part: the resident had potential for weakness and fatigue due to iron deficient anemia, and had potential for pain due to burn. Review of the facility's incident logs revealed Resident #72 had an injury incident reported on 01/15/2025. Review of the Resident #72's incident report dated 01/15/2025 at 00:32 a.m. for an incident that occurred on 01/14/2025 at approximately 7:20 p.m. revealed in part: incident occurred in resident's room, report prepared by S5LPN (Licensed Practical Nurse): called to resident's room per CNA (Certified Nursing Assistant) and noted resident had dropped cup of hot coffee to left arm, from forearm to above elbow. Skin look like huge blister, bursted skin hanging, weeping, red in color with several small blisters intact. Resident says she was drinking her coffee and cup slipped from hand burning her on her arm. -Injury type = burn, injury location = left antecubital, level of pain = 9, level of consciousness = alert, oriented to person, situation, and place. -predisposing physiological factors = weakness -predisposing situation factors = none -other info-very weak, but demanding regarding what she wants. Written statement by S6CNA -resident asked for a cup of coffee on the snack cart. I went and fixed her coffee and came and gave it to her. She started drinking it as I turned around to leave the room, I heard her holler and say she wasted the coffee. I turned the light on to look and that's when I went and got the nurse. Review of Resident #72's Nursing Notes revealed in part: 01/14/2025 at 7:20 p.m. by S5LPN-called to resident's room per S6CNA. Upon entering room noted resident hollering in extreme pain and skin looking like a huge blister burst skin hanging, weeping, red in color and several small blisters intact to left arm (from forearm to above the elbow). S6CNA says resident asked for a cup of coffee and resident had started drinking and cup slipped from hand, scalded resident's arm and she immediately started hollering out in pain. Received order to send to emergency room for evaluation. Ambulance services arrived in a timely manner. Resident continued to complain with extreme pain. When asked her pain scale resident respond #9 (0-10 scale). 01/15/2025 at 00:25 a.m. by S5LPN-resident returned to facility via stretcher per ambulance without new orders. Diagnosis 2nd degree burn. Review of emergency room record dated 01/14/2025 revealed in part: arrival time 8:31 p.m. Patient sent from nursing home for evaluation of burn to left upper extremity from hot coffee. The symptoms/episode occurred just prior to arrival. At their worst the symptoms were moderate. Skin exam: injury, burn (s), 2nd degree burn injury covers approximately 1% of the total body surface area, and is located on the left bicep. Disposition summary: diagnosis-burn of 2nd degree, left bicep. 1% total body surface area. Review of facility inservice training from 05/04/2024 to 04/30/2025 revealed no staff training related to hot liquids and the prevention of resident burns. During an interview on 04/30/2025 at 10:58 a.m., S2DON (Director of Nursing) and S7 Corporate Nurse, all investigation and corrective actions for the 2nd degree burn that occurred on 01/15/2025 were requested. During an interview on 04/30/2025 at 2:38 p.m., S2DON reported she could not find any investigation of how Resident #72's burn occurred, including the temperature of hot liquids served to residents. S2DON further reported she could not locate any corrective actions that had been implemented to prevent resident burns from hot liquids. During an interview on 04/30/2025 at 3:03 p.m., (Dietary Manager) reported kitchen staff prepared the snack and hydration carts, and the CNAs picked it up and delivered it. S8DM reported morning and evening snack carts included coffee service in a pump dispenser that did not keep the coffee hot, it would cool over time. S8DM further reported there was also a self-serve coffee station available to residents in the dining room. S8DM reported temperature checks were not done before putting brewed coffee into the pump dispensers for service to the residents. S8DM reported S1Administrator asked her today about the temperature of the coffee and told her the brew manufacturer informed him the water temperature for brewing had to be 196 degrees F to dissolve the coffee grounds. S8DM reported today was the first time she had heard anything about a concern regarding the temperature of the coffee because Resident #72 was burned with coffee back in January. The temperature of coffee from the self-serve pump dispenser in the dining room available to residents was 127 degrees F as checked by S8DM with surveyor on 04/30/2025 at 3:13 p.m. The temperature of a freshly brewed pot of coffee was 165 degrees F as checked by S8DM with surveyor on 04/30/2025 at 3:18 p.m. During an interview on 04/30/2025 at 3:22 p.m., S9LPN reported S6CNA no longer worked for the facility. S9LPN reported she was not working at the time Resident #72 was burned, but Resident #72 told her she burned her arm by spilling coffee on it. During an interview on 04/30/2025 at 3:26 p.m., Resident #72 reported she burned her arm back in January of this year when she wasted her coffee on her arm. Resident #72 reported it blistered up really fast, and staff cleaned it and put some cream on it and sent her to the emergency room. Resident #72 reported you could still see the scars and showed her left inner upper arm where there was a 3 to 4 inch by 2 to 3 inch dark patchy area. Resident #72 said it didn't hurt long and the medicine for pain worked well. Said she had never had any other burns or burned her mouth on the coffee because it was so hot you couldn't put it in your mouth, you had to give it a minute to cool off. Said it was still served that hot and that's the way I like it. An attempted telephone interview was made on 04/30/2025 at 4:05 p.m. to the telephone number provided by Human Resources for S6CNA. The following voice message was received: We're sorry, the number you have dialed has calling restrictions that have prevented the completion of your call. During an interview on 04/30/2025 at 4:55 p.m., S1Administrator confirmed no corrective actions were implemented to prevent burn injuries prior to today because today was the first I've heard about it. S1Administrator reported he did not do the investigation, and did not interview S6CNA to see how she fixed the coffee for Resident #72 when serving it from the cart. S1Administrator further reported incidents of a clinical nature would be done by the nursing department. S1Administrator confirmed he called the brew machine manufacturer today and was told the brewers were all are set at 196 degrees F to dissolve the coffee grounds and could not be adjusted. The facility implemented the following actions to correct the deficient practice beginning on 04/30/2025: On 4/30/25 dietary staff were in-serviced on tempering coffee by S1Administrator. The process for tempering the coffee is as follows; once the coffee is brewed the dietary department will add a scoop of ice to lower the temperature coffee to 130-135 degrees F to prevent serving excessively hot coffee. The facility uses air pots, and therefore once cooled the coffee temperature will not further rise. The facility also implemented a temperature log for coffee service that is completed by the dietary staff. In-service training to nursing staff in reference to not rewarming coffee, only filling coffee cups to half capacity, and offering coffee with lids to those residents that consume coffee was conducted by the ADON (Assistant Director of Nursing) on 4/30/25 at 1:15pm. The S1Administrator and S2DON were in-serviced by the Regional Supervisor on 4/30/2025 at 4:00 p.m. on the facility policy on Incident Investigation and Reporting to include taking action on adverse events to protect and prevent future recurrences. In-service training to nursing staff in reference to not rewarming coffee, only filling coffee cups to half capacity, and offering coffee with lids to those residents who consume coffee was completed by the ADON on 4/30/25 at 1:15pm via in person lecture. Education with Nursing staff, dietary staff, was completed on 4/30/2025 at 1:15PM. Education involved the process listed and actions the facility will take. The education was verbal from NFA (Nursing Facility Administrator) with dietary staff and verbal from ADON to nursing staff. NFA or designee will review/investigate burn incidents weekly beginning 04/30/2025 for the next 3 months or until substantial compliance is achieved. All results will be reviewed weekly in the QA (Quality Assurance) sub-committee until substantial compliance is achieved. NFA will check the coffee temperature log weekly beginning 04/30/2025 for appropriate temperature ranges and continued compliance with temperature checks. Administrator or designee will monitor this process for corrective action daily for the next 3 months beginning 04/30/2025 or until substantial compliance is achieved. These checks will be kept on a monitoring tool/temperature log. All results will be reviewed weekly in the QA sub-committee until substantial compliance is achieved. Non-compliance with the plan shall be subject to progressive discipline up to and including termination. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 04/30/2025. Validation of Plan of Removal: Review of incident logs from 05/01/2025 to 05/22/2025 revealed no incidents related to burns. Review of grievance logs from 05/01/2025 to 05/22/2025 revealed no grievances related to the temperature of coffee or other liquids served to residents. Review of inservice training records from 05/01/2025 to 05/22/2025 revealed in part: -04/30/2025 to kitchen staff 04/30/2025 at 1:00 p.m.-Temper coffee immediately after brewing so it is palatable but safe temp level for the residents' consumption -04/30/2025 to LPNs, therapy and restorative staff by S3ADON-When giving coffee to residents do not rewarm in microwave, fill cup ½ full, cups with lids for residents at high risk for spills, assist those residents that require assistance. Method of deliver=verbal; response=receptive. -04/30/2025 to nursing staff and CNAs by S3ADON-When giving coffee to residents-don't rewarm in microwave, fill cup ½ full, cups with lids for residents at high risk for spills, assist those residents that require assistance. Method of delivery=verbal; response=receptive -04/30/2025-inservice given to S1Administrator and S2DON by S22Regional Supervisor on Incident investigation and reporting. -05/19/2025 to Nursing Staff-Tips to Achieve Past Noncompliance if an Adverse Event Occurs. Review of facility QA meeting notes revealed an emergency QA meeting was held on 04/30/2025 regarding Resident #72's burn from hot coffee. Review of Coffee Temperature Logs maintained in the kitchen from 04/30/2025 to 05/22/2025 revealed daily temperature checks of coffee prior to service to residents with none greater than 135 degrees F. Review of Resident Council meeting minutes from meeting held 05/01/2025 revealed in part no complaints about the temperature of coffee or other hot liquids. Review of facility monitoring for burn/scald incidents revealed weekly monitoring of all incident reports by the facility administrator. Review of facility monitoring of coffee temperatures revealed twice weekly monitoring (on Mondays and Thursdays) of coffee temperatures prior to being made available for service to residents. Review of Resident #72's progress notes from 05/01/2025 to 05/22/2025 revealed no further burns or incidents with coffee or other hot liquids. During an interview on 05/22/2025 at 8:45 a.m., S25CNA said she has had a lot of inservices about the temperature of hot liquids, make sure it's not too hot, don't overfill the cup so it doesn't splash over sides, put a sip-through lid on the cups, don't reheat. Said snack/hydration cart comes out at 10:00 a.m., 2:00 p.m. and 6:00 p.m.-does not have a microwave on the cart. If resident complains coffee is not hot, don't reheat it and get them a fresh cup. If had spill where resident was burned, she would notify the nurse. During an interview on 05/22/2025 at 8:48 a.m., S17CNA Supervisor confirmed inservice training had been done for the CNAs, nurses, and therapy about serving hot liquids-fill cup ½ full, offer a lid, never re-heat coffee or other hot liquids in the microwave, get a fresh cup of coffee. If what is in the carafe is not hot enough, have the kitchen make a fresh batch. If soup, don't re-heat, get a fresh bowl or have the kitchen re-heat what is on the steam table. During an interview on 05/22/2025 at 8:55 a.m., S23CNA reported had an inservice about hot liquids-don't re-warm in the microwave-if residents complain it is not hot, get them a fresh cup, same with soup, don't fill the cup or bowl all the way up. Said some residents have been complaining the coffee is not hot enough, get them a fresh cup or have the kitchen brew a fresh carafe-never re-heat in the microwave. Said she was not aware of any other residents being burned/scalded by hot liquids. During an interview on 05/22/2025 at 9:20 a.m., S12CNA said they had been inserviced on hot beverages-get a whole new carafe if coffee is not hot enough-never reheat in the microwave, don't fill all the way to the top, put a lid on they can sip through especially if they are weak, have tremors, etc. Snack/hydration cart comes out at 10:00 a.m., 2:00 p.m. , and 6:00 p.m. During an interview on 05/22/2025 at 9:06 a.m., S14LPN reported nursing staff had inservice on hot beverages-don't overfill-set beverage on over-bed table-supervise residents who need assistance, lids with sip spout for residents who are weak or have tremors (i.e. Parkinson's). Reported no further burn/scald injury incidents. During an interview on 05/22/2025 at 9:12 a.m., S8DM reported the kitchen staff now checks the temperature of coffee before it is placed in the carafes to serve to residents. Reported coffee required 196 degree F water to brew, so ice was added after brewing to bring temp to a safe level of not more than 135 degrees F prior to being made available for service to residents. S8DM reported the supply vendor for dietary and the facility's corporate nurse both advised 135 degree F was the max safe temperature for hot liquids. S8DM Confirmed S1Administrator had conducted inservice training to kitchen staff on checking the temperature of the coffee and measures to bring it to a safe temperature for service to residents. Observation and interview on 05/22/2025 at 10:20 a.m. in the dining room-Resident #44 was drinking coffee from an open plastic mug with a handle. Resident #44 reported the coffee was good, was hot enough and not too hot-never been burned by the coffee. Review of Resident #44's record revealed an MDS dated [DATE] with a BIMS score of 3. Observation and interview on 05/22/2025 at 10:21 a.m. Resident #62 was drinking coffee from an open plastic mug with a handle. Resident #62 reported the coffee was good, was hot enough and not too hot-never been burned by the coffee. Review of Resident #62'srecord revealed an MDS dated [DATE] with a BIMS score of 14. Observation and interview on 05/22/2025 at 10:22 a.m. Resident #74 was drinking coffee from an open plastic mug with a handle. Resident #74 reported the coffee was good, was hot enough and not too hot-never been burned by the coffee. Review of Resident #74's record revealed an MDS dated [DATE] with a BIMS score of 4. During an interview on 05/22/2025 at 10:25 a.m. Resident #72 said she had not had any further burns from coffee or other hot liquids, said they now put her coffee in a disposable cup with a lid that she can drink through and pass it to her. During an interview on 05/22/2025 at 10:28 a.m. Resident #15 in her room-reported she was a coffee drinker, said she had never been burned by the coffee or other hot liquids, the coffee was hot enough, not too hot. Review of Resident #15 's record revealed an MDS dated [DATE] with a BIMS score of 10. Observation on 05/22/2025 from 10:40 a.m. to 11:00 a.m.: S23CNA and S24CNA were passing snacks and beverages to residents in their rooms from the snack/hydration cart. The cart-top had recessed spaces for holding pitchers of cold liquids (tea, kool-aid, water) and a space for holding a metal push-pump coffee dispenser. 12 ounce disposable insulated to go cups with non-slip grip with snap-on leak resistant lids with a sip-through opening. S23CNA served surveyor a cup (asked to serve just like she would a resident) in 12 oz. insulated to go cup ½ full, with a lid that had a sip-through opening, temperature palatable and not scalding. Did not do formal temp check. Temp monitoring from kitchen was 125 degrees F. S23CNA and S24CNA served Resident #64 a cup of coffee in his room, cup ½ full with lid. Review of Resident #64's MDS dated [DATE] revealed a BIMS score of 14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews the facility failed to be administered in a manner that used resources effectively and efficiently to prevent avoidable scald injuries for 1 (#72) of 1 residents (#72) who were investigated for burns. The facility failed to have a system in place to ensure safe temperatures of coffee and other hot liquids served to residents. This deficient practice resulted in an Immediate Jeopardy for Resident #72 on 01/14/2025 at approximately 7:20 p.m., when Resident #72 was served coffee and sustained 2nd degree burns to her left arm when she spilled the coffee on herself. Facility administration did not conduct a thorough investigation into the cause of the injury or ensure staff were adequately trained in the prevention of scald injuries related to hot beverages. The deficient practice had the likelihood to cause serious harm or death to 95 residents who were served hot liquids, as identified by S1 Administrator. S1 Administrator was notified of the Immediate Jeopardy on 05/22/2025 at 8:00 a.m. The Immediate Jeopardy was removed on 05/22/2025 at 4:45 p.m. after it was verified through observations, interviews, and record reviews that the provider implemented an acceptable Plan of Removal prior to the survey exit. The deficient practice remains at a potential for more than minimal harm for all of the 95 residents in the facility. Findings: Cross reference F689 All facility policies related to scald prevention were requested of S1 Administrator on 04/30/2025 at 4:55 p.m. None were provided. Review of the facility's Incident Investigation and Reporting Policy (provided to surveyor 05/22/2025) with latest revision date of 05/2024 revealed in part: to provide guidance to the facility for investigation and reporting incidents of abuse, neglect and/or other reportable incidents . 5. Additional incidents that must have a thorough investigation and may require reporting, as determined by the NF .Burns 6. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence while the investigation is in progress. Consider emergency QA meeting and processes as needed. 7. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. 8 .The investigation will include the following: a. Written report from the person reporting the incident b. Name, phone number, address of the person reporting the incident c. Name, phone number, address of all witnesses. d. Signed statements from all witnesses including the accused if applicable, stating time and date. Detailed account of incident using incident witness statement section of incident report e. Resident's statement regarding the incident, if appropriate f. If only oral information can be obtained for a statement there must be at least two persons present to receive information. g. The reporter must have the statement read back to him/her. Reporter must sign. Recorder and witness must also sign. i. Necessary corrective/preventative action Review of facility inservice training from 05/04/2024 to 04/30/2025 revealed no staff training related to hot liquids and the prevention of resident burns. During an interview on 04/30/2025 at 10:58 a.m., S2 DON (Director of Nursing) and S7 Corporate Nurse, all investigation and corrective actions for the 2nd degree burn that occurred on 01/15/2025 were requested. During an interview on 04/30/2025 at 2:38 p.m., S2 DON reported she could not find any investigation of how Resident #72's burn occurred, including the temperature of hot liquids served to residents. S2 DON further reported she could not locate any corrective actions that had been implemented to prevent resident burns from hot liquids. During an interview on 04/30/2025 at 3:03 p.m., S8 DM (Dietary Manager) reported temperature checks were not done before putting brewed coffee into the pump dispensers for service to the residents. S8 DM reported today was the first time she had heard anything about a concern regarding the temperature of the coffee because Resident #72 was burned with coffee back in January. During an interview on 04/30/2025 at 4:55 p.m., S1 Administrator confirmed no corrective actions were implemented to prevent burn injuries prior to today because today was the first I've heard about it. S1 Administrator reported he did not do the investigation, and did not interview S6 CNA (Certified Nursing Assistant) to see how she fixed the coffee for Resident #72 when serving it from the cart. The facility implemented the following actions to correct the deficient practice beginning on 04/30/2025: 1. S1 Administrator and S2 DON (Director of Nursing) were in-serviced by the Regional Supervisor on 4/30/2025 at 4:00 p.m. on the facility policy on Incident Investigation and Reporting - to include taking action to protect and prevent future occurrences. The Dietary Staff was in-serviced on tempering coffee prior to service. CNAs were in-serviced on not rewarming coffee in the microwave, fill cup only ½ full, assisting those residents that require assistance and offering coffee cup lids to residents that consume coffee. In-service was done by ADON (Assistant Director of Nursing) on 4/30/2025 at 1:15pm. 2. How other residents with the potential to be affected by the same deficient practice will be identified and what will be done for them: 95 residents and new admissions have the ability to have this alleged situation affect them. The Dietary staff was in-serviced on tempering coffee prior to service. CNAs were in-serviced on not rewarming coffee in the microwave, fill cup only ½ full and offering to place lids on cups of residents that drink coffee. Inservice was done on 4/30/2025 at 1:15 p.m. 3. What measures will be put into place or what systematic changes will be made to ensure that the deficient practice does not recur: Staff were in-serviced on tempering coffee as follows: once the coffee is brewed, the Dietary staff will add a scoop of ice to temper the coffee to 130-135 degrees F (Fahrenheit) to prevent serving excessively hot coffee. The facility also implemented inservice training to nursing staff in reference to not rewarming coffee, only filling cup ½ capacity and offering lids to cups to residents that drink coffee. 4. NFA (Nursing Facility Administrator) and DON were in-serviced on Incident Investigation and Reporting on 4/30/2025 at 4:00 p.m. The S1 Administrator and S2 DON had an in-service completed via in person lecture by the Regional Supervisor on 4/30/2025 at 4:00 p.m. on the facility policy on Incident Investigation and Reporting to include taking action on adverse events to protect and prevent future recurrences. Inservice training to nursing staff in reference to not rewarming coffee, only filling coffee cups to half capacity, and serving coffee with lids to those residents at high risk for spills was completed by the ADON on 4/30/25 at 1:15 p.m. via in person lecture. Education with Nursing staff, dietary staff, was completed on 4/30/2025 at 1:15 p.m. Education involved the process listed and actions the facility will take. The education was verbal from NFA with dietary staff and verbal from ADON to nursing staff. Policies have been reviewed with no revisions at this time. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 04/30/2025. Validation of Plan of Removal: Review of incident logs from 05/01/2025 to 05/22/2025 revealed no incidents related to burns. Review of grievance logs from 05/01/2025 to 05/22/2025 revealed no grievances related to the temperature of coffee or other liquids served to residents. Review of inservice training records from 05/01/2025 to 05/22/2025 revealed in part: -04/30/2025 to kitchen staff 04/30/2025 at 1:00 p.m.-Temper coffee immediately after brewing so it is palatable but safe temp level for the residents' consumption -04/30/2025 to LPNs, therapy and restorative staff by S3ADON-When giving coffee to residents do not rewarm in microwave, fill cup ½ full, cups with lids for residents at high risk for spills, assist those residents that require assistance. Method of deliver=verbal; response=receptive. -04/30/2025 to nursing staff and CNAs by S3ADON-When giving coffee to residents-don't rewarm in microwave, fill cup ½ full, cups with lids for residents at high risk for spills, assist those residents that require assistance. Method of delivery=verbal; response=receptive -04/30/2025-inservice given to S1Administrator and S2DON by S22Regional Supervisor on Incident investigation and reporting. -05/19/2025 to Nursing Staff-Tips to Achieve Past Noncompliance if an Adverse Event Occurs. Review of facility QA meeting notes revealed an emergency QA meeting was held on 04/30/2025 regarding Resident #72's burn from hot coffee. Review of Coffee Temperature Logs maintained in the kitchen from 04/30/2025 to 05/22/2025 revealed daily temperature checks of coffee prior to service to residents with none greater than 135 degrees F. Review of Resident Council meeting minutes from meeting held 05/01/2025 revealed in part no complaints about the temperature of coffee or other hot liquids. Review of facility monitoring for burn/scald incidents revealed weekly monitoring of all incident reports by the facility administrator. Review of facility monitoring of coffee temperatures revealed twice weekly monitoring (on Mondays and Thursdays) of coffee temperatures prior to being made available for service to residents. Review of Resident #72's progress notes from 05/01/2025 to 05/22/2025 revealed no further burns or incidents with coffee or other hot liquids. During an interview on 05/22/2025 at 8:45 a.m., S25CNA said she has had a lot of inservices about the temperature of hot liquids, make sure it's not too hot, don't overfill the cup so it doesn't splash over sides, put a sip-through lid on the cups, don't reheat. Said snack/hydration cart comes out at 10:00 a.m., 2:00 p.m. and 6:00 p.m.-does not have a microwave on the cart. If resident complains coffee is not hot, don't reheat it and get them a fresh cup. If had spill where resident was burned, she would notify the nurse. During an interview on 05/22/2025 at 8:48 a.m., S17CNA Supervisor confirmed inservice training had been done for the CNAs, nurses, and therapy about serving hot liquids-fill cup ½ full, offer a lid, never re-heat coffee or other hot liquids in the microwave, get a fresh cup of coffee. If what is in the carafe is not hot enough, have the kitchen make a fresh batch. If soup, don't re-heat, get a fresh bowl or have the kitchen re-heat what is on the steam table. During an interview on 05/22/2025 at 8:55 a.m., S23CNA reported had an inservice about hot liquids-don't re-warm in the microwave-if residents complain it is not hot, get them a fresh cup, same with soup, don't fill the cup or bowl all the way up. Said some residents have been complaining the coffee is not hot enough, get them a fresh cup or have the kitchen brew a fresh carafe-never re-heat in the microwave. Said she was not aware of any other residents being burned/scalded by hot liquids. During an interview on 05/22/2025 at 9:20 a.m., S12CNA said they had been inserviced on hot beverages-get a whole new carafe if coffee is not hot enough-never reheat in the microwave, don't fill all the way to the top, put a lid on they can sip through especially if they are weak, have tremors, etc. Snack/hydration cart comes out at 10:00 a.m., 2:00 p.m. , and 6:00 p.m. During an interview on 05/22/2025 at 9:06 a.m., S14LPN reported nursing staff had inservice on hot beverages-don't overfill-set beverage on over-bed table-supervise residents who need assistance, lids with sip spout for residents who are weak or have tremors (i.e. Parkinson's). Reported no further burn/scald injury incidents. During an interview on 05/22/2025 at 9:12 a.m., S8DM reported the kitchen staff now checks the temperature of coffee before it is placed in the carafes to serve to residents. Reported coffee required 196 degree F water to brew, so ice was added after brewing to bring temp to a safe level of not more than 135 degrees F prior to being made available for service to residents. S8DM reported the supply vendor for dietary and the facility's corporate nurse both advised 135 degree F was the max safe temperature for hot liquids. S8DM Confirmed S1Administrator had conducted inservice training to kitchen staff on checking the temperature of the coffee and measures to bring it to a safe temperature for service to residents. Observation and interview on 05/22/2025 at 10:20 a.m. in the dining room-Resident #44 was drinking coffee from an open plastic mug with a handle. Resident #44 reported the coffee was good, was hot enough and not too hot-never been burned by the coffee. Review of Resident #44's record revealed an MDS dated [DATE] with a BIMS score of 3. Observation and interview on 05/22/2025 at 10:21 a.m. Resident #62 was drinking coffee from an open plastic mug with a handle. Resident #62 reported the coffee was good, was hot enough and not too hot-never been burned by the coffee. Review of Resident #62'srecord revealed an MDS dated [DATE] with a BIMS score of 14. Observation and interview on 05/22/2025 at 10:22 a.m. Resident #74 was drinking coffee from an open plastic mug with a handle. Resident #74 reported the coffee was good, was hot enough and not too hot-never been burned by the coffee. Review of Resident #74's record revealed an MDS dated [DATE] with a BIMS score of 4. During an interview on 05/22/2025 at 10:25 a.m. Resident #72 said she had not had any further burns from coffee or other hot liquids, said they now put her coffee in a disposable cup with a lid that she can drink through and pass it to her. During an interview on 05/22/2025 at 10:28 a.m. Resident #15 in her room-reported she was a coffee drinker, said she had never been burned by the coffee or other hot liquids, the coffee was hot enough, not too hot. Review of Resident #15 's record revealed an MDS dated [DATE] with a BIMS score of 10. Observation on 05/22/2025 from 10:40 a.m. to 11:00 a.m.: S23CNA and S24CNA were passing snacks and beverages to residents in their rooms from the snack/hydration cart. The cart-top had recessed spaces for holding pitchers of cold liquids (tea, kool-aid, water) and a space for holding a metal push-pump coffee dispenser. 12 ounce disposable insulated to go cups with non-slip grip with snap-on leak resistant lids with a sip-through opening. S23CNA served surveyor a cup (asked to serve just like she would a resident) in 12 oz. insulated to go cup ½ full, with a lid that had a sip-through opening, temperature palatable and not scalding. Did not do formal temp check. Temp monitoring from kitchen was 125 degrees F. S23CNA and S24CNA served Resident #64 a cup of coffee in his room, cup ½ full with lid. Review of Resident #64's MDS dated [DATE] revealed a BIMS score of 14. During a telephone interview on 05/22/2025 at 3:43 p.m. S22Regional Supervisor reported he has been having a weekly telephone meetings with S1Administrator to review all of the corrective measures and monitoring. S22Regional Supervisor reported he had been doing verbal monitoring, but with this incident he had a monitoring tool sheet for the weekly meeting. S22Regional Supervisor reported he was working with a manufacturer that brews coffee at 125 degrees F and was considering ordering one to try it out. S22Regional Supervisor for right now they are doing an ice dump to get the temperature down to 130-135 degrees F.