**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two Deficient Practice Statements (DPS), A and B: DPS A: This citation pertains to intake MI00144424. Based on observation, interview and record review, the facility failed to ensure hot liquid was served at a safe and appropriate temperature for one (Resident #28) of three reviewed for accident hazards, resulting in Immediate Jeopardy when R28 received coffee of an unknown temperature, which spilled, causing R28 to sustain a second-degree thermal burn (damage to outer and second layer of skin, causing blisters, pain and discoloration) on his left outer thigh and increased pain. Findings include: Resident #28 (R28): Review of the medical record reflected R28 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included multiple sclerosis and unspecified severe protein-calorie malnutrition. The significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/23/24, reflected R28 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for second or third degree burns. During an interview and observation on 07/09/24 at 2:17 PM, R28 reported about three to four months prior, hot coffee fell over and was super hot. He reported having a fourth-degree burn on his leg. He lifted the left leg of his shorts and showed a darkened area, several inches long, on the lateral (outside) aspect of his left leg. R28 reported there was a lid on his cup, which he had next to him, in his wheelchair. According to R28, the lid did not seal good enough, causing the hot coffee to leak out of the side of the cup. R28 reported when the coffee spilled on him, he told staff right away, and they put stuff on to make it heal. A Progress Note for 4/18/2024 at 11:28 AM reflected, .Resident came up to writer stating that they spilled coffee from the kitchen on themselves and the floor. Writer took a look at the left thigh and measured burn. Writer cleaned burn and iced for 20 minutes. After the ice, writer applied medihoney to burn and wrapped with abd [dressing]. Writer educated the resident on safety while drinking hot beverages and also educated the kitchen staff on importance of temping foods and drinks before serving to residents . A late entry Progress Note for 4/18/2024 at 12:00 PM reflected, .Dietary staff temped coffee prior to giving to [R28], Temp in normal range, [R28] stated he placed his coffee cup on the L [left] side of his w/c [wheelchair] and as he was self propelling w/c the coffee cup tipped over. He did not alert staff and went to smoke. Offered [R28] a cup holder to his w/c. [R28] declined at this time. There was no documentation in R28's medical record or on the facility's April 2024 Coffee Temperature Log to support that the coffee temperature was checked and in a safe range prior to serving it to R28. The facility's investigation into the incident was reviewed and included an incident report for 4/18/24 at 11:17 AM, which reflected R28 came up to the nurse, stating he had spilled coffee on himself and the floor. His left thigh was assessed and noted to have blisters and a raised, red area. The immediate action taken reflected the burn was cleansed, then iced for 20 minutes. Once the ice was off, medihoney (wound and burn treatment) was applied to the wound, then covered with an ABD dressing. R28 was educated on safety precautions while drinking hot beverages, such as a lid, sitting at the table and not roaming around with drink in hand. The report reflected, .Writer also educated kitchen staff on appropriate coffee temperatures to prevent further accidents of this nature . The facility's investigation included a sign in sheet for education provided by Registered Dietitian (RD) I on 4/18/24, which reflected: -Temperatures of hot beverages must be done prior to and during meal service -Temperatures of hot beverages must be taken prior to any request by residents in between meals -Hot beverages must be below 135 degrees (Fahrenheit) prior to serving to residents -All hot beverages must have a lid on prior to serving to the resident The education was signed by seven dietary staff. The facility's investigation did not indicate a root cause analysis, nor an identification of which staff member provided the coffee to R28 on 4/18/24. During an interview on 07/12/24 at 12:32 PM, Director of Nursing (DON) B reported Dietary Aide (DA) T provided R28 with the coffee that burned him on 4/18/24 and verbalized putting three ice cubes in it. When asked why ice was placed in the coffee, DON B reported she (personally) did not document the coffee temperature at the time she looked into the incident because it was within normal limits. DON B believed the coffee temperature was in the range of low 140's (degrees Fahrenheit) and reported it may have been 144 degrees Fahrenheit. According to DON B, the temperature of the coffee that was provided to R28 was under 150 degrees Fahrenheit, and she was not concerned. DON B reported R28 sat outside to smoke two cigarettes after the coffee spilled on him. Review of the facility's staff education pertaining to hot liquids on 4/18/24 did not reflect that DA T had signed the education. On 07/10/24 at 02:20 PM, DA T reported coffee was temped after drawing it from the machine and before sending out the tray. DA T stated, The coffee temperature is usually around 160 degrees Fahrenheit from the machine and about 145 degrees Fahrenheit when delivered. The April 2024 Coffee Temperature Log reflected a coffee temperature of 180 degrees Fahrenheit on 4/18/24 at 7:30 AM. The recheck temperature was 148 degrees Fahrenheit. At 11:30 AM on 4/18/24, the coffee temperature was 178 degrees. The recheck temperature was 147 degrees Fahrenheit. The 4:30 PM coffee temperature on 4/18/24 was 135 degrees Fahrenheit. An undated Hot Liquid Safety policy reflected, .2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature . On 07/10/24 at 3:24 PM, Nursing Home Administrator (NHA) A reported the undated Hot Liquid Safety policy was the policy that was current as of 4/18/24 (when R28 sustained the burn). Further review of the April 2024 Coffee Temperature Log reflected each initial and recheck coffee temperature exceeded 140 degrees Fahrenheit until the 4:30 PM coffee temperature on 4/18/24. During an interview on 07/10/24 at 2:59 PM, Licensed Practical Nurse (LPN) L reported being R28's nurse at the time he sustained the coffee burn. R28 came to her and reported receiving coffee from the kitchen, which he put in the side of his wheelchair. When he went outside, the coffee spilled on his leg and burned him. By the time R28 notified her, he had already been changed. She stated he must have told a Certified Nurse Aide (CNA) or cleaned himself up before notifying her. After being notified, she put R28 in bed and placed a cold towel on the burn while gathering wound supplies, including medihoney. During the same interview, LPN L reported she educated kitchen staff on temping of coffee. LPN L stated she knew for a fact if the coffee was temped, it would not have burned R28 the way that it did. She reported also educating R28 that it was not safe to be moving around with a hot cup of coffee (in his wheelchair). LPN L reported the burn initially appeared as the length of her cell phone, with a large blister. When she saw the burn the following week, the blister was no longer intact, and there was raw skin. According to Mayo Clinic, .2nd-degree burn. This type of burn affects both the epidermis and the second layer of skin (dermis). It may cause swelling and red, white or splotchy skin. Blisters may develop, and pain can be severe. Deep second-degree burns can cause scarring .3rd-degree burn. This burn reaches to the fat layer beneath the skin. Burned areas may be black, brown or white. The skin may look leathery. Third-degree burns can destroy nerves, causing numbness . (https://www.mayoclinic.org/diseases-conditions/burns/symptoms-causes/syc-20370539) On 4/18/24, R28's burn measured 20 centimeters (cm) in length by (x) 7 cm in width. The wound photo revealed a red, raised area with intact blisters. R28's pain level was recorded as eight out of ten. On 4/22/24, R28's burn measured 20 cm in length x 7 cm in width. The burn was staged as partial thickness (affects the top two layers of the skin). The tissue type reflected, Necrotic [dead tissue] Soft, Adherent=50%, Necrotic Hard, Firm, Adherent=50%. R28's pain level was recorded as eight out of ten. The assessment reflected the burn was Very painful. R28's burn was evaluated by the Wound Provider on 4/25/24. The assessment reflected R28 had a second-degree burn, measuring approximately 18 cm in length x approximately 6 cm in width and 0.1 cm in depth. The tissue was 75% slough (non-viable tissue that can present as yellow, tan, gray, green or brown) and 25% granulation (pink/red tissue that fills a wound when it begins to heal). On 4/29/24, R28's burn measured 20 cm in length x 5 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=50%, Slough Loosely Adherent=50%. R28's pain level was recorded as eight out of 10. On 5/6/24, R28's burn measured 18 cm in length x 4 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as four out of ten. R28's burn was evaluated by the Wound Provider on 5/9/24. The assessment reflected the burn was second-degree and measured 13.5 cm in length x 3.2 cm in width x 0.1 cm in depth. The tissue was 50% slough and 50% granulation. On 5/14/24, R28's burn measured 12 cm in length x 4 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as three out of ten. On 5/20/24, R28's burn measured 10 cm in length x 2.5 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as three out of ten. R28's burn was evaluated by the Wound Provider on 5/23/24. The assessment reflected the burn was second-degree and measured 8.5 cm in length x 2.3 cm in width x 0.1 cm in depth. The tissue was 50% slough and 50% granulation. Blue/green drainage was noted, with notation that it could be pseudomonas (bacteria) infection. On 6/3/24, R28's burn measured 5 cm in length x 1.7 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as zero. On 6/10/24, R28's burn measured 4 cm in length x 1.7 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as zero. R28's burn was evaluated by the Wound Provider on 6/13/24. The assessment reflected the burn was second-degree and measured 1.5 cm in length x 1 cm in width x 0.1 cm in depth. The tissue was 50% slough and 50% granulation. On 6/17/24, R28's burn measured 1.5 cm in length x 1.0 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as zero. On 6/24/24, R28's burn was recorded as healed, with intact skin. The photo showed an area of pink/red discolored skin, measuring greater than 12 cm in length. The facility's Hot Liquid Safety policy with a revision date of 4/18/24 reflected, .2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature of under 135 degrees . Review of Coffee Temperature Logs for May, June and July 2024 reflected, Coffee temperature needs to be between 130-150 degrees prior to serving. Coffee that is 150 degrees or higher needs a few minutes to cool down to serve and could cause severe burns. Further review of the logs reflected numerous missed temperature recordings as well as temperatures that exceeded the facility's policy pertaining to temperature parameters, without a documented action taken. On 7/10/24, review of the July 2024 Coffee Temperature Log reflected dinner coffee temperatures had not been recorded at all for the month. During an interview on 07/10/24 at 4:30 PM, Dietary Manager (DM) D reported coffee was served at each meal. The coffee machine brewed coffee at a minimum temperature of 165 degrees Fahrenheit and a maximum temperature of 180 degrees Fahrenheit. Dietary staff were to take the coffee temperature and hold the coffee, as the serving temperature needed to be less than 140 degrees Fahrenheit. He reported they did not want the temperature above 140 degrees Fahrenheit because the residents could burn themselves, and it was a safety issue. DM D reported he was told R28 was given a cup of coffee and received third-degree burns on his leg. During the same interview, DM D reported the facility also had self-serve coffee stations that were placed at the unit desks. When asked how the temperature of the self-serve coffee was monitored, DM D reported dietary staff temped the coffee when it was placed in the coffee urn. They then let it sit for 15 to 20 minutes. He reported the temperature for the coffee urns should be at least 150 degrees Fahrenheit, but he preferred it to be between 130 to 135 degrees Fahrenheit. He reported the coffee urns were insulated and would hold a temperature for many hours. When asked how he could be certain that resident's were not receiving self-serve coffee that was 150 degrees Fahrenheit, DM D stated he could not be certain. DM D reported the hot liquid policy was revised after R28's burn, and he believed anything under 140 degrees Fahrenheit was ok. Upon review of the July 2024 Coffee Temperature Log, DM D reported most of the temperatures were out of range, and there was no documented action taken. He reported the staff should have listed that they held the coffee and taken another temperature. DM D agreed the dinner coffee temperatures were missing from the log and should have been documented. In an interview on 07/10/24 at 4:48 PM, DM D reported Coffee Temperature Logs reflected the temperatures of the coffee served on the tray line. He stated the facility did not log the temperatures for the coffee urns before they went to the units. The coffee in the urns came straight from the brew pot at 180 degrees Fahrenheit. It then sat for 15 to 20 minutes, but a temperature was not logged. The Immediate Jeopardy began on 4/18/24 when the facility failed to ensure R28 was provided coffee at a safe temperature, resulting in a second-degree thermal burn and increased pain. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 7/11/24 at 1:58 PM. The Immediate Jeopardy that began on 4/18/24 was removed on 7/11/24 when the facility took the following actions to remove the immediacy: 1. The NHA called an Ad Hoc QAPI meeting, which included the DON, Medical Director (via phone), Assistant Director of Nursing, MDS Coordinator, Registered Dietitian, and Dietary Manager. A root cause analysis was completed for the above-mentioned burn to Resident #28. 2. Dietary Manager and Registered Dietitian educated dietary staff on proper temping and serving of hot beverages. Hot beverages must be temped and logged prior to and during meal service. The temperature of hot beverages must be taken prior to any request by residents between meals. Hot beverages must be below 135 degrees Fahrenheit prior to serving to residents. 3. The DON and Social Services Director educated all staff that only dietary staff is permitted to serve hot beverages, with the exception that after hours (8 PM to 6 AM) only a nurse on duty is permitted to serve hot beverages to residents. 4. The DON educated nurses on correct process for temping and serving hot beverages. Hot beverages must be temped and logged prior to serving to residents. Hot beverages must be below 135 degrees Fahrenheit prior to serving to residents. 5. Signs were placed at both kitchen doors by the Registered Dietitian, stating only nurses can serve hot beverages to residents after hours. The Activity Director was instructed to inform residents of this at the next Resident Council Meeting. 6. The DON assessed all current residents for safe handling of hot beverages using the Hot Liquid Evaluation. Occupational Therapy was then notified for safety screening per written order for those deemed necessary. The Dietary department was notified to use spill proof cups via Dietary Communication forms for those deemed necessary. Tray tickets and care plans were updated as needed by the Registered Dietitian. 7. The Dietary Manager/designee will observe dietary staff at all meals to ensure proper temping and logging of hot beverages until assured that all dietary staff know the proper process. 8. The Dietary Manager/designee will audit temperature logs daily to ensure the process is being followed and temperatures are at approved levels for hot beverages. 9. The NHA will audit hot beverage logs weekly x 2 to ensure compliance. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 7/11/24 but noncompliance remains at a scope of widespread and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. DPS B: Based on observation, interview and record review, the facility failed to perform safe smoking assessments in two of three residents reviewed for smoking hazards (Resident #29 and Resident #4), resulting in the likelihood for injuries. Findings include: Resident #29 (R29) On 7/09/24 at 10:09 AM, R29 was observed sitting in his room in his wheelchair with two disposable pod vaping devices placed on his over-the-bed table. R29 stated he used to smoke cigarettes, but now vapes. R29's Minimum Data Set (MDS), with assessment reference date (ARD) of 6/28/24, introduced a Brief Interview for Mental Status (BIMS, a brief cognitive screener) score of 15 (13-15 Cognitively Intact). The same MDS indicated he had the diagnoses of heart failure, diabetes, end stage renal disease requiring dialysis, lung disease, skin tears, and moisture associated skin damage. In review of R29's electronic medical record, the last smoking safety screen assessment was completed on 12/18/22. In review of R29's care plans, there were no care plans addressing vaping. Resident #4 (R4) R4's MDS with ARD of 6/19/24, revealed a BIMS score of 14 (13-15 Cognitively Intact) and had the diagnoses of traumatic brain injury, hemiplegia (complete or severe paralysis on one side of the body including face, arm and leg), seizure disorder, anxiety and depression. In review of R4's [NAME] (nurse assistant care plan) dated 7/10/24, R4's smoking materials were to be kept with the nurse, and did not specify vaping materials. In review of R4's Smoking screen assessment dated [DATE], there was no mention of her vaping and indicated she was safe to smoke without supervision. The same assessment revealed continues to forget she cannot smoke indoors. Facility keeps lighter and cigarette. Certified Nurse Assistant (CNA) X was interviewed on 7/11/24 at 8:36 AM and stated R4 was not allowed to smoke except when her family was supervising due to bumming cigarettes from other residents and vaping. CNA X stated R4 had vaping materials in her possession. Director of Nursing (DON) B was interviewed on 7/11/24 at 8:48 AM and stated smoking privileges had recently changed for her. DON B stated she was not aware of R4 vaping. DON B stated smoking screen assessments were completed every six months or if there was a change. The facility provided a list of residents that smoke on 7/09/24, R29 and R4 were not included on the list. In review of the Smoking Progress policy dated 6/25/24, there was no guidance on vaping.