**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one Resident (R132) of one resident reviewed for accidents was served hot beverages in a stable, handled, thermal cup and provided proper meal set-up. This deficient practice resulted in an Immediate Jeopardy, when R132 sustained a second-degree burn (a burn affecting the skin layers, causing redness, pain, swelling, and blisters), and developed increased pain. Findings include: The Immediate Jeopardy was identified on 10/23/24, at 12:00 p.m., when R132 spilled hot scalding water for tea on themself, resulting in a second-degree burn and the likelihood of other residents affected due to lack of assessment and monitoring practices which could lead to serious harm, injury, impairment, or death. The Administrator was notified of the Immediate Jeopardy (IJ) on 11/21/24 at 11:30 a.m The Immediate Jeopardy began on 10/23/24. A plan to remove the immediacy was requested. The IJ was removed on 11/21/24, based on the facility's implementation of the plan of removal as verified by the Survey team on site. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with actual harm. On 10/23/24 at approximately 12:00 p.m., R132 sustained a second-degree burn on their abdomen after spilling a cup of hot water on themselves during the lunch meal, which leaked through their blanket, shirt, and onto their skin. On 11/20/24 at 11:59 a.m., an observation revealed R132's hot water was served in a foam cup and was temped on their lunch tray at 164 degrees Fahrenheit, which placed R132 at risk for additional burns due to above scalding temperature. On 11/20/24 at 1:00 p.m., an observation revealed the hot water was temped at 184.6 degrees from the kitchen hot water dispenser for beverages. On 11/19/24 at 11:05 a.m., R132 reported they were burned when they spilled hot tea on themselves. R132 stated, It was in a (name of) foam cup and was not very stable. Sometimes they serve it in a mug. R132 reported they had pain 7/10 on their abdomen during the interview, and stated it was painful when the nurses changed their bandage. R132 explained the incident happened a few weeks ago at the facility. R132 stated, I keep the cup away from me, and make sure I pick it up with both hands. R132 confirmed they were afraid of spilling hot water on themselves, because 90% of the time it is (served in) a foam cup and lid. On 11/19/24 at approximately 12:25 p.m., the surveyors observed R132 in their room seated in a manual wheelchair with their cup of hot water for tea in front of them, in a foam cup with no lid. The surveyors observed the tray was not set up for R132, and the hot water temped at 124.4 degrees Fahrenheit. Review of R132's, Skin and Wound Evaluation, dated 10/23/24 at 1:15 p.m., revealed a new second-degree burn injury on the left lower quadrant of the abdomen, which was designated as in-house acquired. The measurements were 56.7 cm (centimeters) squared (area), 7.7 cm length, 10.7 cm width, and 0.2 cm depth. The wound was observed as a large pink wound, with slight blistering along the wound edges. Review of R132's, Skin and Wound Evaluation, dated 11/19/24, showed the burn wound measurements were 17.2 area in cm squared, 3.2 cm length, 6.4 cm width, and .3 cm depth. The wound was designated as slow to heal. The wound was observed as a medium-size healing blister, with scabbing and yellow blistering in the center of the wound. Review of R132's progress note, dated 10/23/24 at 12:30 p.m., by Licensed Practical Nurse (LPN) K, confirmed the description of the wound. The note revealed R132 reported they were attempting to place their tea bag after removing the cup lid and spilled hot water onto their blanket, shirt, and onto their skin .The noted further described petroleum jelly and burn cream were ordered to treat the wound. Review of R132's progress note, dated 10/23/24, by the wound care nurse, LPN L, revealed R132 spilled hot liquid on their abdomen when in bed, sustaining a burn injury which they described as on the mid-lower abdomen, pink in color with minimal serous (clear yellow) drainage. The note revealed they applied one layer of petroleum jelly and covered the wound with an ABD (wound protective) pad. Review of R132's facility investigation report, dated 10/23/24, revealed the facility interviewed Certified Nurse Assistant (CNA) U, who stated they were passing lunch meal trays and gave R132 their tray and hot tea. When CNA U returned to pick up R132's tray, R132 stated, Oh my G**, the hot water spilled on my belly . Review of R132's pain log revealed increased pain after the burn injury as follows: 10/23/24 at 12:00 p.m.: 5/10 pain (with 10 the highest possible pain) 10/23/24 at 12:40 p.m.: 7/10 10/23/24 at 6:25 p.m.: 0/10 10/23/24 at 8:00 p.m.: 2/10 Review of R132's Minimum Data Set (MDS) assessment, dated 10/17/24, revealed R132 was admitted to the facility on [DATE], with diagnoses including coronary artery disease, kidney disease, muscle wasting and atrophy, and repeated falls. R132 required set-up with eating, and maximal assistance with bed mobility and transfers. The Brief Interview for Mental Status (MDS) assessment score was 13/15, which showed R132 was cognitively intact. Review of the 10/23/24 food and beverage temperature log, showed the coffee temperature at breakfast was 191 degrees. There was no temperature designation on the log for a hot beverage at lunch or dinner. The log showed no category for hot beverages, only for coffee at breakfast. On 11/20/24 at 11:59 a.m., R132 was observed seated in their wheelchair in their room. Their lunch tray was delivered and set on R132's bedside table by the Activity Director, Staff G. R132's hot water for their tea was observed in a foam lidded cup. R132's hot water temped at 164 degrees using a digital food thermometer with Staff G confirmed they observed the same temperature. On 11/20/24 beginning at 12:00 p.m., LPN K, LPN O, and Registered Dietician (RD) J were asked to observe R132's hot water in the foam cup, and the temperatures, as follows: 12:03 p.m.: 158.5 degrees 12:05 p.m.: 152 degrees 12:08 p.m.: 148 degrees On 11/20/24 at 12:08 p.m., RD J was asked about R132's hot water being served at 164 degrees. RD J responded the safe temperature for hot liquids was 130 to 160 degrees, which they reported was their facility policy/process. On 11/20/24 at approximately 12:29 p.m., the Unit manager, Licensed Practical Nurse (LPN) O, was asked about any changes they had implemented since R132's abdominal burn from hot water on 10/23/24. LPN O responded, .Staff deliver (R132's) tray and do the set-up and the tea bag. Surveyor asked about R132 being observed with Styrofoam cup with hot water. LPN O stated, They (kitchen staff) typically use the brown (thermal) cups with lids for (hot) liquids .They (kitchen staff) are supposed to temp it before it leaves the kitchen, and it (the cup) sits there (in the kitchen). On 11/20/24 at approximately 12:35 p.m., LPN K confirmed they were the nurse assigned to R132 when the burn injury occurred on 10/23/24. LPN K stated, When it was reported, it was like three different areas and now it is one large area. The doctor was here when it happened and ordered Petroleum jelly. (R132) was in 6-7/10 pain. They reported they administered Over-the-Counter pain medication, which relieved R132's pain. On 11/20/24 at 12:55 p.m., RD J was interviewed with the Assistant Dietary Manager, DM B. DM B explained the hot beverages were obtained from the hot water dispenser in the kitchen, and cooled down for 15 minutes before being served, which RD J confirmed. RD J reported residents were typically assessed for hot liquid safety by Occupational Therapy staff. Both were asked why R132's hot liquid for tea was temped at 164 degrees on their tray, and neither could explain how this occurred. There was nothing about this process in writing upon Surveyor request. On 11/20/24 at approximately 1:00 p.m , RD J stated R132's Occupational Therapist indicated R132 was safe to handle hot liquids prior and after the burn injury. RD J and DM B both reported they were not instructed to do anything different in terms of providing hot beverage service to R132 after the incident. Both conveyed they usually served hot beverages in plastic, thermal mugs with handles, however stated they had been running out of the stable thermal mugs. When asked why, DM B explained, We order them, and they just run out. Both indicated all the residents were supposed to receive thermal mugs with lids unless otherwise designated. RD J and DM B were asked how R132's hot water had temped at 164 degrees in their room on their tray in a foam lidded cup at lunch on 11/20/24. Neither could not explain how this occurred, as their process was for kitchen staff to cool down the hot water before it left the kitchen. On 11/20/24 at 1:05 p.m., Surveyor and DM B jointly temped the hot water in a foam cup coming out of the hot water dispenser in the kitchen. Surveyor obtained the temperature at 184.6 degrees with a food and beverage digital thermometer, and DM B obtained the temperature at 186 degrees, with their kitchen digital thermometer. On 11/20/24 at 1:10 p.m., Staff I, the day shift cook, was asked about serving hot liquids to facility residents. Staff I indicated they obtained the hot water from the hot water dispenser and then cooled it down. Staff I stated, We (kitchen staff) give it to them (residents) at 140 to 150 degrees. Surveyor asked about the temperature of 164 degrees taken in R132's room at lunch on their tray, and how this occurred. Staff I stated, It's too hot, that's a risk for a burn. On 11/20/24 at 1:23 p.m., DM B was asked about the temperature logs not showing a hot liquids temperature column prior to the incident. DM B explained they did not have the hot temperatures recorded on the old logs, as they only temped the coffee at breakfast prior to R132's burn incident. DM B stated, Our protocol wasn't tempting hot tea. DM B clarified the maximal temperature for serving hot liquids was 160 degrees. DM B was asked about the 191-degree temperature of the coffee logged on 10/23/24, the date R132 received their burn injury. DM B responded, That would have been pretty hot if we took this out (of the kitchen). That's scalding (temperature) hot right there. We should have never put it out (given to residents) at 191 degrees. Review of R132's tray ticket from 10/23/24 and 11/20/24 revealed no designation of a container for beverages, such as a thermal lidded cup with a handle. On 11/20/24 at 3:44 p.m., the Rehabilitation Director, Occupational Therapist (OT) R, was asked if R132 was determined to be safe with hot liquids, and for a copy of any assessments. OT R reported R132 was assessed to be safe with hot liquids during the initial OT evaluation by OT F on 10/08/24, and after the incident by Certified Occupational Therapist Assistant (COTA) H on 10/24/24. OT R reported the hot liquid assessment was a part of the therapy evaluations, and documentation. On 11/20/24 at 3:53 p.m., Certified Occupational Therapist Assistant, (COTA) H, was asked how R132 was determined to be safe with hot liquids after the burn injury on 10/23/24. COTA H reported they assessed R132 by having them set-up and drink their hot tea from a foam cup at their bedside. When asked about R132's functional status, COTA H reported although R132 set-up the tea adequately, they had postural concerns, as they slid down, or sometimes slumped forward, as they tired easily, had mild coordination problems, and fair safety. COTA H stated, .I prefer the mugs because of the handle and because the handle is good security (to prevent spillage). COTA H was asked if they reviewed the results of R132's hot liquid assessment with a supervising occupational therapist, and COTA H responded, No. Review of R132's progress note, dated 10/24/24, by COTA H, revealed they passed R132 on the second hot liquid assessment in a narrative notation and worked on sitting balance exercises and seating and positioning during self-feeding, showing postural concerns which may have impacted R132's safety and performance with self-feeding. Review of R132's physician note, dated 10/21/24 at 8:25 a.m. (prior to the burn incident), revealed R132 had muscle weakness, with 3/5 strength (fair muscle strength) in both arms and legs, and debility. Review of R132's physician note, dated 10/23/24 at 12:56 p.m. (after the burn incident), revealed R132 continued to have muscle weakness, with 3/5 strength in their arms and legs, and debility. Review of R132's Occupational Therapy and Physical Therapy records showed R132 was receiving therapy services from 10/08/24 through 11/20/24, prior, during, and after the burn incident. Review of R132's Occupational Therapy evaluation, dated 10/08/24, revealed R132 had decreased muscle strength in their arms, fair sitting balance, and muscle atrophy. On 11/21/24 at 9:53 a.m., R132's OT, OT F, was asked about the hot liquid evaluation process. OT F reported they simulated the task with residents as the assessment was documented in their evaluations. OT F confirmed they cleared R132 as safe with hot liquids on the OT evaluation on 10/08/24. OT F was asked if COTA H reviewed the assessment results with them or supervising therapists from 10/24/24. OT F responded, No. OT F reported R132 had some coordination problems. OT F explained R132 may have had limitations in reaching and grasping due to frequent infections, which caused slightly decreased coordination, increased weakness and decreased energy (activity tolerance). OT F acknowledged they or another OT did not reassess R132's feeding ability after the spill and burn from hot liquids on 10/23/24. OT F confirmed R132 would be safer with a stable mug with a handle and lid. OT F explained when a resident had breakfast in bed, they were concerned about safe positioning, and reported decreased postural control in bed could have played a role in R132's burn injury. On 11/21/24 at 12:22 p.m., R132's Power of Attorney, (POA) J, was asked about R132's care. POA J stated R132 was burned because the water (for tea) was so hot, and it was just in a foam cup instead of a mug. Maybe they (staff) can't control how hot the water comes out, and it should have been (served) in a mug. POA J explained R132 had neuropathy in their hands, which caused weakness. On 11/24/24 at 2:18 p.m., the NHA was asked about the concerns related to the Immediate Jeopardy. The NHA explained their former certified dietary manager had been on a leave since June 2024, and there had been a gap in kitchen supervisory staffing and training challenges due to limited availability of managerial oversight, as they had only recently moved DM B into the kitchen manager position. The NHA acknowledged a system failure, reporting they had become aware there was a breakdown in the temperature logging process, as this was a newer process, serving hot liquids in the kitchen. The NHA clarified until recently the kitchen had only made and served coffee and hot water for tea or cocoa per resident request from carafes and had only recently began providing coffee or hot water from the coffee and hot water dispenser. The NHA confirmed they were not aware of the shortage of mugs, although they understood the concern was missing lids. Review of the policy, Hot Beverages Temperature Limits, issued 11/03/24, revealed, Policy: Coffee machines will be set at 180 - 190 degrees Fahrenheit. This is industry standards for palatability. Goals for test trays will be to have coffee above 140 during tray line. There are no current regulations that specify temperatures appropriate for the consumption of hot beverages. Procedure: 1. Hot beverage temperatures will be monitored daily with tray line temperatures . There was no reference regarding above 140 degrees (or even as low as 120 degrees) may be scalding temperature for vulnerable adults in the facility. Review of the policy, Hot Liquid Assessment, issued 11/19/2018, revealed, It is the policy of the facility to assess residents for safe consumption of hot liquids .The Registered Dietician will observe all residents for safe handling of hot liquids upon admission and quarterly thereafter. Criteria for the Registered Dietician to consider include: Tremors, weakness .The Occupational Therapist (OT) will be responsible for determining if the resident continues to require a supervised dining setting due to hot liquid risk and if any additional interventions should be used to minimize risk of burns. Dietary will provide cups with sipping lids for all hot liquids during meal times .Activities will provide cups with sipping lids for all hot liquids served . Review of the State of (State Name) Department of Community Health Alert, titled, Scalding Injuries Caused by Excessive Hot Water: Food and Hot Beverage Temperatures, Revised August 5, 2008, revealed, Background: In all age groups, tap water scald injuries have been cited as the second most cause of serious burns. A scald is a burn caused by spills, immersion, splash, or contact with hot water, food and beverages, or steam. The elderly are particularly at increased risk because their skin tends to be less sensitive and reaction times are reduced, causing a tendency to not pull away from hot water quickly enough to avoid scalding. Their thinner skin also burns full depth (through the skin layers and into tissue) more quickly .Although Federal and State agencies do not specify temperatures appropriate to the consumption of hot beverages, facilities should be aware of the risk for harm to a resident from contact or consumption of hot beverages.Scalds can commonly occur from hot food, beverages, or steam . The estimated time for a person to receive second-degree burns was noted as follows: 120 degrees. Time to receive second-degree burn: 8 minutes. 124 degrees. Time to receive second-degree burn: 2 minutes. 131 degrees. Time to receive second-degree burn: 17 seconds 140 degrees. Time to receive second-degree burn: 3 seconds. 150 degrees. Time to receive second-degree burn: Less than one second. The Immediate Jeopardy that began on 10/23/24 was removed on 11/21/24, when the facility took the following actions to remove the immediacy: 1. Resident #132 remains a resident of the facility and as of 11/21/24 is being served their hot liquids in a stable thermal cup with a handle and is being offered assistance with hot liquids. 2. Like residents are residents that reside in the facility and receive hot liquids. On 11/21/24 at 12:15 p.m., like residents have been audited to ensure their liquids are being served in a stable, handled, thermal cup and staff are offering and/or providing assistance with set-up as needed. 3. Dietary staff have been re-educated on 11/21/24 to ensure hot liquids are being served in a stable, handled, thermal cup. Dietary staff has also been re-educated on ensuring hot liquids are being serviced at a temperature less than 160 degrees Fahrenheit. Any staff member who is currently not working will be reeducated prior to the start of their next shift of duty. 4. LPN/RN/CENA has been re-educated on 11/21/24 to ensure when meals are served resident with hot liquids are in a stable, handled, thermal cup and they are offering and/or providing assistance when serving hot liquids as needed. Any staff member who is currently not working will be reeducated prior to the start of their next shift of duty. 5. An Ad Hoc QA Committee meeting was held on 11/21/24 with the Medical Director and IDT (Interdisciplinary Team) to discuss the deficient practice and plan to ensure compliance. The NHA/Designee will conduct audits to ensure that hot liquids are served in a stable, handled, thermal cup. The NHA/Designee will audit to hot liquid temperature logs to ensure temperatures are less than 160 degrees Fahrenheit prior to leaving the kitchen. Audits will be completed weekly x 4 weeks and monthly x 2 months. Results of the audits will be taken to the QA committee for review and recommendation. Any areas of non-compliance will be addressed immediately. The Administrator is responsible for maintaining compliance. 6. The Administrator is responsible for sustained compliance.