**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure care-planned interventions for safety with hot beverages were consistently implemented to reduce the risk of accident and injury for 1 of 1 residents (R1) reviewed who required lids on their hot beverages. This resulted in actual harm for R1 who was served a cup of hot tea without a lid and spilled it onto herself causing multiple second-degree burns. However, the facility had taken multiple corrective action(s) prior to the onsite survey so these findings are issued at past non-compliance. Findings include: A United States (US) National Library of Medicine Burn Classification article, dated 9/2023, identified burns happen with the skin is exposed to heat sources such as flames or hot objects. The article listed definitions and/or types of burns which included a first-degree burn as, . involves the epidermis only. These burns can be pink-to-red, without blistering, are dry and can be moderately painful. The article then listed a section labeled, Partial-Thickness Burns, and recorded them as, A second-degree burn . affects the superficial layer of the dermis. Blisters are common and may still be intact when first evaluated . These burns are painful. Healing typically occurs within 2 to 3 weeks with minimal scarring. A submitted facility-reported incident (FRI), dated 7/22/25, identified an allegation of potential neglect was submitted for R1 by the care center staff. The report outlined R1 was brought into the dining room and was served hot tea in a mug without a lid despite R1 being care-planned to use mugs with a lid for hot beverages. R1 spilled the tea onto herself. R1 was immediately assessed and the provider contacted for treatment orders. The report outlined, The water in the carafe [pitcher] was obtained from the coffee machine which is set at a temp of 170 [F] . Hot beverage policy was followed at the time of the incident. R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment and had no other skin impairments (i.e., burns) present at the time of the review. On 8/8/25 at 9:05 a.m., R1 was observed seated in a high-back wheelchair while in the dining room. R1 was seated at a table with other residents and had a regular plate in front of her on the table which had stacked debris present (i.e., napkins, utensils). R1 had a visible dark-colored, hard plastic coffee cup next to her plate which was turned upside down and underneath of the cup was a white-colored lid. R1 was not served any hot beverages at that time. A white-colored menu slip was placed on the table next to R1's items which outlined R1's name, the date (8/8), and that R1 consumed a regular diet with thin liquids. The slip included a section labeled, Spec [special] Direct [directions], which outlined, HOT BEVERAGES IN MUGS WITH LIDS, ADD ICE TO HOT BEVERAGES IT [sic] REFUSING LIDS, NO STRAWS. Dietary aide (DA)-A was present in the dining room and picked up R1's used cutlery and menu slip from the table. R1 was interviewed and expressed she thought she had eaten pancakes for the breakfast meal but then added aloud, My memory's not that good. R1 stated she didn't have any coffee or tea then added, I got burnt a week ago. R1 recalled the incident and explained a woman was sitting across the table from her whom had spilled her cup which then poured onto her clothes causing a burn. R1 stated, It burnt so bad right into the skin! R1 stated it was painful adding, Oh God yes. R1 was unsure if the person who spilled it was a staff member or another resident responding with, Just a lady in a hurry I guess with her cup. Following this, at 9:12 a.m., DA-A was interviewed and explained the DA staff members are typically the people to make and serve the beverages within the dining room. DA-A stated R1 needed a lid on her coffee cups for hot beverages which was placed at the table for any staff to see and use. DA-A stated R1 had been required to use the lids for a while but was unsure exactly how long adding, Honestly, I don't know. DA-A stated any staff who serve R1 food or beverages should be reading the white-colored menu slip prior to setting the items on the table for her. R1's nutritional care plan, revised 7/28/25, identified R1 had a potential risk for nutritional problems due to requiring additional fluid/nutrition supplement. The care plan outlined R1 was able to eat independently at meals with tray set up and added, . hot beverages in mugs with lids or add ice in hot beverages if she refuses to have a lid. The care plan listed an intervention reading, Assist me with tray set up at meals and provide me with hot beverages in mugs with lids, which had a last revision date listed, 04/09/2025. The care plan listed another intervention which read, Add ice to hot beverages if refusing lids, with a date initiated, 07/28/25.On 8/8/25 at 9:43 a.m., R1's family member (FM)-A was interviewed and verified they were R1's emergency contact. FM-A explained they were aware of R1 having sustained a burn and expressed it had been explained to them that someone got bumped in the dining room which is what caused the hot beverage to spill onto R1. FM-A reiterated they were told the tea was going to someone else and had mistakenly got spilled onto R1. FM-A stated R1 did report having pain from the burns at the time, however, it had been improving more recently. FM-A stated they recalled hearing R1 say, They burned me. R1's progress note, dated 7/22/25, identified R1 had spilled hot tea on her lap. The note outlined, Cool wash clothes [sic] were applied right away to her right upper thigh, right lower abd [abdomen] and towards the back that were red and warm to the touch. The note outlined R1 repeatedly tried to remove the cloths. R1 was recorded as complaining of it hurting and the areas were hot. A subsequent note, dated 7/22/25, identified the medical provider ordered skin prep daily for five days with dictation, . was updated regarding the blisters forming on those areas. R1's corresponding Resident Occurrence Report, dated 7/22/25, identified two (2) burns were obtained including on her right upper thigh, and right lower abdomen towards her back. The report listed an analysis of the occurrence as R1 spilling hot tea on herself and directed to continue using lids with hot beverages along with immediately medical treatment orders. R1's Prescriber Order, dated 7/23/25, identified a telephone order from the medical provider was obtained. The order directed, Apply ABD pads [dressing] to right upper thigh and RLQ [right lower quadrant] blister areas one time a day . do not put tape on burn areas. Burns. R1's progress note, dated 7/24/25, identified a plan of care note which outlined, . wounds are blisters that are not weeping and light pink edging around that area . includes upper right thigh, RLQ [right lower quadrant], and abdomen area towards back area.R1's progress note, dated 7/26/25, identified an eMAR note which outlined, . blister on right thigh continues to be fluid filled with yellow colored fluid. Blister on RLQ is red in color and no fluid is noted in blister. A subsequent note, dated 7/29/25, identified all blisters had reabsorbed but R1's skin remained discolored in the affected areas adding, Still continues to have some areas that are slightly red.R1's progress note, dated 8/1/25, identified another plan of care note entry which outlined, Resident has 4 areas that vary in size, but all are under 5cm [centimeters] long that continue to be red. The areas that are red are the areas that had the blisters that have been reabsorbed. On 8/8/25 at 9:55 a.m., DA-A was interviewed, and explained they were aware of R1 getting burned. DA-A stated what they had heard about it was there was a relatively young DA working in R1's unit that day who had served her (R1) a hot beverage without a lid on it. R1 then spilled it onto herself and obtained the burns adding, I heard the burn was pretty bad. DA-A stated the DA who had served R1 must not have read the ticket which directed to use a lid. DA-A stated staff are trained and told to read those tickets or their I-pad (which had instructions on it) before serving meal or beverage items to the residents and reiterated aloud, You have to look at the ticket. DA-A explained that since the incident happened, they had been given repeated instructions to review the ticket with meal pass and that the kitchen was now sending up a highlighted form which had people who used adaptive equipment on it for another source of reference. Further, DA-A stated the staff involved with the incident directly was DA-B. Following, on 8/8/25 at 10:01 a.m., R1 was seated in her wheelchair in her room. R1 was asked about her burns and if there was still pain when R1 responded, You wanna see them? R1 then pulled down her waistband exposing two separate burn sites on her abdomen and upper leg, respectively. The areas were each dark pink in color around the perimeter getting more red in color towards the center of the wound; and each was approximately 8 to 10 centimeters (cm) in total length with a visible, white-colored center of the wound bed. R1 reiterated the burns were very painful when they happened but were improving now adding, It's getting better I think. When interviewed on 8/8/25 at 10:13 a.m., nursing assistant (NA)-A stated they had worked with R1 prior and described her as needing help with most cares. NA-A stated they were working on the day R1 spilled the tea onto herself, however, did not witness it personally. NA-A stated the burns took like a half a day to turn into what it turned into with blisters and skin damage. NA-A stated they say R1's skin shortly after the incident and the areas looked really hot and R1 kept saying aloud, It's hot, it's hot. NA-A verified R1 was supposed to have covered cups with all hot beverages which had been an intervention for sure six months. Further, NA-A stated since the incident happened, they had been told again to make sure lids were used for hot beverages and to check a resident' meal ticket when serving them. On 8/8/25 at 10:48 a.m., DA-B was interviewed, and verified they were the DA involved with the incident on 7/22/25. DA-B explained the DA staff were typically the people who served the beverages and meals to residents within the dining room adding they work all over kinda on multiple units. DA-B recalled the incident on 7/22/25, and explained they were in the dining room and R1 was seated in her wheelchair at the table. R1 had complained about not feeling well and DA-B offered to get her some tea. DA-B stated she prepared and served R1 hot tea without looking at the I-pad. DA-B stated then about a minute later she heard R1 scream and discovered she had spilled it onto herself. DA-B verified they had been trained to review the I-pad or menu ticket prior to serving, however, expressed they didn't that day as they were working on doing other orders when they offered R1 the hot tea. DA-B stated they figured they'd give the tea to R1 right quick and go back to the other orders. DA-B verified they physically poured and served R1 the hot tea directly with no other residents or staff members being involved. DA-B stated since the incident happened, the assistant culinary director (ACD) had spoken to them and verbally re-educated them on meal service procedures including to review the meal ticket or I-pad with service along with ongoing reminders to other staff. DA-B stated a new listing had been sent up just recently, too, for staff to have available and be able to reference any special equipment needed for residents. DA-B added, I feel horrible [about this].On 8/8/25 at 11:18 a.m., the ACD and director of nursing (DON) were interviewed, and the DON verified the intervention to use a lid with hot beverages was on the care plan and expected to be done on 7/22/25. ACD recalled the incident on 7/22/25, and explained they were in the kitchen working when they were notified someone had a burn and needed to be reviewed. ACD went to R1's unit and spoke with DA-B about it who reported they didn't put a cover on the mug when serving her hot tea. ACD stated they immediately re-educated DA-B on using the e-menu [I-pad] and did a demonstration for them. ACD verified staff should be reviewing the e-menu before serving beverages to a resident adding aloud, Correct. DON stated DA-B was then sent home for the rest of the day while the facility investigated the situation adding DA-B had completed a formal education on meal service before they had been allowed to return to work. DON explained the initial burns presented as red areas which then turned into a blister, and verified they were unaware of anything else which could have burned R1 that day. DON stated the nurses immediately assessed the area and obtained treatment orders from the medical provider for the two burns. DON stated they were unsure if having a lid on the mug that day would have prevented the burns adding, I can't answer that. However, DON acknowledged a lid being attached to the mug would have, at minimum, slowed or reduced the amount of fluid pouring out of the mug onto R1's clothes or skin. DON verified R1 was physically able to manipulate utensils and coffee cups on her own. DON stated they checked the temperature of the water inside the coffee carafe shortly after the incident and it was at 170 [F] then which was allowable per the manufacturer's guidelines.DON then explained that since the incident, several steps had been taken to correct the issue including immediate re-education to DA-B and the other culinary staff members, reviewing other residents for adaptive equipment use, having dietary now pre-setting the table with items needed, and continuing to do quality assurance audits of the dining service. DON stated they felt the care center had adequate systems in place to prevent accidents like what happened, however, with R1's incident it had been one staff member that for some reason that day chose to not do as she had been taught. DON reiterated the facility had a system for serving hot beverages safely adding, There's no way we could have foreseen [DA-B] would do that. A provided Hot Beverage Policy, dated 4/2021, identified the purpose of ensuring hot beverages were provided that were palatable but safe temperature. The policy outlined a procedure which directed to have all beverage machines set according to manufacturer recommended temperature settings, serving the machines as directed by the guidelines, and reporting concerns with resident safety to the interdisciplinary team (IDT) for review or care plan revisions. The past non-compliance harm-level findings were corrected prior to the onsite survey. The steps taken and re-education articulated by the DON were all verified as being implemented during the onsite investigation through observation, interviews with staff members, and review of the corresponding documentation. In addition, no further burns from hot beverages had happened since 7/22/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide safe transfers for 1 of 3 residents (R1) who required gait belts (transfer belt) for transfer and ambulation assistance. This resulted in actual harm when R1 was being ambulated without a gaitbelt, fell, and sustained a fracture of the shoulder. The facility implemented corrective action prior to the investigation, so the deficiency was issued at Past Noncompliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of heart failure, acute respiratory failure, and muscle weakness. The MDS indicated she required partial to moderate assistance with transfers and ambulation, and she had a history of falls in the prior 2-6 months to her admission. R1's care plan dated 4/15/25, directed assist of one staff and walker for transfers. R1's care sheet (nursing assistant care guide) directed use of a hemi walker (walker designed for individuals who require support with one arm) in/out of recliner and assist of 1 from wheelchair for toilet transfers. On 6/5/25 at 9:45 p.m., a progress note indicated R1 had a fall while ambulating to the bathroom with her walker and staff assistance. R1 had increased pain in her left arm/shoulder area at the time of the fall. On 6/7/25 an x-ray report indicated R1 had a nondisplaced fracture of the neck of the acromion (shoulder). On 6/24/25, at 11:08 a.m., nursing assistant (NA)-A stated she always used a gait belt to transfer R1. On 6/24/25, at 11:11 a.m., NA-B stated she always used a gait belt to transfer R1. Further, she stated she consistently observed other staff using a gait belt for R1's transfers. On 6/24/25 at 11:35 a.m., R1 stated she did not have a gait belt on when she fell on 6/5/25. The staff use the gait belt about 90% of the time when they assisted her with transfers. During an observation on 6/24/25, at 11:55 a.m., R2 was observed receiving ambulate assistance by a nurse aide with a gait belt. On 6/24/25, at 12:05 p.m., NA-C stated a gait belt was always indicated for all assistance of one staff (A1) transfers. During an observation, on 6/24/25, at 12:35 p.m., R3 was observed receiving assistance of A1 ambulating with his four-wheeled walker and a gait belt. On 6/24/25 at 1:30 p.m., NA-D stated she was assisting R1 to the bathroom on 6/5/25 when R1 fell. R1 had her walker, but did not have a gait belt on at the time of the fall. She had not been instructed to use a gait belt for transfers that required one assist. Following R1's fall on 6/5/25 she had been reeducated on the facility ambulation and transfers policy. On 6/24/25 at 1:55 p.m., registered nurse (RN)-A stated the care sheets were populated by the care plans. The care plans did not include direction to use a gait belt for transfers and ambulation, gait belts were expected to be utilized at all times for residents who required assist of 1 for transfers and ambulation. It was the facility's policy to use a gait belt for all transfers that required one assist. On 6/24/25 at 2:33 p.m., the administrator stated using gait belts for resident transfers and ambulation was not included in residents' care plans as it was the facility policy and a standard of care. NA-D was hired 4/18/25. Document review of NA-D's Skills Competency, signed by NA-D on 4/29/25, indicated she demonstrated competency assisting a resident to transfer and ambulate. NA-D's Role Orientation Checklist, dated 5/2/25, indicated she had received education on the use of a gait belt. The facility policy Gait Belts for Transfers and Ambulation dated 12/14, directed gait belts are not used as a restraint, and will be used for all transfers of weight bearing residents who require assistance with transfers and/or ambulation. The Past Noncompliance began on 6/5/25. The deficient practice was corrected by 6/6/25, after the facility implemented a systemic plan that included the following actions: immediate education on facility policy for all NA's and nurses requiring the use of a gait belt for all transfers and ambulation that required assist of one. Interviews with staff, on 6/24/25, confirmed understanding of facility policy requiring the use of gait belts with all assisted transfers. Observation of transfers, on 6/24/25, demonstrated compliance with use utilize gait belts for residents' transfers and ambulation.