Based on observation, interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions to prevent burns and for the use of tobacco for one (1) of seven (7) sampled residents. (Resident #1) The facility's failure to develop comprehensive care plan interventions resulted in Resident #1, who had diagnoses including Diabetes Mellitus (DM, Hemiplegia - left side, Vascular Dementia, and moderately impaired cognition sustaining a third-degree burn to his left thigh and placed other residents who drink hot coffee at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/11/24 when Resident #1 sustained a third-degree burn to his left thigh. The facility Administrator was notified of the IJ on 8/2/24 at 11:15 AM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 8/2/243, in which they alleged all corrective actions to remove the IJ were completed on 8/2/24, and the IJ removed on 8/3/24. The SA validated the Removal Plan on 8/5/24 and determined that the IJ was removed on 8/3/24, prior to exit. Therefore, the scope and severity for CFR 483.21(b) Comprehensive Care Plans was lowered to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility's policy Comprehensive Care Plans with revised date of 08/24/22 revealed . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . A review of the medical record for Resident #1 revealed there were no care plan interventions developed for preventing burns from hot coffee or for the use of chewing tobacco. A record review of the Order Summary Report with an Order Date Range: 04/01/24 - 04/30/24 revealed Resident #1 had a Physician's Order, dated 4/11/24 to Clean blister to left inner thigh with NS (normal saline) gently, pat dry, apply Silvadene cover with dry dressing and paper tape QD (every day) and PRN (as needed) dislodgement until resolved. On 04/24/24, the Physician's Order was changed to Clean blister to left inner thigh with NS, apply xeroform, dry dressing. Change daily and PRN dislodgement until resolved. At 9:25 AM on 08/01/2024, during an interview with the Administrator, he explained Resident #1 was admitted to the facility two (2) years ago. Because the facility's census was very low at the time, he agreed to give special permission for the resident to chew tobacco at the facility even though the facility's policy did not allow it. He stated the resident has now been allowed to continue to use chewing tobacco while at the facility. During an interview on 08/01/2024 at 9:55 AM, Resident #1's family member explained that her father was burned on his left side when staff on the night shift took Resident #1 into the dining room, gave him a cup of coffee, left him unsupervised, and he spilled the coffee on himself. The family member also stated that Resident #1 had been at the facility for two (2) years and was cleared on admission by the Administrator and the doctor to use chewing tobacco while at the facility. However, it was taken away for him on 7/4/24 but was returned to him on 7/11/24. During an observation at 12:50 PM on 08/01/24, Resident #1 was sitting up in his wheelchair with his bedside table in front of him in which there were three (3) cups with tobacco in them. At 2:30 PM on 08/01/24, during an interview with Licensed Practical Nurse (LPN)#2/Care Plan/Minimum Data Set (MDS) Nurse, she stated she was responsible for updating resident care plans daily. She confirmed Resident #1 received a third degree burn after spilling coffee on himself and the facility never developed care plan interventions to prevent the re-occurrence of a burn from hot coffee. She stated the facility had developed interventions related to treating the burn. LPN #1 also confirmed she was aware Resident #1 used tobacco and the facility had never developed a care plan with interventions for the staff to follow on his tobacco use. She reported the purpose of a care plan was to provide instructions on how to care for the residents and if there was no care plan, then the staff would not be able to care for the residents as needed. During an interview at 3:00 PM on 08/01/24, the Director of Nursing (DON), reported she was working on 04/11/24 when Resident #1 spilled coffee on himself and had a burn to his left thigh. The DON stated it was a horrible accident and confirmed there were no interventions put in place to prevent the incident from occurring again. She was not aware Resident #1 did not have a care plan for chewing tobacco but expected the care plan nurse to develop care plans as required. At 3:30 PM on 08/01/24, during an interview with the Administrator, he explained he had been made aware Resident #1 had no care plan related to the use of chewing tobacco and confirmed there were no interventions put in place to prevent further incidents with spilling coffee after Resident #1 received a third-degree burn. He stated he expected the staff to develop care plans and for care plans interventions to be implemented to meet each individual resident's needs. A record review of Resident #1's admission Record revealed the facility admitted Resident #1 on 09/15/22 with current diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Vascular Dementia A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/25/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 11, which indicated his cognition was moderately impaired. A review of Section M revealed resident had a burn (second or third degree). The facility submitted the following acceptable Removal Plan on 08/02/24: On 8-2-2024 at 11:15 P.M. the State Survey Agency notified the administrator that the facility failed to ensure adequate supervision when Resident 1, who had diagnoses including Diabetes Mellitus (DM), Hemiplegia (left side), Vascular Dementia, and moderately impaired cognition, spilled hot coffee onto his left thigh, which resulted in a third-degree burn. On 4/11/2024 at lunch, after 11:15 a.m., it was reported to the resident care coordinator (RCC) nurse that Resident 1 had spilled coffee on himself and upon assessment it was noted that there was an intact blister to the left medial thigh. The site was cleaned with normal saline and Silvadene and dry dressing applied. The resident care coordinator notified the provider and order to continue the same treatment were received and to be completed daily. The resident did not complain of any pain at the time. The nurse attempted to notify the resident representative unsuccessfully initially. However, the resident representative did call back and was notified about the burn and the treatments and was updated weekly. After the blister ruptured, the wound care nurse practitioner classified the wound as a third degree burn with new treatment orders. The resident representative was notified and updated. Treatment and care to the burn was ongoing and have since been discontinued as the site has healed. 1. In an effort to immediately protect the residents, the coffee machine was taken out of service on 8-2-2024 so that individuals cannot serve themselves coffee. Individual pots of coffee will be made beginning today, 8-2-2024 and temperatures of the pots will be monitored to ensure that the coffee served is at or below 140 degrees Fahrenheit. Resident #1 will be served coffee at or below 140 degrees Fahrenheit. 2. The root cause of the accident was the hot liquid policy was not followed. This along with the lack of proper supervision resulted in the injury. 3. On 8-2-2024, Coffee Temperature logs were created to indicate the temperature of the beverage prior to serving. This will serve as record of temperatures of coffee being served. 4. Training for all staff prior to working shifts was initiated on 8/2/2024 by the staff development nurse and the Director of Nursing on the following topics: Safety and supervision of residents · Care Plans · Temperature logs for coffee · hot liquids policy No staff will be allowed to work until they have received appropriate training. 5. Updated the care plans for resident # 1 and identified thirty-three residents that were at risk to include interventions to prevent burns. 6. Weekly body audits were completed for all residents on 8-2-2024 and there were no burns noted. 7. Quality Assurance and Performance Improvement committee meeting was conducted on August 2, 2024, at 12:21 p.m. and the issue was discussed including root cause and appropriate remedies. Attending the meeting: Medical Director, Administrator, Director of Nursing, Resident Care Coordinator/ Infection Preventionist, Dietary Manager, Social Worker, Business Office Manager, Staff Development Nurse, Minimum Data Set Nurse, Medical Records Clerk, Environmental Services Manager, Maintenance Director and the staff scheduler. The facility alleges all corrective actions were completed on 8-2-2024 at 2:00 p.m. and the IJ was removed on 8-3-2024. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #25877 through record review and interviews on 8/5/24. The SA determined all corrective actions were completed on 8/2/24 and the IJ was removed on 8/3/24.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure adequate supervision to prevent a burn from hot coffee for one (1) of seven (7) sampled residents, with the potential to affect all residents who drink coffee in the Dining Room. Resident #1 The facility's failure to ensure adequate supervision resulted in Resident #1, who had diagnoses including Diabetes Mellitus (DM, Hemiplegia (left side), Vascular Dementia, and moderately impaired cognition sustaining a third-degree burn to his left thigh and placed other residents who drink hot coffee at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/11/24 when Resident #1 sustained a third-degree burn to his left thigh. The facility Administrator was notified of the IJ on 8/2/24 at 11:15 AM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 8/2/243, in which they alleged all corrective actions to remove the IJ were completed on 8/2/24, and the IJ removed on 8/3/24. The SA validated the Removal Plan on 8/5/24 and determined that the IJ was removed on 8/3/24, prior to exit. Therefore, the scope and severity for CFR 483.25(d)(2) Accidents was lowered to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Safety of Hot Liquids, dated 7/25/22, revealed Policy Statement Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions .Policy Interpretation and Implementation: 1. The potential for burns from hot liquids is an ongoing concern for elderly and compromised residents . 3. Appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include a. maintaining a hot liquids serving temperature of no more than 140 degrees Fahrenheit b. serving hot beverages in a cup with a lid; c. wide-based cups; d. limit Styrofoam cups to residents with no difficulties; e. encouraging residents to sit at a table while drinking or eating hot liquids; f. providing staff supervision or assistance with hot beverages. 4. General safety precautions when serving hot liquids include .d. Regulate temperature of hot liquids to which residents have direct access; e. Place filled containers directly on the table. Do not hand them directly to resident .5. Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. A record review of the facility's policy, Safety and Supervision of Residents, revised 8/2/22, revealed Our facility strives to make the environment as free from accident hazards as possible, with resident safety, supervision, and assistance to prevent accidents being facility-wide priorities . On 08/01/2024 at 09:55 AM, during an interview, Resident #1's family member explained that her father was burned on his left side when staff on the night shift took Resident #1 into the dining room, gave him a cup of coffee, left him unsupervised, and he spilled the coffee on himself. At 10:55 AM on 08/01/24, during an observation of the dining room, residents were observed with coffee cups at their tables. Resident #1 was sitting in the dining room at a table with an empty coffee cup, and there was no lid on the coffee cup or on the table. At 11:30 AM on 08/01/24, during a dining room observation, some residents had coffee cups with lids, and some did not. An industrial-style coffee machine was on a countertop with cups and lids noted nearby. Resident #1 was sitting in his wheelchair eating lunch, and there was an empty coffee cup without a lid noted nearby. At 11:40 AM on 08/01/24, during an observation and interview with Resident #4, he explained he had always been able to get coffee anytime from the machine in the dining room whenever he wanted it. He said that he normally got up around 2:00 AM, came to the dining room, and served himself coffee. He mentioned he liked to use a lid on his coffee cup and reported that he had not spilled coffee on himself or received a burn from hot coffee. On 08/01/24 at 12:00 PM, during an interview with Housekeeper #1, she explained that residents came to the dining room early in the mornings, and some of them got coffee themselves while others needed staff assistance. She was working in the dining room on 04/11/24 when Resident #1 spilled his coffee on himself but was unable to recall what time it occurred. She thought someone from the night shift brought Resident #1 to the dining room, and someone gave him a cup of coffee. Housekeeper #1 said Resident #1 did not like having a lid on his coffee cup. He reported to her that he had spilled the coffee on his pants and needed to be changed. She took the resident to his room and told a Certified Nurse Aide (CNA) that he needed to have his pants changed. She was unable to recall which CNA assisted him, but the CNA changed his clothes and brought him back to the dining room. At 12:50 PM on 08/01/24, during an observation and an interview with Resident #1, he was sitting in his wheelchair with a bedside table in front of him. He explained he did not like to have a lid on his coffee cup because not having a lid helped to cool the coffee. He stated that when he spilled coffee on himself on 4/11/24, it was an accident. He was unable to recall who had served him the coffee that day and commented that he liked to drink about three (3) cups of coffee a day. At 3:00 PM on 08/01/24, during an interview with the Director of Nursing (DON), she reported she was working on 04/11/24 when Resident #1 spilled coffee on himself and had a burn to his left thigh. She said the incident was discussed that morning in the daily Stand-Up meeting. She expressed that she was unaware of the incident until the morning meeting. She confirmed Resident #1 had hemiplegia affecting his left side, causing decreased or no sensation to his left leg. She confirmed that residents in the facility got coffee for other residents, as well as themselves, from the coffee machine in the dining room. She explained that she assessed Resident #1 and the area where he had spilled the coffee, around 11:00 AM when the day shift CNA reported he had a raised blister to his left inner thigh. The DON measured the blister, notified the facility's Nurse Practitioner and received orders for a treatment. She completed the incident report for the incident/burn, and during the investigation, it was determined Resident #1 had told the Housekeeper Supervisor he had spilled his coffee and wanted his pants changed. The DON stated it was a horrible accident and confirmed there were no interventions put in place to prevent the incident from occurring again. At 03:30 PM on 08/01/24, during an interview with the Administrator, he confirmed there were no interventions put in place to prevent further incidents with spilling coffee after Resident #1 received a third-degree burn. The temperature of the coffee had never been checked and the coffee machine had been in the dining room at the facility for a long time. At 06:45 AM on 08/02/2024, during an observation of residents in the dining room waiting for breakfast, there were no staff present in the dining room and there were no kitchen staff at the serving line. Resident#1 had an empty coffee cup at the table, without a lid. Residents were drinking coffee, and some had lids and some did not. Resident #6 went to the coffee machine while sitting in a wheelchair and got a coffee cup and served herself coffee. Resident #6 did not get a lid for her coffee cup. At 06:55 AM on 08/02/2024, during an interview and observation with Dietary #1, she explained the residents can come into the dining room and get coffee at any time and they serve themselves, even though there were some residents who should not serve themselves. Dietary #1 and the SA poured a cup of coffee from the coffee machine, walked it over to Resident #1's table, and checked the temperature using a digital thermometer. The coffee was 167 degrees Fahrenheit (F) and Dietary #1 reported she was unaware the coffee was that hot. She explained the kitchen staff did not check and record the coffee temperatures. At 07:20 AM on 08/02/2024, during an observation and interview, Resident #7 was standing up in front of the coffee machine and got herself a cup of coffee. She explained the coffee was always hot and she tried to be careful not to spill it. At 07:25 AM on 08/02/2024, during an observation and interview, the DON was checking the temperature of the coffee in the dining room. She explained she got a reading of 157 degrees F. The SA obtained another cup of coffee, walked over to Resident #1's table, and the DON obtained the temperature of the coffee which indicated it was 167 degrees F. Dietary #1 confirmed the temperature of the coffee was also 167 degrees F when it was checked earlier with the SA. At 09:45 AM on 08/02/2024, during an interview with the Administrator, he confirmed the coffee temperature had never been checked before or after Resident #1 received a burn from spilling hot coffee on himself. At 11:30 AM on 08/02/24, during a phone interview with the Wound Care Nurse Practitioner, she explained she made aware that Resident #1 received a burn, and she assessed it and classified the burn as a third-degree burn. She stated the area had slough and necrotic tissue (unviable and dead tissue) in the beginning and the treatments were changed a few times, but the area healed. At 12:55 PM on 08/02/2024, during an interview with Dietary #1, she explained the coffee machine was never turned off or put up, it ran continuously, and residents had access to it at any time they wanted it day or night. A record review of Resident #1's admission Record revealed the facility admitted Resident #1 on 09/15/22 with current diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Vascular Dementia A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/25/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 11, which indicated his cognition was moderately impaired. A review of Section M revealed resident had a burn (second or third degree). A record review of the Order Summary Report with an Order Date Range: 04/01/24 - 04/30/24 revealed Resident #1 had a Physician's Order, dated 4/11/24 to Clean blister to left inner thigh with NS (normal saline) gently, pat dry, apply Silvadene cover with dry dressing and paper tape QD (every day) and PRN (as needed) dislodgement until resolved. On 04/24/24, the Physician's Order was changed to Clean blister to left inner thigh with NS, apply xeroform, dry dressing. Change daily and PRN dislodgement until resolved. A record review of the facility's investigation report Self Inflicted Injury dated 04/11/24 revealed . Incident location: Dining room . Incident Description: It was reported in standup this morning that resd(resident) had spilled his coffee in his lap this morning before breakfast. The housekeeper took him to his room to be changed but he was upset because he wanted the housekeeper to change him that she could not change him. Resident Description: Resd stated that he just spilled his coffee . Immediate Action Taken .RESD was taken to his room to have his clothes changed .Other info Unable to determine predisposing environmental, physiological factors or situation at the time of the incident . No witnesses found . A record review of Resident #1's Progress Note with effective date 04/11/24 at 12:49 PM, revealed self-inflicted injury 04/11/24 10:40 AM, . It was reported in standup this morning that resd had spilled his coffee in his lap this morning before breakfast. The housekeeper took him to his room to be changed but he was upset because he wanted the housekeeper to change him, and she was informing him that she could not change him. Around lunch, the CNA notified writer that resd had a blister noted. Upon Assessment, a blister measuring 4.1 cm (centimeters) x 6.0 cm was noted to left inner thigh. Silvadene and dry dressing was applied . nurse practitioner was notified, and she stated to continue with same treatment daily. Attempted to notify RP (responsible party) but no answer. Resd without any pain noted and tolerated well. A record review of Resident #1's Progress Note dated 05/08/24 12:15 PM revealed . Resd was seen by NP (nurse practitioner) with wound management specialists today . Burn blister to left thigh has ruptured and is classified as a 3rd degree burn. New order to clean with NS, apply Medi-honey and Aquacel ag and dry dressing daily. RP notified . A record review of Resident #1's Progress Note dated 06/06/24 10:48 AM revealed . Resd was seen by NP with wound management specialists on 06/05/24. New order for burn to left inner thigh received. Updated orders and notified RP . A record review of Resident #1's Progress Note dated 07/03/24 11:52 AM revealed . Resd was seen by NP with wound management specialists today. No change to orders were made but writer did update treatment orders. Wound assessment completed as well. RP notified . A record review of Resident #1's Progress Note Details from Wound Care NP with notes from 01/03/24 through 05/08/24 revealed . 04/24/24 . report of spilling coffee on himself last week. Now has a large third degree burn to left upper thigh, denies pain. Full thickness tissue loss, slough covering wound bed. Plan to start covering with xeroform daily . 05/01/24 . Burn to left thigh remains covered with some adherent slough. Provided gentle debridement . 05/08/24 . Burn also slowly improving with some pink granulation tissue along edges, continues to have a large area of adherent slough. Plan to start applying Medi-honey daily . A record review of Resident #1's Progress Note Details from Wound Care NP with notes from 05/08/24 through 06/26/24 revealed . 05/15/24 . Burn to left thigh with similar dimensions, however increased about of pink tissue noted along edges, adherent slough remains in middle. Continue Medi-honey daily . 05/22/24 . Burn to left thigh continues to have a large amount of slough to middle of wound bed, pink granulation tissue surrounding. Peri wound moist and macerated. No s/s (signs and symptoms) of infection. Tolerated gentle debridement, was able to remove most of the slough. Plan to start applying collagen plus super absorber dressing daily . 05/31/24. Burn with slightly smaller dimensions. Continue collagen plus aquacel ag . 06/05/24 . No change to burn left thigh-pink wound bed, scant slough, less drainage, no s/s of infection. Resume covering with Xeroform . 06/12/24 . Burn to left thigh with similar dimensions. Pink wound bed, moderate amount of yellow drainage. Peri-wound intact, no erythema. Plan to start covering with Dakins moist dressings daily . 06/19/24 . Burn to left thigh improved this week with smaller dimensions, less drainage. Plan to continue covering with Dakins moist dressing daily . 06/26/24 . Burn to left thigh unchanged, peri-wound macerated. Plan to start covering with Gentamicin plus Aquacel Ag . A record review of Resident #1's Procedure/Progress Note-Outreach Component for wounds completed by the wound nurse practitioner revealed measurements of the burn third degree burn to the left thigh for Resident #1 measured 4.5 centimeters (cm) x (by) 5.8 cm x 0.2 cm on 04/24/24 and the area was healed on 07/10/24. The facility submitted the following acceptable Removal Plan on 08/02/24: On 8-2-2024 at 11:15 P.M. the State Survey Agency notified the administrator that the facility failed to ensure adequate supervision when Resident 1, who had diagnoses including Diabetes Mellitus (DM), Hemiplegia (left side), Vascular Dementia, and moderately impaired cognition, spilled hot coffee onto his left thigh, which resulted in a third degree burn. On 4/11/2024 at lunch, after 11:15 a.m., it was reported to the resident care coordinator (RCC) nurse that Resident 1 had spilled coffee on himself and upon assessment it was noted that there was an intact blister to the left medial thigh. The site was cleaned with normal saline and Silvadene and dry dressing applied. The resident care coordinator notified the provider and order to continue the same treatment were received and to be completed daily. The resident did not complain of any pain at the time. The nurse attempted to notify the resident representative unsuccessfully initially. However, the resident representative did call back and was notified about the burn and the treatments and was updated weekly. After the blister ruptured, the wound care nurse practitioner classified the wound as a third degree burn with new treatment orders. The resident representative was notified and updated. Treatment and care to the burn was ongoing and have since been discontinued as the site has healed. 1. In an effort to immediately protect the residents, the coffee machine was taken out of service on 8-2-2024 so that individuals cannot serve themselves coffee. Individual pots of coffee will be made beginning today, 8-2-2024 and temperatures of the pots will be monitored to ensure that the coffee served is at or below 140 degrees Fahrenheit. Resident #1 will be served coffee at or below 140 degrees Fahrenheit. 2. The root cause of the accident was the hot liquid policy was not followed. This along with the lack of proper supervision resulted in the injury. 3. On 8-2-2024, Coffee Temperature logs were created to indicate the temperature of the beverage prior to serving. This will serve as record of temperatures of coffee being served. 4. Training for all staff prior to working shifts was initiated on 8/2/2024 by the staff development nurse and the Director of Nursing on the following topics: Safety and supervision of residents -Care Plans · Temperature logs for coffee · hot liquids policy No staff will be allowed to work until they have received appropriate training. 5. Updated the care plans for resident # 1 and identified thirty-three residents that were at risk to include interventions to prevent burns. 6. Weekly body audits were completed for all residents on 8-2-2024 and there were no burns noted. 7. Quality Assurance and Performance Improvement committee meeting was conducted on August 2, 2024, at 12:21 p.m. and the issue was discussed including root cause and appropriate remedies. Attending the meeting: Medical Director, Administrator, Director of Nursing, Resident Care Coordinator/ Infection Preventionist, Dietary Manager, Social Worker, Business Office Manager, Staff Development Nurse, Minimum Data Set Nurse, Medical Records Clerk, Environmental Services Manager, Maintenance Director and the staff scheduler. The facility alleges all corrective actions were completed on 8-2-2024 at 2:00 p.m. and the IJ was removed on 8-3-2024. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #25877 through record review and interviews on 8/5/24. The SA determined all corrective actions were completed on 8/2/24 and the IJ was removed on 8/3/24.