**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to ensure residents were free from abuse for one (1) of five (5) residents (Resident #13) reviewed for abuse. In addition, this failure has the potential to affect 143 other residents residing in the facility who were not protected from the alleged perpetrator. The facility's failure to ensure all residents were free from abuse, by not investigating an allegation of abuse reported by Resident #13 posed a likelihood of serious harm to Resident #13 and all residents. This resulted in an Immediate Jeopardy (IJ) situation. On 06/11/24 at 9:50 PM, the Administrator and Director of Nursing (DON) were notified that the failure to identify and protect one resident from alleged abuse which constituted an Immediate Jeopardy to the health and safety of all residents in the facility at F 600: Free from Abuse and Neglect. The Immediate Jeopardy began on 01/05/24, when Resident #13 reported that Certified Nursing Assistant (CNA #1) pushed him/her. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 06/12/24 at 8:24 PM. The survey team verified the implementation of the removal plan through staff interviews, and review of facility training. The Immediate Jeopardy was removed on 06/13/24 at 6:30 PM. Findings include: Review of Resident #13's undated admission Record, provided by the facility, indicated that Resident #13 was re-admitted to the facility on [DATE], with diagnoses of diabetes mellitus, chronic pain syndrome, and personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of the Progress Notes, provided by the facility and dated 01/05/24, revealed, ''At around 9:00 PM, heard [Resident #13] yelling at a CNA .When approached, [Resident #13] stated .[CNA #1] pushed [Resident #13] out of the way making the hot coffee spill .pantry floor was wet with coffee and [Resident #13's] lap was a little wet .Both hands were checked, but are dry and skin normal temperature. [Resident #13] claims that hands and lap feel tingling .Further skin assessment made. No apparent injury.'' Review of the Full Quality Assurance (QA) Report'' provided by the facility and dated 01/05/24, revealed '' .first degree burn .pelvic area .according to [Resident #13], tingling sensation on lap (close to groin area), [Resident #13's] skin was normal temperature, normal to touch, no redness, no flaking or scales .preventative/protective skin care, cold compress for five minutes .Conclusion: . [Resident #13] stated 'the hot coffee fell on me.' Upon .interviewing [Resident #13] and the [Certified Nursing Assistant (CNA #1)], coffee indeed was noted to spill on [Resident #13's] lap . [CNA #1] was attempting to get fresh ice water for her residents, while [Resident #13] was warming up their coffee. [Resident #13] became angry with [CNA #1] for being in the nourishment room at the same time [Resident #13] was in there. As [CNA #1] attempted to leave the nourishment room, [Resident #13] positioned themselves blocking the entranceway and threatening [CNA #1]. [Resident #13] would pour coffee on her as [Resident #13] stood up from the wheelchair. In the process of [CNA #1] trying to get pass [Resident #13] so [Resident #13] would not pour coffee on her, [Resident #13] spilled a small amount of coffee on themselves. [Resident #13] reported that [CNA #1] physically pushed [Resident #13]. Review of the QA Investigative Statements: (Typed written statement by [Licensed Practical Nurse (LPN #3)] revealed, .[Resident #13] was heard in the hall yelling at a [CNA #1], very upset .[Resident #13] stated that the [CNA #1] pushed [him/her] out of the way making the coffee spill on [Resident #13] and walked away .immediately inspected the surroundings and noted coffee spill on the floor. Checked [Resident #13] and noted smell of coffee lingers on [Resident #13] and lap was a little wet with coffee .Coffee spills was wiped off the floor .[Resident #13] stated tingling sensation on both lap closer to groin. Further review of the QA report revealed a typed written statement documented by [Resident #13]) .that aide [CNA #1] pushed me and made me spill my coffee on me.'' Review of facility provided, undated and untitled handwritten document by CNA #1, revealed ''On 01/05/24 at about 4:00 PM, I was entering the nutrition room to get ice for my residents. [Resident #13] was already in there heating up their meal. [Resident #13] was sitting near the sink. I asked [him/her] to let me get to sink to pour out water. [Resident #13]replied why every time I am in here, you come to disturb me . [Resident #13] continued to curse at me as [he/she] sat back down in the wheelchair. So I left the room to pass ice water. As I returned to get more ice water, [Resident #13] was still using the microwave. I asked [Resident #13] to excuse me again, [Resident #13] replied, I have killed 100 persons-I will kill you . As I was attempting to leave out of the nutrition room [Resident #13] positioned themselves blocking the doorway with the coffee container in [Resident #13's] hand. [Resident #13] was carrying a basin was in their lap. [Resident #13] said to me, I will burn you . I became afraid, and I squeezed past [Resident #13] to get out of [Resident #13's] way.'' On 06/11/24 at 3:15 PM, the surveyor interviewed CNA #1 who confirmed during the incident on 01/05/24, Resident #13 was in the ice room using the microwave, which was on the counter next to the medication room, when she went in there for a cup of ice for one of her 600-hall residents. She stated Resident #13 started yelling at her, asking her why she was in here and said that she was not to be in here when [Resident #13] was in here. She stated she took the cup of ice and left the room without speaking with Resident #13. She then stated that Resident #13 stood up, and threatened to slap her if she did not get out of the room. CNA #1 stated [Resident #13] threatened to beat her up after cursing her out. She stated Resident #13 sat back down in the wheelchair, and this was when she took her ice and left the room. She stated she was only in the nutritional room one time, denied going back for a second time, as her written statement indicated. CNA #1 further stated that she went back to her hall and started doing rounds after exiting the nutrition room. CNA #1 indicated that the nurse [LPN #4] told her that the supervisor [LPN #1], who was not at the facility during this incident, wanted her to write a statement because Resident #13 accused her of burning Resident #13. Then CNA #1 stated because she burned him, pushed [Resident #13] or something like that. CNA #1 stated after she wrote her written statement, she gave it to LPN #1 and confirmed that she was not asked to leave the facility. She stated she wrote Resident #13 was heating coffee in the microwave and had nothing in their hands while speaking with her. CNA #1 indicated that the next day, she was asked to come to the facility in the morning and spoke with the Director of Nursing (DON) and LPN #1. She indicated they asked her what happened, and she said that Resident #13 was warming their coffee, while she got ice, and she left the nutritional room, while Resident #13 remained in the room. CNA #1 confirmed that Resident #13 was sitting near the opened door when she passed Resident #13 and went onto the floor. On 06/11/24 at 7:10 PM, the surveyor interviewed the DON who stated even if the incident happened today, the facility would have suspended CNA #1, but allow CNA #1 to return to work because CNA #1 was not in the room with Resident #13 and Resident #13 made things up. The DON confirmed that when the QA report was completed, it was reviewed the next business day during the morning meeting. The DON stated after completing the QA report, it triggered an email to management and corporate, which generated follow up emails as to what happened. She stated she was told by LPN #3, LPN #4, and CNA #1, that CNA #1 was not in the nutrition room when Resident #13 spilled coffee on themselves. After the DON reviewed the statements, where Resident #13 reported physical abuse by CNA #1, the DON confirmed that this should have been reported within two hours of the staff's knowledge, and that CNA #1 should have been suspended. On that same date at 7:37 PM, after re-reading the abuse policy, the DON stated she would re-open this investigation and report. She stated CNA #1 would have been suspended immediately and confirmed that she dropped the ball. During a follow up interview at 8:32 PM, she confirmed that CNA #1 had been suspended and that the staff currently in the building had been in-serviced on abuse. She stated the state agency (SA) and police had been notified. On 06/12/24 at 11:00 AM, the surveyor interviewed Resident #13 who stated the 01/05/24 incident occurred while [Resident #13] was heating up food in the microwave. Resident #13 confirmed CNA #1 came into the nutritional room, where [Resident #13] was sitting by the ice machine, and CNA #1 pushed past [Resident #13]. Resident #13 stated that [he/she] told CNA #1, At least you can say excuse me. Resident #13 confirmed that CNA #1 said something, but [he/she] could not understand her, and CNA #1 left the nutritional room. Resident #13 indicated that [he/she] finished warming up their food, and coffee. Resident #13 further stated [he/she] had taken the coffee out of the microwave, had it in [his/her] right hand, and was getting ready to go out of the nutritional room, and was near the ice machine. Resident #13 stated CNA #1 entered the nutritional room, pushed past [him/her] on the right side to go to the sink, causing the hot coffee to spill on [Resident #13]. Resident #13 stated [he/she] started yelling and verbally threatening CNA #1 and CNA #1 did not stop and walked out of the nutritional room. Resident #13 stated when CNA #1 went out of the nutritional room, she went straight to the LPN #4 on the 600-hall, where Resident #13 heard CNA #1 telling the LPN #4 what happened and laughing about it. Resident #13 further stated LPN #3 came to find out what was wrong. Resident #13 stated [he/she] told LPN #3 that CNA #1 pushed [Resident #13] causing the hot coffee to spill on [Resident #13] legs. Resident #13 stated a day later, LPN #1 came and spoke with [him/her] about the incident. Resident #13 confirmed that [he/she] told LPN #1 that CNA #1 pushed [Resident #13] causing the coffee to spill on [Resident #13]. Resident #13 stated LPN #1 told [him/her] that CNA #1 was not to be around [Resident #13] anymore. Resident #13 stated that the same day [he/she] spoke with LPN #1 and CNA #1. On 06/12/24 at 2:40 PM, the surveyor interviewed LPN #1 who stated she spoke with Resident #13 following the 01/05/24 incident. She confirmed Resident #13 told her that CNA #1 pushed [Resident #13] and that Resident #13 was able to identify CNA #1 by name. She indicated she would not classify Resident #13's statement to be abuse and indicated that Resident #13 was both verbally and physically threatening towards CNA #1, making CNA #1 afraid. The LPN #1 stated CNA #1 may have accidentally hit Resident #13's wheelchair when exiting the nutritional room. Review of Resident #13's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #13 was cognitively intact and able to make themselves understood and understand others. Review of facility provided CNA #1's ''Regular Monthly Schedule,'' provided by the facility for January 2024, revealed evidence that CNA #1 worked the following dates: 01/05/24, 01/06/24, 01/07/24, 01/09/24, 01/10/24, 01/11/24, 01/12/24, 01/15/24, 01/16/24, 01/17/24, 01/19/24, 01/20/24, 01/21/24, 01/23/24, 01/25/24, 01/26/24, 01/29/24, 01/30/24, and 01/31/24. This schedule showed that CNA #1 worked for 19 days after the allegation of physical abuse occurred. Review of facility policy titled, ''Abuse, Neglect, Exploitation and Misappropriation Prevention Program,'' dated 10/22, revealed ''Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to .physical abuse. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation program consist of a facility-wide commitment and resource to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff .9. Identify .all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.'' An acceptable Removal Plan on 06/12/24 at 8:24 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including suspending CNA #1 pending investigation, notifying the New Jersey Department of Health of the allegation of abuse, and educating all staff on the facility abuse policy. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 06/13/24. NJAC 8:39-4.1(a)5 NJAC 8:39-9.4(f) NJAC 8:39-13.4(c)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that two (2) of two (2) residents (Resident #13 and Resident #40) reviewed for accident hazards were given adequate supervision while transporting hot liquids. This failure caused Resident #13 to have a first degree burn on the pelvic area on 01/05/24 and a first degree burn to the abdomen with second degree burns on the left thigh and penis on 05/10/24. Both burns resulted from Resident #13 heating up coffee in the unit microwave which was located in the unlocked nutritional room on the unit. On 11/01/23, Resident #40 suffered a second degree burn to the right hip from self-transferring coffee from the dining room. On 06/10/24, a Past-Non-Compliance (PNC) Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were safe from accident hazards. The IJ was determined to exist on 05/10/24, when a second-degree burn occurred to Resident #13. The IJ was removed on 05/13/24, when the microwaves were removed from the unit nutritional rooms. The Administrator was informed on 06/10/24 at 10:33 PM, that the PNC Immediate Jeopardy situation existed which also constituted Substandard Quality of Care (SQC) for 42 CFR 483.25-Free of Accident Hazards/Supervision/Devices (F 689). The facility provided an Immediate Jeopardy Removal Plan that was accepted on 06/11/24 at 6:51 PM. The survey team verified the implementation of the Removal Plan through interviews and review of training records on 06/13/24 at 2:15 PM. Based on the facility's implementation of corrective actions, the IJ and SQC were determined to be PNC and the IJ was removed, with substantial compliance achieved on 05/13/24. The deficient practice was determined to be PNC related to the facility identifying the IJ and implementing interventions to prevent reoccurrence of the situation, completed on 05/13/24. The facility's actions included the following: -Resident education and care plans updated as indicated. -On 05/13/24, the interdisciplinary care (IDC) team met to discuss hot beverages policy, microwave use, and reviewed trends surrounding hot beverage spills. -On 05/13/24, microwaves were removed from the common area by Maintenance staff/designee. -On 05/13/24, the resident council president and residents were made aware by unit managers/interdisciplinary team (IDT) that microwaves were removed from common areas by maintenance staff/designee and that requests should be made to staff for reheating of food and beverages. -On 05/13/24, the resident council/food committee was held. Residents were educated on hot beverage safety and the removal of microwaves from common areas. The residents were educated that dietary staff would reheat meals and beverages upon request to minimize the risk of injury and validate appropriate beverage temps before resident consumption and/or transporting of hot beverages. -On 05/13/24, staff education was initiated and remained ongoing. -Education on monitoring during meals and during resident transport of hot beverages to assist in minimizing the risk of potential injury and following plan of care. -On 05/13/24, staff were educated to request reheating of meals and beverages from dietary staff. Education to dietary staff regarding reheating food and beverages per policy and facility-initiated process. -On 05/13/24, a review was completed of resident incidents with identified residents reviewed. Care plans were in place, and no further variances were noted. -Kitchen audits related to test trays remain ongoing. Variances addressed as indicated. Findings include: 1. Review of Resident #13's admission Record, provided by the facility, indicated Resident #13 was re-admitted to the facility on [DATE], with diagnoses of diabetes mellitus, chronic pain syndrome, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. During an observation and interview on 06/10/24 at 10:20 AM, Resident #13 stated they had a third degree burn to the abdomen, left thigh, and penis. Resident #13 stated that approximately one and half weeks ago during the evening shift around 6:00 PM, they were warming up coffee in the microwave that was located in the nutritional room. Resident #13 stated the hot coffee spilled on them and that they were hollering. Resident #13 stated no staff were around to warm up the coffee and that was the reason Resident #13 warmed it up themselves. Resident #13 stated that he/she warmed up the coffee for two minutes. Resident #13 denied any further incidents. During the interview, Resident #13 was observed to have a healed area to the abdomen. In addition, Resident #13 showed the surveyor their left thigh area, which had a dressing. During another interview on 06/10/24 at 4:28 PM, Resident #13 stated for the 05/10/24 incident, they were heating up coffee in two plastic 16-ounce (oz) cups, which were doubled. Resident #13 stated I was wheeling out of the open door of the nutritional room that had cardboard holding the door open and the cardboard came loose causing the door to bump into my wheelchair. Resident # 13 stated when the door hit my wheelchair; it caused me to spill the coffee. Resident #13 stated the coffee spilled on their left thigh first and then on the abdomen area. Regarding the incident on 01/05/24, Resident #13 stated, I was in the nutritional room, the door was held opened by a piece of cardboard and I got into an altercation with another resident. Resident #13 stated they went into the nutritional room first and was warming up coffee. Resident #13 stated that the other resident pushed him out of the way, while Resident #13 was by the ice machine and attempting to exit the door. Resident #13 stated this was when the coffee spilled on my legs. Review of ''Full Quality Assurance (QA) Report,'' provided by the facility and dated 01/05/24, revealed '' .first degree burn .pelvis area .according to [R #13], tingling sensation on lap (close to groin area), [Resident #13's] skin was normal temperature, normal to touch, no redness, no flaking or scales .preventative/protective skin care, cold compress for five minutes .Conclusion: . [Resident #13] stated the hot coffee fell on me. Upon investigation and interviewing of [Resident #13] and staff [Certified Nursing Assistant (CNA #1) ], coffee indeed was noted to spill on [Resident #13's] lap. [CNA #1] was attempting to get fresh ice water for her residents, while [Resident #13] was warming up coffee. [Resident #13] became angry with [CNA #1] for being in the nourishment room at the same time [Resident #13] was in there .In the process of [CNA #1] trying to get past [Resident #13] so the resident would not pour coffee on her, [Resident #13] spilled small amount of coffee on [him/herself] .[Resident #13] was assessed by floor nurse and no changes to skin textures were noted .Nurse Practitioner (NP) notified of first degree burn to groin area; however, no changes were visible at the time and new orders to apply cold compress were initiated . Root Cause: No, [R #13] is self-willed and refuses assistance when offered by staff.'' Review of the ''Occupational Therapy Treatment Encounter Note(s),'' provided by the facility and dated 01/12/24, revealed '' .During evaluation process patient demonstrated fair safety awareness with use of microwave, associated transfers and management of hot food items. [Resident #13] did endorse having [his/her] own way to do it. Reviewed safety techniques with patient and patient reporting understanding.'' During another interview on 06/12/24 at 11:00 AM, Resident #13 indicated that the 01/05/24, incident occurred when the Certified Nursing Assistant (CNA #1) came into the nutritional room at the same time Resident #13 was in there. Resident #13 stated I had coffee in my right hand, that I just finished warming up. Resident #13 stated I was getting ready to go out of the nutritional room, when [CNA #1] pushed past me on the right side, causing the hot coffee to spill on me. Resident #13 stated the nurse, [Licensed Practical Nurse (LPN #3)], assessed me and the physician came and saw me. Resident #13 stated that the physician said it was a minor burn. During an interview on 06/12/24 at 11:25 AM, the Director of Rehab (DOR) confirmed that he completed a therapy screen on Resident #13 back in January 2024, that indicated Resident #13 was fairly okay with microwave use. He stated Resident #13 was aware to ask staff for any help. He stated upon Resident #13's hospital return in May 2024, he did not complete a formal evaluation, but did speak with Resident #13. He stated Resident #13 said he/she was not going to drink coffee anymore. Review of the ''Full QA Report,'' provided by the facility and dated 05/10/24, revealed '' .burn to mid left abdomen, reddened area initially then started forming blister within half an hour and burn to left thigh, reddened initially then started forming blister in half an hour .cold compressed wrapped in towel .transferred to [name of hospital] .Conclusion: . On 05/10/24 at 5:45 PM, [Resident #13] was utilizing a different cup to warm up their coffee in the microwave, as [Resident #13] removed the cup, [he/she] spilled the hot coffee on themselves. A full nursing assessment was completed by the nurse, and first aid was immediately rendered. [Resident #13] was noted with a reddened area to mid left abdomen and left thigh, cold compress was refused by [Resident #13], and the resident was transferred to the emergency report (ER) .[Resident #13] returned to the facility on [DATE], the resident was informed that the facility policy was changed and that no residents would be allowed to use microwave independently .Root Cause: most likely [Resident #13] has episodes of forgetfulness and refuses to accept care/assistance.'' Review of the undated ''Summary of the Incident,'' provided by the facility and signed by the DON, revealed ''[Resident #13] is a [AGE] year-old .resident that has been residing at [name of facility] since 03/06/23, with medical diagnoses of diabetes, coronary artery disease (CAD), anemia, gastroesophageal reflux disease (GERD), syncope, benign prostatic hyperplasia (BPH). Resident #13's BIMS score was 13 .On 05/10/24 at 5:45 PM, [Resident #13] was utilizing a different cup to warm up the coffee in the microwave, as the resident removed the cup, the hot coffee spilled onto the resident. A full nursing assessment was completed by the nurse, and first aid was immediately rendered. Resident #13 was noted with a reddened area to the mid left abdomen and left thigh, cold compress was refused by [Resident #13], and was transferred to the emergency department (ED) .[Resident #13] was informed that the facility policy was changed and that no residents would be allowed to use microwave independently. The staff will take any item of food or liquids to the kitchen, where the kitchen staff will warm it up. All microwaves have been removed from the units and staff in-serviced on the new policy.'' During an interview on 06/10/24 at 2:13 PM, the Regional Director of Operations stated Resident #13's incident on 05/10/24, was not reported to the state agency (SA). She stated the Ombudsman came out and investigated at which the case was closed. Review of LPN #3's ''Employee's Statement of Incident,'' dated 05/10/24, revealed, ''At around 5:45 PM, while I was feeding a resident. I heard someone screaming in the distance. When I walked out of the room to investigate, I saw [CNA #2] pulling [Resident #13] out of the pantry. [Resident #13] stating that the hot coffee spilled on him/her and the resident was burned. I told [CNA #2] to get ice and called out for [CNA #3] to help. I immediately took [Resident #13] to their room and [CNA #3] followed me there to take Resident #13's clothes and assess. Noted reddened area on left side stomach and left thigh. Non-blanching, sensitive to touch. Ice compression wrapped in towel placed but [Resident #13] cannot tolerate it. Resident #13 then applied petroleum gel cocoa butter to themselves. [Resident #13] requested to be sent to emergency room (ER). Transport unavailable until 11:30 PM. 911 ambulance called instead .Right before 911 ambulance on last check with [Resident #13], skin noted on left thigh forming blisters.'' Review of CNA #2's ''Employee's Statement of Incident,'' dated 05/10/24, revealed ''I was in [room number] .I heard someone yelling .So I went to see who it was and looked in the pantry, it was [Resident #13]. Resident #13 said they had burnt themselves with hot coffee, so I got the nurse.'' Review of CNA #3's undated ''Employee's Statement of Incident,'' revealed ''I was with another resident when I was called by the nurse. The resident [Resident #13] had burned themselves with hot coffee at that time. The nurse and I went in and took care of the resident, and [Resident #13] was sent to the hospital.'' During an interview on 06/10/24 at 12:40 PM, the LPN #1 confirmed Resident #13 had an incident during the evening shift on 05/10/24. She stated Resident #13 warmed up the coffee in the microwave for two to three minutes which was in a plastic cup and caused burns to the Resident #13's left upper thigh, lower abdomen, and groin/penis area. The LPN #1 confirmed that the facility wound physician called the burns third degree. The LPN #1 stated that Monday after the incident, all microwaves were removed from the nutritional units in the facility. The LPN #1 stated if residents needed their food and/or liquids heated up, the staff took them to the dietary department, who re-heated them for the resident. The LPN #1 stated staff and residents were given education, through word of mouth, about these new guidelines. Also, the LPN #1 stated that the incident was reported to the Ombudsman. During an observation and interview on 06/10/24 at 4:35 PM, LPN #1 stated Resident #13 could transfer themselves into their wheelchair, and that was their mode of transportation. The LPN #1 stated Resident #13 did not walk. LPN #1 confirmed that Resident #13 was independent in their activity of daily living (ADL) and had a history of refusal at times. LPN #1 stated Resident #13 tended to roll themselves backwards in their wheelchair. In addition, during the interview, the nutritional door was observed propped open by a piece of cardboard which was wedged between bottom of door and floor. The LPN #1 stated the nutritional room was usually propped open at the change of shift due to the aides passing ice water. LPN #1 stated that it was made for easy access. LPN #1 could not answer when asked if the door was allowed to be propped open. LPN #1 confirmed the nutritional door was always unlocked. LPN #1 indicated that residents, visitors, and/or staff were allowed to heat up things in the microwave, and staff would always ask residents if they needed any help when staff observed residents using the microwave. When asked if residents had a screen for self-use of the microwave, she stated that after the first incident for Resident #13, he/she was screened by therapy and found safe to use the microwave. She indicated that for the incident on 01/05/24, Resident #13 spilled coffee on themselves during a verbal communication with a staff member. The LPN #1 stated Resident #13 became upset when the staff member came into the nutritional room, and as the resident was backing out, they spilled coffee on themselves. Review of ''Hospital History and Physical,'' provided by the facility and dated 05/11/24, revealed '' .[Resident #13] was having dinner .when he/she spilled coffee to their thigh and penis. [Resident #13] has what appears to be superficial burns on the abdomen with partial thickness burns to his/her thigh and penis. Total body surface area (TBSA) burn: 1% .partial thickness burns .left thigh and penis.'' Review of the ''Quality Assurance Performance Improvement-Action Plan,'' provided by the facility and dated 05/13/24, revealed ''Goal: To ensure resident safety with hot liquids .Resident Communication: Residents have been informed via resident council of the removal of microwave ovens from facility nourishment rooms; to prevent accidentally burns when independently reheating/heating food and hot beverages .target date: 05/31/24. Resident Assessment: Newly admitted /readmitted residents, and those with changes in condition affecting activity of daily living (ADL) functionality/decline will be evaluated by therapy (Occupational Therapy) to determine meal assistance needs .target date: Ongoing. Staff education: Education to facility staff on safety of hot liquids. Reheating of foods by dietary staff; microwave unit removal .target date: 05/18/24. Monitoring: Resident requiring meal assistance including those who receive hot liquids of choice will continue to be monitored by facility staff during dining room, and when eating in rooms to ensure assistance is provided to ensure safety. Residents who request beverages/foods to be re-heated will have this facilitated by facility staff. Dietary staff will continue to monitor food temperatures including hot liquids prior to service to residents. Hot liquids will not be served greater than (>) 180 degrees.'' Review of Resident #13's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact and able to make themselves understood and understood others. 2. Review of the facility's accident/incident log for 2023-2024 and provided by the facility, revealed Resident #40 sustained coffee burns while attempting to transport coffee from the dining room to their room. Resident #40 sustained a second degree burn to the right thigh/hip areas. Review of the facility's investigation of the incident, dated 11/01/23, and provided by the facility, revealed Resident #40 had gone to the dining room for coffee. A dietary staff member placed the coffee cup on the dining room table. The report documented the resident deciding to take the coffee to their room. Resident #40 placed the coffee cup inside the right side of their wheelchair next to their right thigh. Review of an undated witness statement provided by the Maintenance Director revealed the employee was coming out of his office when he observed the resident trying get out of the wheelchair after the resident spilled the coffee on themselves. The Maintenance Director assisted the resident to another chair and notified the nurse of the accident. Interventions put in place after included complete pain assessment, frequent skin checks, and treatments as ordered. Educated the resident to ask for assistance for carrying hot items to his/her room, not to attempt wheeling themselves, and trying to carry items at the same time. Staff education to make sure coffee was cooled before offering it to the residents. Review of Resident #40's Nursing notes, dated 11/01/23 at 7:43 PM, located in the resident's EMR under the Progress Notes tab, revealed the nurse was called to resident's room after the resident spilled hot coffee on themselves. The nurse documented the resident was found grimacing in pain. The resident stated that they had placed a cup of hot coffee by their side in the wheelchair as he/she was trying to propel themselves to their room when the coffee spilled and burned them. The physician was notified and ordered Silvadene cream to the burn area every shift. The resident's responsible party was notified. At the time of the incident, the resident was noted to have redness on their right thigh and upper gluteal area. It was determined that this was a first-degree burn. Additional review of Resident #40's nurses notes, dated 11/03/23 at 7:36 PM, it was noted the resident had developed a blister on the right hip area. The MD [Medical Doctor] was notified and ordered the blister to be cleaned and covered with four-by-four dressings. The burn was now classified as a second-degree burn. During an interview on 06/10/24 at 5:15 PM, the Unit Manager, LPN #5 revealed Resident #40 had gone to the dining room and requested a cup of coffee. LPN #5 stated the dietary staff placed the cup on the table and instructed the resident to stay in the dining room with the coffee. LPN #5 stated the resident was a loner and liked to stay in their room. LPN #5 stated the resident decided to take the cup of coffee to their room. She stated the resident placed the cup of coffee in the wheelchair next to their right leg and left the dining room without asking for assistance. LPN #5 stated the Maintenance staff member was passing by and observed the resident had spilled coffee on themselves. She stated the Maintenance staff member notified the nurse and assisted the resident to transfer to another chair. LPN #5 stated the resident was given a complete physical assessment; at that time, and it was noted the resident had redness on the right hip and upper gluteal area. She stated the facility physician was notified, and orders were obtained to apply Silvadene cream to the affected area three times a day. LPN #5 stated on 11/03/23, the resident's burn changed to a second-degree burn. LPN #5 stated both the resident and staff were educated. She stated the resident was educated on asking for help to carry hot items to their room and not attempt wheeling themselves and trying to carry items themselves. She stated staff were educated in making sure that hot tea and coffee were cooled prior to being given to residents upon request. During an observation on 06/12/24 at 5:15 PM, Resident #40 received their dinner tray in their room. The resident was served coffee with a lid covering the cup to prevent spillage. Review of Resident #40's admission Record located in the electronic medical records (EMR) under the Profile tab, revealed the resident was initially admitted on [DATE], with diagnoses that included diabetes mellitus type II, depression, acute kidney failure, transient ischemic attacks, and cerebral infarction. Review of Resident #40's five day MDS with an ARD of 07/10/23, located in the resident's EMR under the MDS tab, revealed the resident had a BIMS score 15 out of 15 which indicated the resident had intact cognition. The resident required limited supervision with their activities of daily living (ADLs). Resident #40 utilized a walker and wheelchair for mobility. Review of Resident #40's quarterly MDS with an ARD of 08/28/23, located in the resident's EMR under the MDS tab, revealed the resident had a BIMS score 13 out of 15 which indicated the resident had intact cognition and the resident required supervision with their ADLs. Review of the facility policy titled, ''Safe Use of Microwave Ovens,'' revised 01/08/24, revealed '' .Patient Safety: .2. Hot beverages like coffee, tea or hot chocolate should be served with a lid to help prevent spills if needed.'' Review of facility policy titled, ''Safety of Hot Liquids,'' revised 10/14, revealed '' .Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury.'' NJAC 8:39-27.1(a)