**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY00372408) the facility failed to ensure the resident environment remains free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #1) reviewed for safety and supervision. Specifically, on 1/5/2025, Resident #1 obtained hot water from the hot liquid cart, filled their basin and carried it to a room and immersed their feet without the knowledge or detection of unit staff. Resident #1 was found with blisters to bilateral feet and sustained second- and third-degree burns. On 1/15/2025, Resident #1 was transferred to the hospital with a fever and for burn evaluation. On admission to the hospital, Resident #1 was determined to have third degree burns and underwent a skin graft on 1/21/2025. There was no facility policy that addressed the monitoring of hot water carts when they are on the resident units. Furthermore, the monitoring of the hot water cart was sporadic and arranged by word of mouth and monitoring was not consistently in place for the period when the hot water carts are on the units. This resulted in actual harm for Resident #1 which was Immediate Jeopardy with the likelihood of risk for harm to the health and safety of other residents. The Findings are: Review of the facility Hot Liquids Safety Policy last reviewed 6/20/2024 documented hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. The temperature of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches appropriate temperature. General safety precautions when serving hot liquids include but are not limited to regulate temperature of hot liquids to which residents have direct access. Resident #1 was admitted with diagnoses including but not limited to diabetes mellitus, peripheral vascular disease, polyneuropathy (a condition that damages multiple peripheral nerves affecting sensation, movement or both). A Quarterly Minimum Data Set (an assessment that measures health status) dated 11/17/2024 documented the resident was cognitively intact with no behaviors noted. Resident #1 used a walker for locomotion and had no impairments to their upper and lower extremities. Resident #1 required set-up assistance with eating and supervision with toileting, bed mobility, transfers, and ambulation. Resident #1 had an infection of their foot and was receiving surgical wound care with the application of dressings to their feet. Review of a diabetes mellitus care plan initiated 4/13/2024 documented the following interventions: avoid exposure to extreme heat and cold, assess feet daily for any open areas, sores, pressure areas, blisters or redness and monitor/document/report as needed any signs and symptoms of infection to any open areas. Review of an activities of daily living care plan initiated 10/15/2024 and revised on 2/15/2025 with no changes documented Resident #1 was dependent on staff daily for meeting activity of daily living needs. The resident required set-up assistance with eating, supervision with showering/bathing, and putting on and removing their shoes. Facility Summary of Investigation dated 1/5/2025 documented Registered Nurse Supervisor #1 was summoned to see Resident #1 for the presence of blisters to bilateral (both) feet. Resident #1 was noted with fluid filled blisters on dorsal (top) aspect of bilateral feet. On interview, the resident admitted they sneaked out to get water from the tea cart without anybody seeing to intentionally wash their feet with the warm water; I soaked my feet in the water for about 30 minutes in another resident's room. I didn't feel anything, but it felt weird because my feet turned white, so I reported it to the nurse. Medical Doctor was notified and ordered treatment with a topical antimicrobial cream every shift for five (5) days and to monitor site for symptoms of infection. Family notified and agreed with plan of care. Review of the coffee and hot water temperature chart for January 2025 documented the following temperatures: January 4, 2025 4:45 PM 119 degrees Fahrenheit; January 5, 2025, 4:45 PM 122 degrees Fahrenheit. Review of an accident/incident report dated 1/5/2025 documented Resident #1 was assessed for a change in skin condition by Registered Nurse #2 at 10:00 PM. The accident/incident was reported by Licensed Practical Nurse #1 on 1/5/2025 at 10:00 PM. Resident #1 was ambulatory and the incident occurred in the resident's room. The Attending Physician was notified on 1/5/2025 at 10:02 PM and Resident #1's representative was notified on 1/5/2025 at 10:05 PM. Actions taken to prevent reoccurrence included educating Resident #1 to not poke the blisters, and how to properly care for the blisters. Review of Registered Nurse #2's incident note dated 1/5/2025 at 10:00 PM documented they were called to assess Resident #1 regarding the presence of blisters to bilateral feet which started from a small blister on 1/4/2025. Resident #1 reported on interview that they washed their feet with warm water during dinner time. On assessment, Resident #1 was noted with fluid-filled blisters on bilateral dorsal feet. No redness was noted between Resident #1's toes. The Attending Physician was notified and ordered to start a topical antimicrobial cream for five (5) days to bilateral feet blisters. Resident #1 was to be monitored for signs of infection and their family made aware. Review of a Nurse Practitioner #1 medical progress note dated 1/6/2025 at 2:01 PM documented they were asked to see Resident #1 for burns on both feet. Resident #1 was noted to have huge blisters covering both feet. As per Resident #1, they soaked their feet in hot water yesterday from their tea container. Documentation revealed Resident #1 has no feeling in their feet due to neuropathy and did not notice that their feet got burned. Safety was reinforced with Resident #1 and communicated with nursing staff and administration regarding Resident #1's access to hot water. The Assessment/Plan documented second degree burn, do not pop blisters, continue to monitor, reinforce safety with Resident #1, if blisters pop, apply a topical antimicrobial cream two (2) times daily and schedule wound consult. Review of the Attending Physicians medical visit note dated 1/8/2025 at 3:49 PM documented Resident #1 was seen for follow-up regarding second degree burns on bilateral feet. Resident #1 was noted to have huge blisters popped up on both feet, wound treatment applied. Safety was reinforced with Resident #1. The Attending Physician documented they communicated with nursing staff and Administration regarding Resident #1's access to hot water and resident's safety. The assessment/plan documented second degree burns-do not pop blisters, continue to monitor, reinforce safety to resident. The Plan continued: Resident #1's blisters are popped at this time, no need for antibiotic but will continue antibiotic skin cream or topical antimicrobial cream to sites. Review of an actual skin impairment care plan initiated 1/5/2025 documented Resident #1 had skin impairment to their bilateral dorsal feet related to burns. Interventions listed included follow facility protocols for treatment of injury and identify/document and eliminate/resolve where possible. Review of wound care notes dated 1/10/2025 documented Wound 1 with date of onset 1/5/25, etiology: 3rd degree burns on right dorsal foot measuring length: 9.0 centimeters width: 18.0 centimeters Depth: 0.1 centimeters. wound bed: 100% collapsed blister, scant exudate (drainage) with no odor. Recommended primary dressing of Xeroform + Calcium alginate + gauze + Kerlix daily and as needed Wound 2 with onset date 1/5/2025, etiology: 3rd degree burns of right plantar foot measuring: length: 5.0 centimeters width: 6.0 centimeters depth: 0.1 centimeters, wound bed: 100% collapsed blister and scant exudate with no odor. Recommendation for primary dressing to apply Xeroform + Calcium alginate + gauze + Kerlix daily and as needed. Wound 3 with onset date 5/2025, etiology: 3rd degree burns of left foot measuring: length: 9.0 centimeters with width: 18.0 centimeters and depth: 0.1 centimeters. Wound Bed is 100% collapsed blister. Moisture with scant exudate, serous (yellowish colored drainage) with no odor. Recommended primary dressing of Xeroform + Calcium alginate + gauze + Kerlix daily and as needed There is no documented evidence of the wound progression. Resident #1 was discharged to the hospital on 1/15/2025 for fever and evaluation of burns. Resident #1 was admitted to the hospital with second- and third-degree scald burns to bilateral feet with cellulitis. Resident #1 had a surgical technique where a surgeon removes burned or damaged skin layer by layer until they reach healthy tissue, and then covers the resulting wound with a thin layer of skin taken from another part of the body (split thickness skin graft) to the left foot and application of a mesh structure to help cells attach to the right foot on 1/21/2025 during the admission. Hospital discharge notes documented Resident #1 returned to the facility on 2/3/2025 On 2/10/2025 following an out-patient burn clinic post-operative follow-up appointment, it was decided Resident #1 needed to be admitted back to the hospital for possible wound infection. Review of hospital Discharge summary dated [DATE] documented Resident #1 had failure of skin graft and cellulitis of the fifth toe on the left foot. Resident #1 was treated for wound management, intravenous antibiotics, and pain control. During an interview on 2/19/2025 at 12:32 AM, Resident #1 stated they went to the tea kettle that came to the unit with the meal truck for tea or coffee. Resident #1 stated they filled up their basin with the hot water from the tea kettle and went to Resident #2's room. Certified Nurse Assistant #1 asked what they were doing, and they told Certified Nurse Assistant #1 they were soaking their feet. Resident #1 stated they put their feet in the water for 25 to 30 minutes and did not feel anything because they have had neuropathy for the last 19 years. Resident #1 stated when they removed their feet from the basin their feet were two big bubbles. Resident #1 stated they did not check the temperature of the water. Resident #1 stated they figured the water was hot or warm but did not know that it was scalding. During an interview on 2/19/2025 at 1:30 PM, Certified Nurse Assistant #1 stated during the evening shift on 1/5/2025 they went to give care to a resident in room [ROOM NUMBER]. Resident #1 usually goes to room [ROOM NUMBER] because they know the residents in that room. Certified Nurse Assistant #1 stated they saw Resident #1 in the room sitting in the chair with their feet soaking in water. Certified Nurse Assistant #1 stated when Resident #1 saw them they stated they had soaked their feet in hot water, and they are popping. Certified Nurse Assistant #1 stated they told Resident #1 they are not supposed to do that because they are diabetic, and they may not feel if they are getting burned. Certified Nurse Assistant #1 stated Resident #1 then took their feet out of the water, and they saw blisters on their feet. Certified Nurse Assistant #1 stated Resident #1 then stated they were in pain and could not walk. Certified Nurse Assistant #1 stated they do not know where Resident #1 got the water, and the resident already had their feet in the bucket of water when they saw them. Certified Nurse Assistant #1 stated they saw blisters to Resident #1's feet when they removed their feet from the water and reported it to Licensed Practical Nurse #1. During interview on 2/19/2025 at 1:56 PM, Registered Nurse #1 stated the hot liquid cart comes up with each meal. The residents know not to touch this cart. Registered Nurse #1 stated the incident happened on the weekend, so they are not sure why no staff saw Resident #1 getting the water from the hot liquid cart. Registered Nurse #1 stated they have now instituted that on the day and evening shift a nurse or certified nurse assistant remains in the area by the hot liquid cart. Registered Nurse #1 stated the hot water cart is now out of the dining room and is monitored. Registered Nurse #1 stated the nurses on the west side are responsible to be in the dining room when the trucks arrive to the unit and if there are residents in the dining room, a nurse needs to remain in the dining room. During an interview on 2/19/2025 at 2:29 PM, Registered Nurse #2 stated they are not sure how Resident #1 got enough hot water to fill a basin. The certified nurse assistants may have been busy. Registered Nurse #2 stated they were approached by Licensed Practical Nurse #1 who asked them to assist with Resident #1. Registered Nurse #2 stated they were told at 10:00 PM that Resident #1, at 7:00 PM during dinner, had washed their feet with the water from the hot liquid cart. Registered Nurse #2 stated Licensed Practical Nurse #1 stated they were just informed about the incident at 10:00 PM by Certified Nurse Assistant #1. Registered Nurse #2 stated Certified Nurse Assistant #1 had reported to Licensed Practical Nurse #1 that they saw Resident #1 soak their feet with warm water. Registered Nurse #2 stated Licensed Practical Nurse #1 was the medication nurse for Resident #1 at the time of the incident. Registered Nurse #2 stated they were not informed by any staff that they saw Resident #1 getting the hot water. The kettle for tea on the hot liquid cart has a faucet drain and it would take about 20 minutes to fill a bucket. Registered Nurse #2 stated after the incident occurred there is now one certified nurse assistant assigned to stay by the hot liquid cart and they also spoke with dietary to ensure the water brought to the units is warm and not scalding hot anymore. Registered Nurse #2 stated there is an assignment sheet now to monitor the hot liquid cart. During an interview on 2/19/2024 at 3:11 PM, the Director of Nursing stated after the incident on 1/5/2025 they provided an in-service to the staff. The facility now designates an aide to be to be near the hot water cart but there is no sign-in sheet. They have one (1) nurse always assigned to the dining room. Director of Nursing stated they are not aware of a policy change since the incident. It is possible the facility could have updated a policy without them being aware, since they were out for one (1) month. During an interview on 2/19/2025 at 4:02 PM, Dietary Supervisor Weekends stated the hot liquid carts are picked up from the unit about 45 minutes to an hour after meals are served. The Dietary Supervisor Weekends stated the hot liquids are left outside of the dining room by the dietary staff when delivered to the units. Dinner begins at 4:45 PM and is supposed to end at 5:45 PM, but sometimes it ends at 6:10 PM. The Dietary Supervisor Weekends stated it will be unusual for the hot liquid truck to be on a unit at 7:00 PM. The Dietary Supervisor Weekends stated in January the facility only had one (1) elevator in service, so it may have been possible for the hot liquid truck to be on the unit until 7:00 PM. The Dietary Supervisor Weekends stated they were not informed of any changes to the policy regarding hot liquids. During an interview on 2/20/2025 at 10:38 AM, Resident #2 stated Resident #1 came into their room to wash their feet in some warm water. Resident #2 stated they assumed Resident #1 got the water to wash their feet from where they get the water for coffee and tea by the dining room. Resident #2 stated the water in the sink is never warm enough, and this was the first time they've known Resident #1 to get the water from the kettle. Resident #2 stated Resident #1's feet were very dark, so they felt they were dirty and said they were going to clean their feet themself. Resident #2 stated Resident #1 then put their feet in the water and their feet started to bubble and blister up. Resident #2 stated the hot liquid cart is kept right outside the dining room on the unit and is always accessible to the residents. During a telephone interview on 2/20/2025 at 2:11 PM, the Attending Physician stated they have serviced the facility for three (3) years now. The Attending Physician stated they were informed by Registered Nurse #2 on 1/5/2025 that Resident #1 got hot water from the hot liquid cart, and it dropped on their foot and had sustained blisters on both feet. The Attending Physician stated they instructed Registered Nurse #2 to apply ointment to Resident #1's feet and they saw and evaluated Resident #1 the next day. The Attending Physician stated after they saw Resident #1's feet they instructed the resident and the nurses not to pop the blisters, because if they are not popped there will be no infection. The Attending Physician stated they did not order a wound care consult at that time because the blisters were intact. The resident was already on pain medication and their pain has been managed therefore no additional pain medications were ordered. The Attending Physician stated they and the Nurse Practitioner saw Resident #1 again when the blisters were popped, and a wound care consult was ordered at that time. The Attending Physician stated after the burns occurred, they saw Resident #1 within the next 2-3 days after the incident and they were alternating with the Nurse Practitioner making visits to see the resident. The Attending Physician stated they do not believe that the blisters Resident #1 sustained were from submerging their feet in hot water. Resident #1 sustained blisters only to the dorsum of their feet. The Attending Physician stated when they evaluated Resident #1, they only saw the blisters on the top of their feet. The Attending Physician stated the plantar surface of the foot skin is thicker and would take longer to develop blisters. The Attending Physician stated they had a discussion with the Administrator regarding not having the hot liquid carts on the unit and limiting the residents access to the hot water and they stated they would take care of this no problem. The Attending Physician stated they were not sure if a there is a policy about reporting these types of injures like burns. Maybe the Medical Director might know. They will ask and find out if one exists. During an interview on 2/20/2025 at 4:09 PM the Administrator stated they do not remember who informed them, but they were informed Resident #1 got a hold of some water somehow and had a blister on their foot. The Administrator stated they were further informed Resident #1 got the water from the hot liquid cart on the unit and instructed the staff to continue their investigation. The Administrator stated they were told Resident #1 called one of the staff to the room and informed them they got the hot water from the urn and put the water in a basin, placed their feet in the water and got a burn or blister or something like that. The Administrator stated they told the supervisor to treat Resident #1 and inform the physician. The Administrator stated they were not in the building when the incident occurred on 1/5/2025, but when they returned to the facility, they spoke about the details of the event in morning report and the investigation was taken over by the Assistant Director of Nursing. Since the incident, the steps they have implemented to prevent reoccurrence are they have a temperature log of when the hot liquid cart leaves the kitchen, the hot liquid cart are monitored by staff when they are in the dining room, and they have ongoing staff education on hot liquids. During an interview on 2/21/2025 at 1:15 PM the Director of Dietary Services stated the hot liquids get temperature tested, and they complete the testing three (3) times day as they are in the building for all three (3) meals throughout the day during the week. The Director of Dietary Services stated the hot liquids do not go to the units unless the temperature is between 115 and 125 degrees. The Director of Dietary Services stated most of the time the liquids are sent to the units at 120 degrees. The Director of Dietary Services stated the dietary aides place the hot liquid carts by the nurse's station when they deliver the truck to the units. The dietary aides do not leave the hot liquids on the unit until they locate a nurse to sign off on the delivery truck sheet. The Director of Dietary Services stated if a nurse is busy, a certified nurse assistant will assume the responsibility and sign for the carts. 10 NYCRR 415.12(h)(1)