Based on observation, facility documentation, and clinical record review, as well as staff interviews, it was determined the facility failed to ensure the hot water dispensing machine produced water at a safe temperature resulting in actual harm to Resident R1 who sustained burns on the left thigh and groin, requiring treatment in an emergency room. This resulted in an Immediate Jeopardy, when it was determined that the facility failed to monitor the temperatures of the hot water dispensing machine and facility policy failed to identify hot beverage temperature parameters which had the potential to cause the residents discomfort or pain, to jeopardize the health and safety for 54 residents. Findings Include: Review of Resident R1's clinical record revealed diagnoses including but not limited to the following: Anxiety (intense, excessive and persistent worry and fear regarding everyday situations), Hydrocephalus (accumulation of cerebrospinal fluid (CSF) occurs within the brain typically causing increased pressure inside the skull. Older people may have headaches, double vision, poor balance, urinary incontinence, personality changes, or mental impairment ), and Hypertension (high blood pressure). Review of Resident R1's clinical record including nursing progress note dated July 13, 2024, at 5:20 p.m. revealed the resident spilled hot tea at dinner on her groin and inner thighs. Resident immediately transferred back to her room, placed in bed. Examined. Redness noted to inner thighs, left greater than right. Resident also complained of labial pain after initial exam. RN called on call, transfer to ED for exam. [Daughter] made aware. 911 called for transfer to ED (Emergency Department). [Local Police] Officer arrived and spoke with Resident. EMS arrived and transferred to [local hospital]. Further review of Resident R1's medical record revealed a wound consult from Doctor of Medicine (MD) dated July 16, 2024, indicating 8 Left, Medial Thigh (front) is an acute Partial Thickness Burn and has received a status of Not Healed. Initial wound encounter measurements are 1.8 centimeter (cm) length x 4.5 cm width x 0 cm depth, with an area of 8.1 sq cm. Additional review of Resident R1's clinical record revealed a progress note dated July 13, 2024, at 10:23 p.m. indicating the patient returned from the hospital with a dressing on [resident's] left thigh. Subsequent review of Resident R1's clinical record revealed a progress note dated July 14, 2024, at 11:24 a.m. indicating investigated incident recently of spillage of hot liquid onto resident lap. Resident and eyewitness report that resident was attempting to place 2 sugar packets in cup, while reaching resident struck spoon that was in vessel and subsequently spilled fluid onto lap. eyewitness (roommate) reports that table height was appropriate as both have identical w/c and require increased height to sit under table appropriately. Review of information dated July 13, 2024 submitted by the facility to Department of Health, on July 13, 2024, revealed The temperature of the hot tea was 150 degrees. The policy is that hot beverages are served no lower than 155 degrees. The machine from which the hot water was dispensed dispenses the water or coffee at 165 degrees. Interview with the Culinary and Nutritional Services Manager (Employee E1) on July 30, 2024, at 10:15 a.m. reported The only time we take temperatures of the [coffee and tea] is when the resident complains. Employee E1 reported they do not take daily temps of hot beverages. Further interview with Employee E1 on July 30, 2024, revealed the facility does not check the temperatures of hot beverages due to the State Operations Manual Appendix PP (Federal regulations for Skilled Nursing Facilities) does not specifically tell you when a drink is too hot. Review of facility policy titled Hot Beverages indicates Hot water and coffee will be dispensed at a temperature no lower than 155 degrees to ensure residents are receiving the highest quality beverages upon delivery. Director of Nursing (DON) on July 30, 2024, at 10:50 a.m. confirmed dietary staff did not take a temperature of the hot tea before giving to Resident R1; and Director of Nursing further indicated the facility had no policy in place for the use of the coffee machine for residents and no temperature logs in place prior to the resident being burned on July 13, 2024. The facility failed to have a policy and procedure in place for determining safe serving temperature of hot beverages from the dispensing machine for residents either at the time of service or periodically. An Immediate Jeopardy situation was identified on July 30, 2024, at 11:31 a.m. and the Immediate Jeopardy template was presented to the Director of Nursing (DON), regarding the facility's failure to ensure the prevention of burns sustained by one resident and placing additional residents at risk of serious burns due to lack of policy and procedure in place for the temping of hot water from the Hot Beverage dispensing machine for residents either at the time of service or periodically to ensure safe hot beverage service. The facility submitted an action plan on July 30, 2024, which included taking the hot beverage dispensing machine out of service until the dispensing machine can be serviced and dispensing temperature lowered. Developing a policy and procedure identifying a max temperature for liquids and taking the temperature of every hot beverage before serving and logging the temperatures. Temperature logs to be reviewed by Dining Manager or designee will audit the temperature logs daily for compliance. All dietary staff will be educated on the new policy and procedures for hot beverages prior to start of shift. The action plan was accepted on July 30, 2024, at 2:06 p.m. On July 31, 2024, a review of audits, documentation of completed employee education, and interviews with two dietary aids revealed the facility completed the interventions developed for the action plan on July 30, 2024. The Immediate Jeopardy was lifted on July 31, 2024, at 11:36 a.m. after confirmation that the action plan was implemented and completed. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services