Based on observation, facility policy review, staff interview, and resident interview, it was determined that the facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units, which placed residents at risk for burn injuries. (Homestead and B Unit) In addition, the facility failed to provide adequate supervision and interventions to prevent accidents related to hot beverages for one of 35 sampled residents which resulted in actual harm of a burn to the abdominal area. (Resident 105) These failures resulted in an Immediate Jeopardy situation. Findings include: Review of documentation by the American Burn Association's Burn Prevention Committee entitled, Scald Injury Prevention, revealed that a scald injury occurred when a hot liquid damaged one or more layers of skin and hot beverages were a frequent source of scald burns. Older adults were the most frequent victims of scald injuries due to thin skin, reduced mobility, and reduced ability to feel heat. Hot liquid at a temperature of 155 degrees Fahrenheit (F) could result in a scald injury in one second. Review of the facility policy entitled, Safety of Hot Liquids, last reviewed January 17, 2025, revealed that staff were to ensure that serving temperatures for hot liquids were maintained not more than 180 degrees F. The policy indicated that hot beverages could be served at temperatures greater than 155 degrees F, contrary to the safety parameters outlined by the American Burn Association's Burn Prevention Committee. Clinical record review revealed that Resident 105 had diagnoses that included Parkinson's disease (progressive movement disorder of the nervous system), Lewy body dementia (a type of dementia that damaged part of the brain that affects cognition, behaviors, and movement), Apraxia (a motor disorder caused by damage to the brain which causes difficulty to perform tasks or movements), xerosis cutis (dry skin), and anxiety. The Minimum Data Set assessment (a periodic evaluation of resident care needs) dated April 10, 2025, indicated that the resident was cognitively impaired and required assistance from staff to set up his meals. The care plan identified that Resident 105 was on a restorative nursing program (a program intended to restore or maintain a specific function) for feeding and that staff was to provide supervision for self-feeding during meals. On June 6, 2025, at 5:00 p.m., a nurse noted that while passing medication outside the (Homestead) unit dining room, Resident 105 was heard screaming. The Resident had a coffee cup turned upside down in his hand. A spill was noted to the abdomen and on his lap. Resident 105's clothing was removed and a burn was noted to the center of his abdomen that measured 15 centimeters (cm) by two cm. A verbal order by the physician instructed staff to cleanse the resident's abdominal burn with normal saline solution and apply sliver sulfadiazine ointment (a topical medication primarily used to prevent and treat infections in burn wounds) three times a day for five days and to monitor the burn every shift for changes. In addition, the Resident was to utilize a coffee cup with a lid to prevent future injury. A review of the food temperature form dated June 6, 2025, revealed that the temperature of the hot beverages for dinner were recorded in the kitchen as 174 degrees to 181 degrees F. There was no evidence that the hot beverages were retested prior to serving. On June 8, 2025, at 12:50 p.m., Resident 105 was observed unsupervised in the Homestead dining room drinking coffee. There was no lid on the cup. There was no evidence that the coffee was tested at the point of service. On June 9, 2025, at 11:40 a.m., Resident 105 was observed unsupervised in the Homestead dining room drinking coffee. There was no lid on the cup. There was no evidence that the coffee was tested at the point of service. Observation during a hot beverage audit conducted on the Homestead Unit on June 9, 2025, at 11:55 a.m., at the time the last resident beverage was served, it was determined that the coffee provided to residents and poured from an insulated carafe was 166 degrees F. In an interview during the audit, the Food Service Director confirmed the temperature of the coffee was 166 degrees F. In an interview on June 9, at 11:40 a.m., Activities Employee 1 (AE 1) stated that he did not test the temperature of the coffee before the start of service. He also stated that he did not typically test the temperature of the coffee before serving to residents. There was a lack of evidence to support that any staff were testing the temperature of the coffee before serving to residents. In an interview on June 9, 2025, at 11:45 a.m., Licensed Practical Nurse (LPN 1) stated that she did not typically test the temperature of the coffee before serving it to residents. In interviews on June 9, 2025, at 12:30 p.m., in the dining room on unit B, Residents 65 and 97 stated that the coffee was served too hot to drink and had to sit before drinking it. In an interview on June 9, 2025, at 1:45 p.m., the Director of Nursing stated that Resident 105 should have had a lid on the coffee cup when observed on June 8 and 9, 2025. On June 10, 2025, at 1:32 p.m., a physician noted that Resident 105 was assessed and that the burned area of the abdomen remained pink in color. On June 9, 2025, at 5:45 p.m., the Administrator was notified that the failure to ensure that hot beverages were served at a safe temperature constituted an Immediate Jeopardy situation at F689 K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility provided an acceptable action plan for removal of Immediate Jeopardy on June 9, 2025, at 9:45 p.m. The facility's action plan contained the following: 1. The temperature of hot beverages would be recorded by a dietary aide on a log at the start of every meal service at the tray line and before the hot beverages leave the kitchen. The temperature would not exceed 150 degrees F before leaving the kitchen. The dietary manager or designee would verify the temperature was taken correctly and sign the procedures on the Tray-Line Food Temperature Log. 2. The facility revised their policy to reflect a safe serving temperature of hot beverages to be between 130 degrees F and 150 degrees F. 3. All scheduled dietary staff who were onsite were educated on the safe service temperature of hot beverages and the procedure to monitor temperatures of hot beverages. The Director of Dining and Nutrition Services will be onsite prior to breakfast June 10, 2025, to educate the dietary staff on the revised Safety of Hot Liquids policy. All nursing and ancillary staff would be educated by June 10, 2025, at 11:59 p.m. Any staff member who was not educated by June 10, 2025, at 11:59 p.m., would not be able to work until the education was completed. Staff would be educated to notify supervisors of unacceptable hot beverage temperatures, and supervisors would be educated to report the high temperature of hot beverages to the dietary department. 4. The Dietary Manager or designee will update the meal tray ticket to ensure adaptive feeding equipment is added to the resident's tray. Nursing staff will ensure that the adaptive equipment is available for the resident's use. An adaptive feeding equipment audit will completed by the Director of Nursing or designee for five residents daily for two weeks and 20 residents weekly for four weeks. 5. The Administrator or designee will conduct audits of the temperature logs daily for two weeks and weekly for four weeks to ensure that temperatures were properly obtained and were within the safe range for service. The results of the audits will be reviewed at the monthly Quality Assurance Performance Improvement meeting. The Quality Assurance Performance Committee will determine the need for further audits. The survey team validated that Immediate Jeopardy was removed on June 9, 2025, at 9:45 p.m., through observation, staff interview, review of staff training, and review of the facility policy and procedure following the facility's implementation of the action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.