Based on observation, review of the facility's policy and procedures, facility documentation, clinical records, and staff interviews, it was determined the facility failed to ensure direct care staff were educated on the safe food heating/reheating process. This failure resulted in Immediate Jeopardy situation when it was determined a licensed nurse whom the facility failed to educate regarding safe food heating protocol failed to check the temperature of ramen soup after heating it in a microwave resulting in Resident 78 sustaining a second-degree burn to the chest. Failure of the facility to provide education to all direct care staff regarding safe food heating resulted in a situation that jeopardized the health and safety of Resident 78. This was identified as a past non-compliance situation. Findings include: Review of the facility's policy titled, Dietary Services: Food Palatability/Re-heating revision date of January 2021, revealed it is the policy of the facility, meals are prepared and readied at proper (safe and appetizing) temperature, meaning both appetizing to the resident and minimizing the risk for scalding burns. Further review of the same policy revealed food/beverages will be heated, stirred, temped (temperature taken), stirred again, and re-temped before delivery: Ensure no hot spots are in the food/beverages by stirring The temperature of the food/beverages will be taken before delivering the item to the resident; Temperatures of any hot food/beverage items, such as commercially processed and packaged ready-to-eat foods are at least 140 F and not exceed 165 F. Review of Resident 78's diagnosis list included Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), and Peripheral Vascular Disease (PVD-circulatory condition that affects blood vessels outside the heart and brain, particularly in the legs and arms). Review of Resident 78's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 5, 2025, revealed Resident 78 was cognitively intact and had no impairments of the upper extremities. Review of the Occupational Therapy (type of rehabilitation therapy that focuses on helping people perform the tasks necessary for daily life) progress notes dated March 18, 2025, revealed Resident 78 requires set-up assistance with feeding/eating. Observation conducted on May 6, 2025, at 10:00 a.m., revealed Resident 78 lying in bed without a shirt. A light red mark was observed on the resident's chest and abdomen. Interview with Resident 78 conducted on May 6, 2025, at 10:00 a.m. revealed, Resident 78 reported a few weeks ago, at nighttime (unable to provide exact date and time), he/she requested staff prepare him/her a cup of instant ramen noodle soup. The staff delivered the soup overfilled with hot water, enough that when he/she grabbed the cup, the soup spilled onto his/her chest which resulted in a burn. Review of the nursing progress notes dated April 1, 2025, at 10:08 p.m., revealed staff reported at approximately 4:30 p.m., the resident spilled soup on his/her chest area. The resident was noted with an intact reddened area measuring 12 x 15 cm. (centimeters) to the upper chest. The resident stated he/she was eating the noodle soup and some of it spilled on the chest. Review of the NP's (Nurse Practitioner) notes dated April 2, 2025, at 10:15 a.m., revealed resident was seen for chief complaint of burn/pain. Resident indicated, yesterday, one of the girls heated up my soup and there was more water in there than I was expecting so when I went to eat it, I spilled it on my chest. The resident complained of pain immediately but indicated area no longer painful unless it was touched. The NP ordered a treatment of Silvadene (medication used to treat burns) to the burn area and wound consult. Review of the wound care consult dated April 8, 2025, at 12:02 p.m., revealed resident was seen to assess mid chest post burn. The same consult revealed resident had a second-degree burn (damage to the outer layer of the skin and the underlying layer) measuring 12 x 12 cm field to the upper mid-chest and a 5.0 x 5.0 cm field inferior to the larger burn site. An order to continue the Silvadene to the burn area was initiated. Review of the facility's investigation, revealed a statement from licensed nurse Employee E3 indicating: At 4:30 p.m., I heated up a cup of noodles and some other food for [resident]. I brought the soup to him/her and left (room) to finish heating the rest of his/her food. When I returned to his/her room, his/her soup was all over him/her. I asked him/her what happened, (resident) said he/she spilled it on him/herself. His/her shirt was wet, and I asked him/her if I could remove it to look at his/her skin then I went to get the nurse. Review of clinical records and facility documentation failed to reveal documented evidence of food temperatures taken by Employee E3 indicating Employee E3 did not followed the facility's policy of safe food/beverages heating/reheating by not checking the soup temperature before serving the cup of ramen noodle soup to Resident 78. Interview with the Nursing Home Administrator (NHA) conducted on May 6, 2025, at noon, confirmed Employee E3, served Resident 78 the noodle soup without checking its temperature. The Nursing Home Administrator confirmed Employee E3 did not follow the facility's policy regarding the safe heating of the food/beverages. Further interview with the NHA revealed that all direct care staff which includes nurses and nursing assistants were not educated/trained regarding the facility policy and procedure on safe food/beverages heating/reheating to prevent burns. An Immediate Jeopardy situation was identified on May 6, 2025, at 1:36 p.m. and the Immediate Jeopardy template was presented to the NHA, regarding the facility's failure to ensure all direct staff were educated/trained on safe food/beverages heating/re-heating to prevent burns to the residents. The facility submitted and completed an immediate action plan on May 6, 2025, and was accepted on May 6, 2025, at 2:54 p.m. The facily's immediate action plan included the following: Education was provided to the staff (Employee E3); A whole house audit was conducted to check all microwaves in the facility had thermometers attached to it; All residents were assessed to ensure no other residents received a burn from re-heated food items; Process signage for re-heating food in the microwave were attached to the microwaves; House-wide education developed and implemented for all facility staff on re-heating process, education was implemented and presented during the new hire and agency orientation; Dietary performed audits to ensure thermometers are present and functioning on all microwaves in resident areas; Audits were completed and ongoing time a week for four weeks, then every other week times four; The outcome of audits will be reviewed at the QA meeting. The facility self identified the jeopardy at the time of the incident, April 1, 2025. The facility implemented a corrective action of education, whole house assessments, and monitoring audits. On May 7, 2025, after review of audits and documentation of completed employee education as well as interviews with 20 staff members revealed the facility had completed the interventions developed for the action plan on April 26, 2025. The Immediate Jeopardy was lifted on May 7, 2025, at 11:12 a.m., after confirmation 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 with Immediate Jeopardy lifted. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/24/23 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 6/14/24, 3/16/24, 8/24/23