**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 2 of 14 residents (Resident #17 and Resident #184) reviewed for accidents hazards from hot coffee. The facility failed to ensure safety measures were in place after Resident #184 received a second-degree burn (burns that involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful) from hot coffee that required treatment. The facility failed to ensure safety measures were in place to prevent Resident #17 from obtaining an injury from hot coffee. An Immediate Jeopardy (IJ) situation was identified on 05/09/23. The IJ template was provided to the facility on [DATE] at 11:14 a.m., While the IJ was removed on 05/10/23 at 4:14 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for serious burns, infection and even death. Findings included: 1.Record review of Resident 184's face sheet dated 12/02/20 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses including transverse radius fracture (wrist break), cerebrovascular accident (stroke - when blood flow to the brain is blocked), Dementia (impaired ability to remember), and depression (feeling sad). Record review of Resident #184's significant change in status MDS assessment dated [DATE] indicated she was usually understood and usually understood others. The MDS indicated Resident #184 was severely impaired (BIMS score was 02). The MDS indicated Resident 184 required total assist with transfers, dressing, bathing, extensive assist with bed mobility and supervision with eating. The MDS indicated Resident #184 had other skin problems requiring treatment. Record review of Resident #184's physician order summary report dated for the month of November 2022 did not indicate a treatment order for right upper leg. Record review of Resident #184's comprehensive care plan dated 12/01/22 indicated she was at risk for skin breakdown as evidenced by incontinence, impaired bed mobility and cognitive impairment. The interventions were to assist with repositioning as needed, give medication as ordered, assess skin weekly and report any changes to the physician. Record review of an incident report dated 11/19/22 at 7:00 a.m., indicated Resident #184 obtained three reddened areas to right upper leg from coffee spill. Area #1 measured approximately 3cmx2cm, area #2 measured approximately 5cmX1cm, and area #3 measured approximately 8cmX2cm. Resident #184 did complain of pain and received Morphine (pain medication) 0.25ml for pain. Resident #184 received a new order to apply Silvadene cream (medication to help heal burns) to affected areas twice daily for seven days. The incident report indicated the DON was notified on 11/19/23 at 8:10 a.m. During an interview on 05/10/23 at 2:09 p.m., LVN B said she was the nurse who assessed Resident #184 after staff reported she had spilled coffee on herself. LVN B said Resident #184 originally had three reddened areas but after reassessing after breakfast she developed a blister to area #3. LVN B said she notified the physician and received new treatment orders. LVN B said she did not know this was a reportable incident, but she reported the incident to the DON on 11/19/22. During an interview and observation on 05/07/23 at 9:40 a.m., observed two coffee pots sitting on side table assessable to residents, visitors, and staff. Dishwasher BB tested temperature on both coffee pots. The first coffee pot temperature was 147-degree Fahrenheit and second coffee pot temperature was 140-degree Fahrenheit. Dishwasher BB said she did not test the temperature of the coffee before pouring into the coffee pots. During an observation and interview on 05/08/23 at 1:41 p.m., observed two coffee pots sitting on side table assessable to residents, visitors, and staff. Dishwasher CC tested temperature on both coffee pots. The first coffee pot temperature was 149- degree Fahrenheit and second coffee pot temperature was 142-degree. Dishwasher CC said she had never tested the temperature of the coffee. During an interview on 05/08/23 at 1:42 p.m., the dietary manager said coffee pots were assessable to everyone on the side table. He said the coffee temperature was not checked prior to leaving the kitchen. The dietary manager said he was aware a resident received a coffee burn sometime last year but could not remember who. He said he was unaware of Resident #17's hot coffee spill on 05/05/23. He said they did not implement any changes in the kitchen after the Resident #184 received burns from the hot coffee. The dietary manager said he was not aware the coffee should have been checked prior to leaving the kitchen. The dietary manager said he tested the coffee periodically but did not have a log. The dietary manager said he would start a temperature log for the coffee. During an interview on 05/08/23 at 4:22 p.m., the DON said she was aware Resident #184 obtained a coffee burn but did not realize it needed to be reported to HHS. The DON said she thought if they knew what happen it was not reportable. The DON said they put a plan in place for Resident #184 which included supervision for meals and a two handled cup for safety after the coffee spill. The DON said they did not do any in-services or implement a plan for other residents who might be at risk of coffee burns because she had implemented a plan for Resident #184 and did not think about any other residents who might had been at risk. During an interview on 05/08/23 at 4:28 p.m., the ADON said she was aware Resident #184 received a coffee burn the following Monday, 11/21/22 after the incident occurred. The ADON said she was not aware this type of incident needed to be reported since they were aware of how the incident occurred. The ADON said she did not look at any other residents who could have been at risk because they implemented a plan for Resident #189 During an interview on 05/08/23 at 4:39 p.m., the Administrator said initially she was not aware Resident #184 had a burn from the coffee. The Administrator said at some point later she became aware Resident #184 had a burn. She said she did not report to HHS because they had implemented a plan to protect Resident #184 from further burns and when they tested the coffee shortly after Resident #184 spilled the coffee on herself, the temperature was within their policy range of 133-degree Fahrenheit. The ADM said she did not think about the risk of other residents after she learned about Resident #184 because it was an isolated event and they had implemented a plan for Resident #184. During an interview on 05/10/23 at 10:39 a.m., the facility physician said Resident #184 had a second degree burn from the spilled hot coffee. 2. Record review of Resident 17's face sheet dated 03/20/20 indicated he was a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses including psychotic disorders (severe mental disorders that cause abnormal thinking and perceptions), peripheral vascular disease {PVD} (problem with poor blood flow), arthritis (swelling and tenderness of joints), and Parkinson (a brain disorder that causes unintended or uncontrollable movements, such as shaking, and difficulty with balance and coordination). Record review of Resident #17's annual MDS assessment dated [DATE] indicated he was usually understood and usually understood others. The MDS indicated Resident #17 was moderately impaired (BIMS score was 08). The MDS indicated Resident 17 required limited assistance with personal hygiene, dressing and supervision with bed mobility, transfers, toileting, and eating. The MDS indicated Resident #17 was continent of bowel and bladder. Record review of Resident #17's comprehensive care plan dated 02/16/23 indicated he had cognitive impairment as evidenced by memory problems and impaired ability to make daily decisions. The interventions were to explain all procedures, allow time for task, and reorient as needed. Resident #17 was on a regular diet and needed supervision for eating. The interventions were to assist with setup, explain to Resident #17 where his food was using the clock method due to his blindness. Record review of Resident #17's incident report dated 05/05/23 at 8:15 p.m., revealed Resident #17 spilled his coffee on his left thigh and obtained a 3-inch X 1-inch reddened area to his left thigh area. During an observation on 05/09/23 at 7:21 a.m., several residents in dining room for breakfast and observed Resident #12 spilling coffee on his shirt while drinking. Resident #12 noted with tremors and had to have his other hand to help with mobility while drinking coffee. During an observation and interview on 05/09/23 at 08:25 a.m., Resident #17 was sitting up in a wheelchair in his room. Resident #17's left upper leg assessed with no injuries noted. Resident #17 said his left leg/thigh was fine. Resident #17 did not recall what happened 05/05/23 on the evening of the coffee spill. During an interview on 05/10/23 at 2:16 p.m., CNA F said she was the aide who took Resident #17 the coffee. CNA F said Resident #17 was sitting in his wheelchair when she brought in the coffee. CNA F said she was supposed to tell Resident #17 where his coffee was located because he was blind CNA F said before she could tell Resident #17 where his coffee was located on the table, he knocked it over spilling it on himself and the floor. CNA F said Resident #17 was wearing grey sweatpants when the coffee spilled. CNA F said she assisted Resident #17 to change his clothes, but she did not see any marks because he covered himself up. CNA F said she notified the nurse and then left the room. During an interview on 05/09/23 at 8:34 a.m., LVN E said she was the nurse on duty when Resident #17 spilled coffee on himself. LVN E said she assessed his left leg and noted a small, reddened area to his left inner thigh. LVN E said she did not think much about the reddened area because it was small, and Resident #17 said it was fine and he did not complain of pain. LVN E said she made a note about the coffee spill in the physicians' book at the nurse's station. LVN E said the physician would check the book on his next rounds. LVN E said she did not report Resident #17's reddened area to the physician because he did not have any visual openings to his skin; he had no pain, and it was a minor change. LVN E said it was important to notify the physicians of changes, but she did not feel this was anything major, so she did not notify the doctor. LVN E said she did not report the coffee spill on 05/05/23 to the DON or administrator because it was a redden area, it was not serious, and she knew what happened. LVN E said she did not realize the redden area from the coffee spill was considered a first-degree burn. During an interview on 05/10/23 at 10:39 a.m., the facility physician said Resident #17 had a first degree burn from spilled hot coffee. Record review of Resident #17's nurses note charted by LVNE dated 05/05/23 at 9:00 p.m., revealed Resident #17 spilled coffee on his left thigh. Denied pain. Red area 3-inchX1-inch noted to front of left thigh. Record review of Resident #17's nurses note dated 05/05/23 at 9:00 p.m., did not indicate any notification to physician, nurse managers or administrator. During an interview on 05/10/23 at 2:36 p.m., the ADON said she was not aware of hot coffee spilling on Resident #17's left thigh until Monday 05/08/23. The ADON said she was not aware this type of incident needed to be reported to HHS since they were aware of how the incidents occurred. The ADON said she now knows this was a reportable event. The ADON said because they initiated the hot liquid safety assessment on 05/09/23 she did identify some residents who would benefit from some added safety such as: assist with hot liquids, drink hot liquids only at the table or drink hot liquids in a cup with a lid. During an interview on 05/10/23 at 2:53 p.m., the DON said when any abnormal incidents occur such as a burn the nurses were supposed to call her or the administrator. The DON said she was not aware of Resident #17's coffee burn on 05/05/23 but identified it on 05/08/23. The DON said she did not know it needed to be reported to HHS. The DON said she after reading the reporting letter she was aware of the criteria of what to report to HHS. The DON said failure to investigate incidents properly could delay safety for others. During an interview on 05/10/23 at 3:26 p.m., the administrator said she became aware on 5/8/23 of Resident #17's coffee burn that occurred on 05/05/23. The administrator said she was not aware why staff had not reported the incident on 05/05/23. The administrator said she was the abuse coordinator and should have been notified when Resident #17 obtained the coffee burn. The administrator said she reread the guidelines for reporting to HHS on 05/09/23 and realized she should have reported Resident #184's and Resident #17's coffee burn within 2 hours after learning about them both. Record review of the facility policy titled, Accidents, Incidents, investigating and reporting, dated July 2017, indicated All incidents or accidents involving residents .occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor or charge nurse shall promptly initiate and document investigations of the or accident. The nurse supervisor or charge nurse shall complete a report of incident/accident form and submit the original to the director of nurse's services within 24 hours of the incident or accident. The director of nurse's shall ensure the administrator receives a copy of the report of incident/ accidents for each occurrence. Record review of the facility policy titled, Abuse prevention, dated May 2017, indicated The facility will assure that all residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. #4 E all injuries to a resident will have an incident report completed. Injuries of unknown origin will be investigated. Administrator and director of nursing will determine what injuries are to be reported to HHS per regulation. #7 the administrator will report all abuse, neglect, misappropriation of resident property allegations to HHS per regulation. This was determined to be an Immediate Jeopardy (IJ) situation on 05/09/23 at 10:33 a.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/09/23 at 11:04 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 05/10/23 at 2:14 p.m. and indicated the following: Immediate action: Implement measures to prevent other coffee spills with burns. Immediate removal of coffee from dining room coffee will be kept in the kitchen completed 5/9/23 at 10:45 AM. Coffee temperature immediately lowered to 110 degrees by adding ice. Coffee temperature will be maintained in a thermos. All hot liquids will be served at a safe temperature from our kitchen, per our policy for the safety of all residents. Completed 5/9/23 at 10:45 AM. Kitchen staff will check temperature of all hot/warm liquids before it leaves the kitchen. Resident #17 was screened by physical therapy and a recommendation of a cup with lid, screen completed 5/9/23 at 11:00 AM. In service all staff on setting up meals/drinks for all residents started on 5/9/23 by DON. (All staff to have in service completed prior to working next scheduled shift) currently 33 out of 39 staff members have been in-serviced. To be completed by 5/9/23. All staff in-serviced on safety procedures for serving hot liquids/coffee completed 5/9/23 by DON. (All staff to have in service completed prior to working next scheduled shift) currently 33 out of 39 staff members have been in-serviced. To be completed by 5/9/23. Added in-service on safety procedures for serving hot liquids to hire pack for all new employees to complete prior to working. Completed by business office 5/9/23. Hot liquid assessments to be done today for all residents 5/9/23. Completed on 5/9/23. Hot liquid assessments to be completed quarterly and on all admission done by a licensed nurse. Monitor temperature of hot liquid served to resident. All hot liquids will have temperature checked in kitchen prior to being served. Completed by kitchen staff. All kitchen staff will be in-serviced on new hot/warm beverage requirement. Completed 5/9/23 at 11:00 AM. Identify at risk residents: 15 residents at risk, all residents accessed for hot liquid safety done by nurse management 5/9/23. -amended 5/10/2023 coffee temperature per facility hot beverage policy. In-services: Coffee/hot liquid safety Safety procedures for serving hot liquids/coffee Assisting the impaired with in room meals Assistance with meals/snacks Monitoring: Interviews on 05/10/23 from 1:30 p.m. until 4:00 p.m. revealed the following: Interviews with 2 RNs: DON and RN L (6am-6pm); 1 LVN PRN nurses, (6a-2p),1 LVN B(6a-2p), 2 nurses (2a-10p), LVN B and LVN E (2p-10p), LVN K and LVN G (10p-6a), 3 CNA's (6a-2p) CNA N, CNA P and CNA Q,3 CNA's (2p-10p) CNA O CNA R and CNA F and 2 (10-6p) CNA AA and CNA S, 1 laundry T, 3 Housekeepers (8a-4p) Housekeeper U, housekeeper V and housekeeper W, 4 dietary (1p-7p) Dietary X Dietary Y, Dietary Z and cook D, Dietary Manager, Activity Director, ADON, and Adm in-serviced on hot liquid process. All coffee will come from the kitchen. Kitchen staff must test coffee temperature before serving to the residents. All hot liquids must be below 140 degrees Fahrenheit. Residents who need lids will be provided a cup with a lid. Record review of the facility policy titled, Hot beverage, dated 05/09/23, indicated Our long-term nursing care facility is committed to providing a safe and comfortable environment for all our residents, including their enjoyment of hot beverages such as coffee and tea. In accordance with state regulations, we have established the following policy regarding the temperature of hot beverages served in our facility. #1 hot beverages served will be cooled to a temperature below 140 degrees Fahrenheit. #2 residents that have been assessed to need hot beverages with a lid will receive their beverages in one. It will be delivered on their tray. #3 the temperature of hot beverages must be checked using a calibrated thermometer to ensure compliance with company policy before being served. #4 the kitchen staff will log the temperature of hot beverages on a hot temperature log once the beverage it is below 140 degrees Fahrenheit. #5 all hot beverages will go out on trays from the kitchen. #6 hot beverages that are not 140 or below must be cooled to 140 degrees Fahrenheit before being served to the resident. #7 all staff members involved in preparing and serving hot beverages must receive training on the proper temperature requirement for coffee and the importance of maintaining these standards. #9 residents who request hot beverages must be served promptly, but only with hot beverages that meet the temperature requirements outlined in this policy. On 05/10/2023 at 4:14 p.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.