Inspection·February 4, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to ensure staff monitored temperature of hot liquids to mitigate the risk of injury. This failure resulted in actual harm to one resident (Resident R1), who sustained burn injuries to the chest and upper thigh.Findings include:Findings include:Review of the facility policy titled Safety of Hot Liquids, dated October 2014, revealed facility interventions to prevent burns included maintaining hot liquid serving temperatures at no more than 180 degrees Fahrenheit.Review of a facility procedure, undated and untitled, stated: All liquids heated in the microwave should be heated at 6 ounces per one beverage setting cycle.Review of information dated January 21, 2026, submitted by the facility to the Department of Health, revealed Resident R1 sustained first- and second-degree burns to the right chest and lateral right thigh from hot tea. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure (heart's inability to pump sufficient amount of blood throughout the body) and muscle wasting and Atrophy (thinning of the muscle mass). Further review of the clinical record revealed Resident R1 was discharged home on January 22, 2026.Review of Resident R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident R1 had a BIMS score of 15, indicating intact cognitive function. The MDS further indicated Resident was independent with eating.Review of Resident R1's clinical record revealed an Occupational Therapy treatment note dated October 2025 which indicated Resident R1 required set-up and clean-up assistance for meals.Review of Resident R1's clinical record including nursing progress note dated January 15, 2026, at 9:50 p.m., revealed Resident R1 spilled hot tea on (his/her) right chest and right hip. Skin slightly red and thin layer of skin peeling off. Resident was reclining the recliner chair, and caught the bottom of the bedside table, tilting the table and spilling the hot tea onto resident.Review of Resident R1's skin evaluation completed by a Wound Specialist on January 20, 2026, identified two burn wounds:Right posterior thigh: full-thickness wound measuring 13.7 cm x 5 cm, depth unmeasurable due to tissue overgrowthRight chest: wound measuring 4 cm x 5.6 cm, depth unmeasurable due to tissue overgrowthWound treatment orders for the right posterior thigh included:Xeroform (non-adhesive) gauze applied three times per week and as needed for 30 daysSterile gauze sponge applied three times per week and as needed for 30 daysRetention tape applied three times per week and as needed for 30 daysWound treatment orders for the right chest included:Xeroform (non-adhesive) gauze applied three times per week and as needed for 30 daysSterile gauze sponge applied three times per week and as needed for 30 daysRetention tape applied three times per week and as needed for 30 daysReview of the facility's investigative report completed by the Director of Nursing (DON) on January 16, 2026, at 9:16 a.m., indicated Resident R1 was provided hot tea of an unknown temperature.Review of facility investigation documents revealed a written statement by Certified Nursing Assistant (CNA) Employee E3 dated January 15, 2026; At change (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395631 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE United Zion Retirement Communi 722 Furnace Hill Pike Lititz, PA 17543 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)