**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of clinical record, and facility policy, the facility failed to ensure adequate supervision consistent with the resident's needs was provided to one resident (#3) to prevent an accident of spilling a hot liquid beverage. The deficient practice resulted in the resident sustaining a burn.-Findings include:Resident #3 was admitted to the facility May 31, 2025, with diagnoses of encephalopathy, attention and concentration deficit, cognitive communication deficit, frontal lobe and executive function deficit, weakness, and Alzheimer's disease.A brief interview for mental status (BIMS) assessment dated [DATE] revealed the resident had a score of 2, indicating severe cognitive impairment.The General Progress note dated May 31, 2025, revealed Resident #3 arrived via transport in a wheelchair, was a 2-person transfer into bed, and required 2-person assistance to change. Per the documentation, the resident was unable to verbalize needs or acknowledge the use of the call light, was combative with brief changes and medication distribution, and needed continuous rounds.The Hot Liquids Safety Evaluation dated May 31, 2025, revealed that Resident #3 did not have moderately to severely impaired cognition, despite documentation of cognitive impairment and combativeness. The evaluation also revealed that that the resident was not easily agitated, had no frequent impulsive acts/short tempered, had no weakness or paresis in the resident's upper extremities, and, had a mood that did not vary over the course of the day. Interventions selected from the Hot Liquids Safety Evaluation were for resident to use the dominant hand for drinking, for the temperature of drinks not to exceed 140 degrees, and for the resident to drink hot liquids while sitting at table only. However, there was no evidence found that the care plan was updated to include the interventions for the resident to use the dominant hand for drinking, for the temperature of drinks not to exceed 140 degrees, and for the resident to drink hot liquids while sitting at table only.A Mood/Behavior Note dated June 1, 2025, revealed the Certified Nursing Assistant (CNA) reported that when Resident #3 was checked in the morning, the resident was anxious and panicky. Per the documentation, Resident #3 had a diagnosis of Alzheimer's mixed with vascular dementia; and that, the encounter was of a serious nature. It also included that the resident told the CNA, I (referring to Resident #3) want to watch you (referring to the CNA) bleed. Further, the documentation included that the Director of Nursing (DON) and nurse practitioner (NP) were made aware of the behavior and statement made by Resident #3.The Skilled Evaluation note dated June 1, 2025 included that Resident #3 was oriented to person, was confused, had short term memory impairment, and had impaired decision-making ability.A General Progress Note dated June 1, 2025, revealed the resident was experiencing mood/behaviors in the evening when medications were given, and had pushed her medications away. Per the documentation, Resident #3 got agitated, raised her voice, had garbled speech, was impulsive, had tried to get up on her own, did not comprehend how to use the call light and had a disregard for her own safety. The documentation also included that the resident had done these the last two nights since admission; and that, the resident eventually took her medications after she was slowly instructed and explained to. Further, the documentation included that consistent rounding on Resident #3 was crucial to avoid a potential fall.An Occupational Therapy (OT) Evaluation dated June 2, 2025, revealed Resident #3 was right-hand dominant, had cognitive impairments, and required supervision or touching assistance when eating.The OT treatment encounter notes dated June 2 and June 3, 2025, included the resident required partial/moderate assistance with eating.The OT treatment encounter note dated June 4, 2025, revealed resident required set-up or clean-up assistance with eating.The OT treatment encounter note dated June 5, 2025, included resident #3 required supervision or touching assistance with eating.A provider encounter note dated June 6, 2025, revealed Resident #3 had significant dementia, so reminders were difficult, and that, she had poor impulse control and no safety awareness, so future falls were likely.The OT treatment encounter note dated June 9, 2025, included the resident required supervision or touching assistance with eating.A Change of Condition note dated June 10, 2025, revealed the resident was having difficulty taking her evening medications and was holding them in her mouth. The documentation included that the resident had difficulty understanding how to drink through a straw; and that, the straw was removed and the resident required total assistance to drink from the cup. Further, the documentation included that this seemed to only happen in the evenings during med pass.A Skilled Evaluation note dated June 12, 2025, revealed Resident #3 had an increase in confusion and behaviors today more than baseline due to cognition. The documentation included the resident was anxious and aggressive, had physical and verbal aggression with exit-seeking behaviors, and was continually getting out of her wheelchair and attempting to walk unassisted.An e-Mar (electronic Medication Administration Record) note dated June 14, 2025, revealed the resident was moved to a different table as she continued to turn and kept grabbing and putting hands on another resident sitting next to her.A Skilled Evaluation note dated June 14, 2025 included Resident #3 had some anxiety and minimal behaviors this morning, continued with inability to follow simple commands, and had no safety awareness leading to non-compliance with plan of care.The OT treatment encounter note dated June 17, 2025, included the resident required supervision or touching assistance with eating.The care plan dated June 17, 2025 revealed the resident had an Activities of Daily Living (ADL) deficit due to impaired balance and limited mobility. An intervention dated June 17, 2025 revealed that the resident required one staff participation to eat.The OT treatment encounter note dated June 23, 2025 included the resident required supervision or touching assistance with eating.An e-Mar note dated June 24, 2025 revealed the resident was displaying aggression and agitation toward a CNA.A Health Status Note dated June 25, 2025 included that at approximately 8:30 p.m., the resident was sitting on the floor in front of her bathroom. Per the documentation, the resident was not able to explain or tell nurse what she was trying to do.An e-Mar - Medication Administration Note dated June 25, 2025, revealed Resident #3 refused all medications in the evening and was verbally aggressive.A Discharge Planning note dated June 26, 2025 revealed the resident had no safety awareness and needed cues for all care including transfers, toileting, eating, dressing, and pressing her call light. Per the documentation, the resident was impulsive, and gets up without asking staff for help and that, this was also due to the resident's cognition.The OT treatment encounter note dated June 27, 2025 included the resident required supervision or touching assistance with eating.The general Progress note dated June 28, 2025 revealed that Resident #3 was up and down for the first three hours of the shift, had attempted to transfer herself three different times. The documentation included that the medication cart was parked outside of the resident's room where the nurse could watch her every move. Further, the documentation included that the resident was impulsive and persistent, but was not verbally aggressive.A General Progress Note dated June 29, 2025 included that the resident tried to go into other residents' rooms in another hall. Per the documentation, the resident was brought back to the hall where her room was; and that, she was verbally aggressive to the CNA and nurse for trying to keep her upright in her wheelchair. It also included that the resident attempted to scoot out of her wheelchair, was offered help to her bed but was verbally abusive again; and, had refused and spit all medications onto the floor.A Change of Condition note dated June 30, 2025 revealed the resident had a ground-level fall this morning onto her right side, and favoring her right arm. An x-ray for the right humerus/shoulder was ordered.The General Progress Note dated June 30, 2025 revealed the resident arrived back to the facility from the hospital; and, the resident had a proximal right humerus fracture, and a sling was applied. Per the documentation, the nurse reported that the resident had to have the sling on during the day and off in bed.There was no evidence that Resident #3 was re-assessed for safety with hot liquids after returning from the hospital with a right (dominant hand) humerus fracture until July 2, 2025, after an incident involving Resident #3 spilling hot coffee on herself.The clinical record was reviewed, and there was no evidence or documentation found in the clinical record regarding any incident on July 1, 2025, during breakfast time, that Resident #3 spilled coffee on herself.A Skilled Evaluation dated July 1, 2025, at 9:08 AM, revealed Resident #3 was very anxious, unable to sit still, which is her baseline. Her legs were swinging in the wheelchair, and she could not sit still.A General Progress Note dated July 1, 2025, revealed that the resident refused to go to the dining hall or even get out of bed for lunch today, even with two different staff encouraging her. Therapy worked with her, and was able to get her out of bed and assist her with lunch. Resident is right-handed and therapy worked with her to use her left hand. Therapy stated she will need assistance with meals. After therapy worked with the resident, the resident has been sleeping in bed.A General Progress Note dated July 1, 2025, revealed Resident #3 was up this evening in her chair so the CNA and nurse could keep an eye on her. She was extremely restless.The OT treatment encounter note dated July 1, 2025, revealed the resident required partial/moderate assistance with eating. Additionally, the documentation included that the resident had an injury to right upper extremity sustained and was now in sling. Skilled interventions included compensatory training to increase independence in self-feeding, self-feeding techniques; and, training in one-handed techniques during self-feeding.The OT treatment encounter note dated July 2, 2025 included the resident required partial/moderate assistance with eating.A Skin/Wound Note dated July 2, 2025 revealed the hall staff reported that Resident #3 sustained a burn of her right side of her abdomen yesterday with hot fluids; and that, the burn area was red and had a blister noted. It also included that the NP (nurse practitioner) was informed and silver sulfadiazine (SSD) cream was ordered to start twice a day until resolved.A Health Status Note dated July 2, 2025, included that the CNA reported that she reported to the charge nurse yesterday that the resident had an incident with hot liquid yesterday morning; and that, the resident was wet on her shirt and hands. Per the documentation, the charge nurse gave the direction to apply an ice pack; and that, the charge nurse would assess the patient. An ice pack was applied to the area at time of incident. The documentation also included that the CNA reported this morning that the resident has a red area on her abdomen and the wound nurse was called to look at the area. According to the documentation, the area was assessed by the nurse and the NP and it showed evidence of a burn, and has a blister at the lower portion of the burn; and that, silver sulfadiazine cream was applied to the area. Further, the note included an action plan to make sure coffee was lukewarm rather than hot, and to add ice if needed.A Summary for Providers note dated July 2, 2025 revealed the change in skin color or condition. The Functional Status Evaluation revealed the resident needed more assistance with ADLs, and had pain. The documentation included that a burn was noted to abdomen post incident of spilling coffee with recommendations to apply SSD (silver sulfadiazine) cream twice a day and leave open to air.A Weekly Skin Check dated July 2, 2025, revealed a red area on the abdomen, on the front of the right iliac crest, with a blister on the bottom section.A Pain Evaluation dated July 2, 2025, revealed Resident #3 did not have the ability to verbalize or communicate, had occasional labored breathing, had occasional moan or groan, sadness, was frightened, or was frowning, was tense, and had distressed pacing, or fidgeting.A Hot Liquids Safety Evaluation dated July 2, 2025, revealed the resident had moderately to severely impaired cognition, mood that varies over the course of the day, was easily agitated, hadweakness/paresis in the upper extremities, and had impaired functional mobility. Interventions included for the resident to use a cup with a lid, for temperatures of drinks not to exceed 140 degrees Fahrenheit, for the resident to drink hot liquids while sitting at table only, and for the resident to wear clothing protector/lap protector.A provider encounter note dated July 2, 2025, revealed the resident was very uncomfortable and Tylenol (analgesic) was not treating her pain adequately; and that, the plan was to order for oxycodone (narcotic opioid). Per the documentation, the resident's new fracture was resetting her progress with therapy and she will need to start all over; and, the resident's cognition was requiring increased time with therapies. New diagnosis included burn involving 2% total body surface area. The plan was to get an order for Silvadene in place, and have the wound care nurse practitioner look at the resident. Further, the documentation included that a care plan will be started to give the resident warm coffee versus hot coffee to avoid further injuries.Despite documentation of provider recommendations and interventions, there was no evidence that the care plan was updated to include the following interventions: serve the resident warm coffee instead of hot coffee, temperature of drinks not to exceed 140 degrees Fahrenheit, for resident to drink hot liquids while sitting at a table only, and for resident to wear clothing protector/lap protector.A care plan initiated and dated July 3, 2025, revealed the resident had dehydration or potential fluid deficit due to cognition. Intervention added on July 3, 2025 included only for Lids for hot fluids. The other recommendation/interventions such serving the resident warm coffee instead of hot coffee, temperature of drinks not to exceed 140 degrees Fahrenheit, drinking hot liquids while sitting at a table only and for resident to wear clothing protector/lap protector.A late entry General Progress Note dated July 3, 2025 revealed that on July 1, 2025, at approximately 7:45 a.m., a CNA (Staff #71) reported to the nurse (Staff #33) who was walking to the medication cart that Resident #3 had spilled some coffee on her; and that, the resident's clothes were changed by the CNA and an icepack was applied to the resident's abdomen. Per the documentation, the nurse checked the area after the resident's clothes were changed and an ice pack applied; and that, there was slight redness noted to the abdomen after the resident was done with breakfast.Another late entry General Progress Note dated July 3, 2025 included that on July 1, 2025 at approximately 10:00 a.m., the resident was checked very frequently for safety checks; and, the CNA had asked the nurse if it was okay to remove the icepack and this nurse stated that it was. The documentation included that the nurse checked the area and saw the same amount of redness to the resident's abdomen as earlier and after the icepack was removed.A Weekly Skin Check dated June 7, 2025, revealed a red area on the resident's right abdomen with scabbed area from a blister that has popped.A Nutritional Note dated July 7, 2025, revealed the resident was sitting in the dining room table during lunch on July 2, 2025, and spilled hot coffee on her lap. Per the documentation, the resident had an order for a lid and to drink hot liquids at the table; and, needed supervision and assistance with meals.Despite documentation, the clinical record revealed no evidence of any orders or reason why the other interventions were not included in the resident's care plan.There was no evidence that supervision and assistance with meals was provided to the resident to include the use of a lids for hot liquids or to drink hot liquids at the table.There was no documentation found in the clinical record of reason why these interventions were not implemented.A physician order dated July 9, 2025, revealed an order for an adaptive equipment - adult training cup. However, the order did not include specific directions related to its use and when will this cup be used.An observation was conducted July 11, 2025, at 8:23 a.m. Resident #3 was sitting at a table in the dining area of the unit and had a cup of juice in front of her. The Director of Nursing (DON) was sitting next to her and was assisting her with eating. The resident was not served with any hot beverage.An observation was conducted with the Lead Dietary Aide (Staff #87) on July 11, 2025, at 10:14 a.m. Staff #87 calibrated the thermometer in a cup of ice to confirm an accurate thermometer read, and then poured a cup of coffee from the coffee machine on the 400-hall unit, and took the temperature of the coffee. Staff #87 stated that the temperature of the coffee just poured was 156 degrees Fahrenheit (F).A skin observation of Resident #3 was conducted with a Licensed Practical Nurse (LPN / Staff #89) on July 11, 2025, at 11:40 a.m. The resident gave consent for observation, and in the privacy of the resident's room, the nurse lifted the resident's shirt to reveal the resident's abdomen. On the front of Resident #3's abdomen, toward her right side, was a red area of skin surrounding a scab. An interview with Staff #89 was conducted at this time, and Staff #89 stated that's a scab from the blister and it looks like it's shrinking. Staff #89 stated that the size of the blister was 2 centimeters (cm) by 3 cm.An additional observation was conducted of Resident #3 on July 11, 2025, at 12:39 p.m. A CNA (Staff #21) delivered a lunch tray to Resident #3 who was sitting up in her bed in her room, and the CNA remained in the room to assist the resident. The resident had an open cup with juice, with no lid, and no adaptive cup.An interview was conducted with a CNA (Staff #10) on July 10, 2025, at 3:11 p.m. The CNA stated that she was familiar with the residents on the 400 Hall, and that Resident #3 had dementia and is confused, and needs assistance and cues in order to eat. The CNA stated that Resident #3 is pretty impaired in her safety awareness and cognition.An interview was conducted with another CNA (Staff #21) on July 10, 2025, at 3:17 p.m. who stated that Resident #3 can sometimes feed herself if staff assist by cutting up her food and picking up the fork for her to get started, but sometimes staff have to provide total assistance with eating. The CNA stated that Resident #3 is pretty confused and while eating about a week and a half ago, the resident spilled coffee and had a blister. After the incident, the CNA stated that now we put lids on all hot drinks.An interview was conducted on July 10, 2025, at 3:26 p.m. with a Dietary Aide (Staff #60), who stated that both coffee makers (the one in the kitchen and the one on the 400 hall unit) have temperature controls that are set to 160 degrees F, and that back in November 2024, the facility had requested that dietary staff maintain the coffee machine temperature at 160 degrees, and check the temperature using thermometers when the coffee is poured to ensure it is 160 degrees. Staff #60 stated that there was not concern of coffee being too hot because dietary staff had not gotten any complaints of it being too hot, and that to his knowledge, nobody had spilled hot coffee on themselves.A phone interview was conducted on June 11, 2025, at 8:59 a.m. with a Registered Nurse (RN/staff #33), who stated she had never done any assessments for hot liquid risk, but that maybe the dietary staff completes this assessment. She stated she was the floor nurse at the time of the incident when resident #3 spilled her coffee. The RN said that she was walking past the CNA to her med cart at a little before 8:00 a.m. when she heard the CNA say that the resident spilled coffee on herself; and Staff #33 instructed for the CNA to stick an ice pack on it, and I'll (Staff #33) come look at it. The RN stated that she went and assessed the resident a little later at approximately between 9:00 a.m. and 9:30 a.m. and saw that the resident had no ice pack on, had a light redness on the abdomen; and, she assumed the redness was from the ice pack. The RN said that she looked at the resident's legs, arms, and abdomen, but that she did not look at the groin area; and that, she did not let anyone know of the incident and did not write a progress note about the incident on July 1.An interview was conducted with a CNA (Staff #71) on July 11, 2025, at 10:01 a.m. The CNA stated that she served residents in the unit coffee by getting a cup from the cupboards in the unit dining area, and pouring a cup of coffee from the coffee machine that was also located in that same dining area, and then serving those cups to the residents in the dining room. The CNA stated that on July 1, 2025, she assisted in getting Resident #3 to the dining area, then she poured the cup of coffee from the machine and set the cup of coffee with no lid on in front of Resident #3, and left the dining area to get up the next resident for breakfast. She stated that she got the next resident up for breakfast and brought that other resident into the dining area. The CNA stated that this was when she noticed that Resident #3 had spilled coffee on herself, and that the clothing of Resident #3 was wet on the front of her shirt and pants from the coffee. The CNA said that she changed the resident's clothing right away and informed the nurse (Staff #33) that there was redness on the resident's skin extending from her abdomen near the rib cage to her mid-thighs on both her legs. The CNA said that she checked on the resident's skin later in the day, and that the redness had gone down a little, but the area was still red. The CNA said that during the incident, there was one of the nurses at the nurse station who was coming in and out of the dining room; but, there were no staff at the dining table with Resident #3. The CNA said that the following day, on July 2, she was getting Resident #3 ready in the morning and checked her skin again, and that was when she noticed that she had a blistered area on the right side of her abdomen. The CNA said she told the nurse right away; and, after that incident, the facility management did an in-service training with everybody. She further stated that staff are now supposed to put lids on coffee cups and cool the coffee down before serving to the residents.A telephonic interview was attempted with a wound nurse / Registered Nurse (Staff #13) on July 11, 2025, at 12:27 p.m. A voicemail was left for a return call, and the staff did not return the call.An interview was conducted with an Occupational Therapist (OT / Staff #46) on July 11, 2025, at 12:42 p.m. The OT stated that she evaluated Resident #3 when she first admitted to the facility, and assessed the resident to have severe cognitive impairment, and that therapists were working on basic skills, including self-feeding. The OT stated that Resident #3 had been getting worse, and has been requiring more assistance. Staff #46 stated that Resident #3 would not be able to use any adaptive equipment for self-feeding because of her cognition.An additional interview was conducted with the Dietary Aid (Staff #60) on July 11, 2025, at 12:50 p.m. who stated that the kitchen has two-handled cups with lids and a drinking spout, and stated that it is called an adult training cup.An interview was conducted with the Director of Nursing (DON / Staff #90) on July 11, 2025, at 1:30 PM. The DON approached the surveyor and made a statement that Resident #3's order for the adaptive adult training cup is for hot beverages only.An interview was conducted with the Assistant Director of Nursing (ADON / Staff #106) on July 11, at 2:58 p.m., who stated that the nurses assess residents' risk with hot beverages by completing a hot liquids assessment for all residents upon admission, and that the admitting nurse is mostly the staff who completes the assessment. The ADON stated that staff would know to implement those interventions on the hot liquids assessment by word of mouth through report, and by notifying dietary, and those items are discussed by management in morning meetings. The ADON stated that temperatures of hot beverages are taken by dietary, and that nurses and CNAs do not temp the liquids before giving beverages to residents. The ADON confirmed she was at the facility on the date of Resident #3's coffee-spill incident on July 1, and to her knowledge, no management was notified of the incident. The ADON stated that Resident #3 was at the dining room table in the 400 unit and she had coffee spilled on herself, and the CNA took her to change her clothes, and notified the nurse. The ADON stated there was an ice pack applied to the resident. The ADON stated that she did not know how many times the nurse looked at the resident's skin on July 1. The ADON stated that the morning of July 2, 2025, she was informed of the incident by the floor nurse, and the resident had a blister on her abdomen and that the wound nurse was involved in assessing it and getting an order for treatment. The ADON stated that the wound nurse determined that the resident's skin condition was a blister, and it was assumed it came from the coffee spill because the CNA was relaying the details of the incident at that time on July 2. The ADON stated that in the beginning of the resident's stay, she did not require assistance with eating, however when the resident returned to the facility from the hospital with a new humerus fracture in her arm, then she needed assistance with eating, and that is when she would have needed assistance with hot liquids. The ADON also stated that Resident #3 has always been impulsive and has had anxiety and behaviors. The ADON stated that the hot liquids assessment was completed on initial admission, but was not completed for the resident when she returned from the hospital with her humerus fracture. The Hot Liquids Safety Evaluation dated May 31, 2025, was reviewed together regarding the intervention that hot beverage temperatures not to exceed 140 degrees. The ADON stated that it would take a matter of seconds for a CNA to fill a cup of coffee on the 400 hall and hand it to resident at the dining table in the same room. The ADON also stated that I don't think you could determine how fast (the coffee) would take to cool down and the CNAs don't temp the coffee when they pour and serve it in the 400-hall dining area.An additional interview was conducted with the DON on July 11, 2025, at 3:19 p.m. The DON stated that the nursing staff assess residents' cognition upon assessment through the initial admission assessment and through the BIMS assessment that is completed. The DON stated that that the nursing staff assess each resident's risk for hot liquids on admission, and also quarterly, and also if there has been a change in that resident and it needs to be re-assessed. The DON stated that the importance of that assessment is to prevent burns and injury acquired from hot liquids. The DON stated that the assessment asks questions such as determining the resident's dominant hand, if the resident needs a particular degree liquid, if the resident has weaknesses in their hand or extremities, tremors, and that it also addresses the resident's cognition. The DON stated that all of those factors determine the resident's risk with hot liquids. The DON stated that the interventions on that assessment such as beverage lids and temperature would be care-planned and communicated to the CNAs. The DON stated that the facility implements the temperature intervention when the hot beverage is poured and brought to resident, that she would imagine the temperature of the beverage would drop by the time the resident is served. The DON stated she believed it is the kitchen staff's responsibility to ensure the hot beverages are within the parameters, and that the staff on the 400-hall do not temp the coffee there, that the temperature is set from the machine. Regarding Resident #3's coffee-spill incident, the DON stated it happened around 7:45 in the morning, and that she did not know if the CNA was there. The DON stated she did not know who served the resident coffee. The DON stated that she was not aware of any staff who were at the table with the resident at the time of the incident. The DON stated that the resident spilled the coffee, and then the CNA noticed it, and stopped to notify the nurse about the coffee spilled on the resident, the nurse said she would come in and evaluate her, and then the CNA changed the resident's clothes. The DON stated the CNA took off the resident's clothing that was soaked, and the nurse and evaluated the resident's skin and asked the CNA to put ice on it. After the CNA changed the resident's clothes, the resident was taken back out to breakfast. After breakfast, the DON said that the nurse looked at the resident again and thought the redness was from the ice pack, and the nurse removed the ice and left it open to air and dry. The DON stated that the nurse told her, in follow-up conversations, that she put eyes on the resident's skin twice, and it was red both times. The following day, the CNA (Staff #71) let the nurses know, because she had worked the day before, and she wanted the nurse to know about the situation. The DON stated that the wound nurse (Staff #13) assessed the resident and determined it to be a burn, and got orders from the provider to treat it. The DON stated that after this incident, that the facility has done in-services to staff regarding the hot liquid safety assessment, and making sure liquids are not too hot, and that they are not supposed to be higher than 140 degrees. The DON stated that the resident she should have been re-assessed for hot liquids risk after her return from the hospital with the humerus fracture. The DON stated that moving forward, if Resident #3 asks for coffee, then staff will take the temperature of it and be sure it is less than 135 degrees.Review of the State Operation Manual, Appendix PP, issued August 8, 2024, revealed that for water temperature of 155 degrees F, the contact time required for a third degree burn to occur is 1 second.Review of the facility policy titled Food Temperatures, revised December, 2020, revealed the purpose is to provide the nutrition services department with guidelines for food preparation and service temperatures. Acceptable serving temperature of coffee indicated at equal to or greater than 135 degrees F.Review of the facility policy titled Behavior Management, revised June 2020, revealed the purpose is to implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. Additionally, to ensure that Facility Staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions. The concept of behavior management is an interdisciplinary process. The key components of this process are identifying residents whose behaviors may pose a risk to self or others and developing individual and practical care strategies based on assessed needs. The facility must provide necessary behavioral health care and services which include ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.Review of the facility policy titled Care Planning, revised October 24, 2022, revealed the purpose is to ensur