**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 11/17/23, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #14) of five residents reviewed. Specifically, Resident #14 was care planned to receive a straw lid mug for hot beverages due to a history of spilling hot liquids and on observations, the resident received the mug with a hot liquid in it and there was no lid on the mug. The finding is: The policy and procedure (P&P) titled Food & Nutrition Services- Preparation and Service of Meals revised date 8/2023 documented it is the policy of the facility to maximize an individual's degree of independence in self-feeding. Each resident will be screened by Occupational Therapy (OT) upon admission/ readmission to facility with regards to their self-feeding skills and the need for adaptive devices to facilitate self-feeding. Reassessment at a later date will be done upon referral from the dietitian or nursing, rehabilitation maintenance check, and/or physician's recommendation. Once the OT has assessed the safest, highest practical level of independence able to be demonstrated by each individual resident, the OT will initiate an ADL (activities of daily living) care plan, including functional feeding levels, in addition to adaptive equipment as required to maintain resident goals. Recommendations for adaptive devices will be communicated to the Dietary Department by OT. Nutrition and Food Services will be responsible for placing the assistive device on the resident's tray when the trays are prepared in the Nutrition and Food Service's Kitchen. The P&P titled Adaptive Devices revised date 3/8/17 documented OT shall fabricate and purchase adaptive devices to enhance proper sitting/ supine posture, prevent further contractures or skin break-down, to support upper/lower extremities and to enhance independent function in ADL skills. The OT and/or COTA (certified occupational therapy assistant) will assess and issue adaptive devices to residents as needed. Device are monitored for appropriateness and effectiveness jointly by OT and Nursing Department. Devices are documented in OT evaluations, daily notes, progress notes, nursing assistant and resident chart care plans as needed. 1. Resident #14 has diagnoses including dysphagia (difficulty swallowing), Alzheimer's disease, and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 11/16/23 documented Resident #14 was understood, usually understands and severely cognitively impaired. Resident's functional status with eating was supervision with set- up help. The comprehensive care plan titled Plan of Care dated 3/4/23 documented resident had a potential for alteration in nutrition, hydration, and impaired skin due to hot beverage spills with incident dates of 4/8/21, 10/28/22, 12/15/22, and 4/21/23 all with no injuries. Under ADL function resident was self-care deficit with an intervention for adaptive feeding equipment recommendation of a straw lid mug with no straw for hot beverage- resident has history of removing lids. If falls asleep during meal, please remove cup from hand to prevent spilling. Review of the CP (care plan) Tasks dated 11/16/23 revealed under ADL Eating: Straw lid mug with no straw for hot beverage- resident has history of removing. If falls asleep during meals, please remove cup from hand to prevent spilling. During a lunch observation on 11/13/23 between 12:00 PM and 1:15 PM in the [NAME] (Unit 2) dining room Resident #14 was sitting at the table. The tray was served to the resident who received a plastic blue handled mug with a dark hot liquid in it. There was no cover on the mug or on the tray. The meal ticket with Resident #14's name on it documented Regular Diet-Pureed Honey and Straw Lid Mug for hot beverages. During a lunch observation on 11/16/23 between 12:00 PM and 12:35 PM in the [NAME] (Unit 2) dining room Resident #14 was sitting at their table and Licensed Practical Nurse (LPN) #1 brought over their tray and assisted them with set-up. Resident #14 received a blue plastic handle mug with hot liquid in it and no cover. Observation of the tray itself had no cover on it. Review of the resident's meal ticket revealed Straw Lid Mug for hot beverages. After alerting the staff they place a lid on the mug. Resident was accepting of the lid. Review of the Minor Incident Report dated 12/15/22 revealed Resident #14 spilled coffee on the front of their shirt with no injury noted. Care plan was followed. Resident received a straw lid mug with the lid on and was noted to have removed the cover and attempted to place the cover back on then proceeded to attempt to take a drink spilling coffee on the front of their shirt. Care plan was updated to reflect upright position in wheelchair (w/c). Review of the Minor Incident Report dated 4/21/23 revealed Resident #14 was at breakfast holding their coffee when they fell asleep, and the coffee spilled onto their upper thighs. Mug w/ lid noted to be on, some spilled out of the mouthpiece. No injuries were noted. Intervention included therapy referral which indicated resident to be appropriate for mug cups with lids, with no straws for beverages. Care plan modified for table change to move to a more central table. Review of the progress notes titled Occupational Therapy Note dated 5/1/23 revealed Resident #14 continues to be appropriate for mug cups with lids, with no straws for beverages. They continue to be independent following set up for meals. Review of the progress note titled Quarterly Nutritional Review dated 8/18/23 revealed under adaptive equipment; sectional plate, straw lid mug for hot beverages (h/o-history of removing lid), no straw. During an interview on 11/16/23 at 12:38 PM, the Diet Technician (DTR) stated by looking at the ticket I would think the Resident #14 should have a lid on their mug. The resident sometimes removes the lid. The staff preparing the tray and the staff member who was serving the tray should be double checking the ticket making sure the proper equipment was being provided. During an interview on 11/16/23 at 12:51 PM, LPN #1 stated they accidentally missed the cover for the straw lid mug. They stated they should have looked at the ticket and made sure the adaptive equipment matched what was on the tray to possibly help prevent injury. During an interview on 11/16/23 at 2:36 PM, the OT stated they recommended the straw lid mug for Resident #14's hot beverages because the resident has a history of spilling beverages on themselves. They expected the staff to be providing it with all hot beverages as it was to protect the resident from possible injuries. During an interview on 11/16/23 at 3:37 PM, Registered Nurse (RN) #1 Unit 2 Manger stated they would expect their staff to verify the meal ticket with what was on the tray to make sure the resident received the recommended adaptive equipment. They stated Resident #14 should have had a lid on the mug for their safety as there would be a risk of them spilling the liquid and possibly burning themselves. During an interview on 11/16/23 at 3:53 PM, the Director of Nursing (DON) stated they would expect their staff to review the tray ticket for accuracy. They stated the mug should have had a secured lid on it to help prevent spillage and could possibly cause a burn. They stated, It is unacceptable to provide the mug without the lid. 10 NYCRR 415.12(h)(2)