**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of fifteen residents reviewed for abuse. The facility failed to protect Resident #1 from being verbally abused by SA on April 29th 2024. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began. This failure placed all residents at the facility at risk of severe psychosocial harm by being forced to interact with an employee that verbally abuses residents. The findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female with an admission date of 01/12/2023. Pertinent diagnoses included depression unspecified (patient is primarily depressive but does not meet the full criteria for any specific depressive disorder) and type 2 diabetes mellitus. Record review of Resident #1's quarterly MDS assessment section C, cognitive patterns, dated 05/29/2024 reflected a BIMS score of 15 (cognition intact). Record Review of Resident #5's face sheet reflected a [AGE] year-old male with an admission date of 03/10/2024. Pertinent diagnoses included depression unspecified, generalized anxiety disorder, and alcohol-induced persisting dementia (damage to the brain caused by regularly drinking alcohol over many years resulting in memory loss and difficulty thinking things through). Record review of Resident #5's quarterly MDS assessment section C, cognitive patterns, dated 06/06/2024 reflected a BIMS score of 13 (cognition intact). Record review of Resident #6's face sheet reflected a [AGE] year-old female with an admission date of 06/04/2024. Pertinent diagnoses included vascular dementia (general term for problems with reasoning, planning, judgement, memory and other thought processes), anxiety disorder, unspecified depression, and bipolar disorder (mental illness causing unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of Resident #6's MDS assessment section C, cognitive patterns, dated 06/10/2024 reflected a BIMS score of 13 (cognition intact). Record review of the provider investigation report dated 05/01/2024 revealed that on 04/29/2024 The alleged perpetrator (SA) was in the patio washing the concrete area. This is when the alleged victim (Resident #1) started confronting the alleged perpetrator about washing the concrete during smoke break. According to witness' the alleged perpetrator became upset with the alleged victim and cussed at her. Once the facility was advised of the incident at about 2:15 PM., the Administrator suspended the alleged victim pending the outcome of the investigation. The provider investigation report found the results of the investigation to be inconclusive. Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #1 stating I went outside to have a cigarette after lunch. SA was wetting down the patio (smoke area) with the water hose, I asked why he was doing that, he said they asked him to. So I went inside to find his boss (HR) to tell her he was not passing cigarettes because he was cleaning the patio. She asked why I was telling her. I said because you are his boss and I went outside to where he was then pouring liquid soap. Then HR came out and asked if he was giving cigarettes out, he said in a few minutes, but he was on the first part of the patio. At this point I told him his head was a little big with his job, and I was tired of him being so controlling. He said fuck you, I said what did you say to me? He said it a little louder. I am not defending my behavior, but I did not deserve that. I went and to SSD, then administrator and my witnesses came forward and corroborated my complaint. The DON came and talked to me, and again before she left for the night. Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #7 stating I heard SA, the smoke monitor, tell Resident #1 'Fuck you.' 4/29/24 Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from FT stating On April 29th I was outside SA was scrubbing the patio and Resident #1 came outside and asked for a cigarette. He told her she had to wait she questioned why they had to wait and his reply was after she asked what did you say and he said 'fuck you.' Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse was conducted by the Administrator with the SA on 04/28/24 and signed in ink by both. In an interview with SM on 08/06/2024 at 10:41 AM, SM stated that the patio was open to residents that wish to smoke from 7 AM to 7 PM. SM stated there was a lunch break from 12 PM to 1 PM where the patio was closed for smoking. SM stated that he was familiar with SA and he had heard from residents that SA would frequently yell and cuss at all of them. SM stated he was not familiar with any specific incident involving Resident #1, and that he had not started working yet at the facility on 04/29/2024. In an interview with Resident #5 on 08/06/2024 at 1:07 AM, Resident #5 stated that SA would cuss and yell at all the residents in the smoking area. Resident #5 stated that he was aware of the incident involving Resident #1 when SA said Fuck you to her on 04/29/2024, but could not elaborate further on other incidents. In an interview with Resident #6 on 08/06/2024 at 2:49 PM, Resident #6 stated that SA told one of the ladies in the smoking area to Fuck off. Resident #6 stated that she was not there at the time of the incident, but that she heard it from everyone that goes out to the patio to smoke. In an interview with Resident #1 on 08/07/2024 at 9:50 AM, Resident #1 stated that SA said fuck you to her. Resident #1 stated that a lot of other residents were out there and heard it as well. Resident #1 stated that she immediately reported the incident to the Administrator. Resident #1 stated that SA was suspended, but that he came back to work as a maintenance person and that she had seen him walking around the building. In an interview with HR on 08/07/2024 at 11:09 AM, HR stated that the last day SA worked was on 07/10/2024. HR stated that SA was not fired after the verbal abuse incident. HR stated the reason SA no longer works at the facility was because he stopped showing up for work after 07/10/2024. In an interview with the Administrator on 08/07/2024 at 11:33 AM, the Administrator stated that, during the initial incident on 04/29/2024, Resident #1 was upset because SA was washing the patio and not handing out cigarettes. The Administrator stated that SA allegedly told Resident #1 to fuck off when she told him to stop cleaning the patio. The Administrator stated they reported the incident to Texas Department of Health and Human Services for verbal abuse and suspended SA. The Administrator stated that SA was suspended for a few days before returning to work, but he could not remember exactly how long the suspension lasted. In a follow-up interview with Resident #1 on 08/08/2024 at 9:41 AM, Resident #1 stated that when the incident first occurred, she felt embarrassed and anxious because she did not like being talked to that way in front of other residents. Resident #1 stated that after the incident, when she saw SA working in the facility, she felt fearful that he might confront her because she made him change job roles at the facility. Resident #1 stated that there was one incident once SA returned to work at the facility where he was painting other resident's doors outside her room in the 300 hall. Resident #1 stated that a lot of her fear and anxiety returned when she saw him so close to her room. Resident #1 stated that she felt like the facility did not care to protect her from him, or future aggressors if a similar event happened again. In a follow-up interview with the Administrator on 08/08/2024 at 10:53 AM, the Administrator stated that the findings of the provider investigation were inconclusive because SA never admitted to saying fuck you. The Administrator refused to answer if he had reasonable suspicion on whether SA said fuck you to Resident #1. The Administrator stated that verbal abuse of this nature does not reach the threshold of needing to call the police. The Administrator stated that the resident never voiced any concerns about SA still working at the facility. The Administrator stated that this incident did not violate Resident #1's rights because she could have waited a few minutes for her cigarette. The Administrator stated that he did not know if SSD did wellness checks on Resident #1 after the incident. In an interview with the SSD on 08/08/2024 at 1:20 PM, the SSD stated approximately two weeks after SA was suspended where Resident #1 saw SA painting the doors near Resident #1's room. SSD stated that Resident #1 was upset at that time, but SSD calmed Resident #1 down and let Resident #1 know that SA would finish his work soon. SSD stated that was the only incident she was aware of involving Resident #1 and SA after the incident on 04/29/2024. In an interview with the DON on 08/08/2024 at 1:25 PM, the DON stated that she talked with Resident #1 a few weeks after the incident and Resident #1 expressed concerns about SA still working in the facility. The DON stated that she reported this to the Administrator and SSD. Record review of the Time Card Report for SA revealed that on the day of the incident, 04/29/2024, SA clocked out at 2:44 PM. The Time Card report revealed that on the day after the incident, 04/30/2024, SA worked from 7:01 AM to 7:16 PM with a break from 11:57 AM to 12:37 PM. Record Review of the facility's undated policy titled Abuse Prevention defined Verbal Abuse as The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Following that, in the section titled PROCEDURE: STEPS TO PREVENT, DETECT AND REPORT: SCREENING: #3 stated It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Record review of the facility's policy titled Statement of Resident Rights dated 07/20/2015 stated under the DIGNITIY AND RESPECT section You have the right to: Be free from abuse, neglect, and exploitation. Be treated with dignity, courtesy, consideration, and respect. Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance. Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. Record review of the facility's Abuse Prevention policy and procedure undated. Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation for 1 of 5 residents (Resident #1) reviewed for neglect and abuse. The facility failed to report verbal abuse by the SA to local law enforcement in accordance with state law on 04/29/24 The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of the undated facility Abuse, Neglect, and Exploitation policy stated the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Definitions: b). Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Procedure: A. Steps to prevent, detect, and report: Screening: Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security act's time limits for reporting a reasonable crime (immediately but no later than 2 hours if serious bodily injury and 24 hours for all others) In addition to reporting to the state agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency. Record review of the facility policy reference to Section 1150B of the Social Security Act: Guidance for Reporting Suspicion of a Crime. Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility to State Survey Agencies and Law Enforcement. Record review of Resident #1's face sheet revealed a [AGE] year-old female with diagnoses including diabetes, neuropathy, rheumatoid arthritis, heart disease, chronic skin infections, anxiety, left below the knee amputation. Record review of Resident #1's MDS Quarterly dated 05/28/24 revealed Resident #1 had a BIMS Score of 15 indicating no cognitive impairment and needed little to no assistance with all ADLs. Record review of the provider's investigation dated 05/01/24 described on 04/28/24, the smoking attendant became upset with Resident #1 and cursed at her twice telling her Fuck You each time during a smoking break. There was a total of 4 residents who attested to, witnessed, and confirmed the incident. The provider investigation included Penal Code Title 9 Ch. 42 Sec. 42.01 Disorderly conduct (a) a person commits an offense if he intentionally or knowingly: (1) uses abusive, indecent, profane, or vulgar language in a public place, and the language by its very utterance tends to incite an immediate breach of the peace (a-1) (d) An offense under this section is a class C misdemeanor. There was no Case # and local law enforcement were not contacted. There was a signed 1:1 Teachable Moment dated 04/29/24 between the ADM and the SA. The employee was suspended initially and in-serviced on the importance of respecting the residents. The details revealed the employ was in the smoking area and cussed at one of the residents. The SA was not available for interview. Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse reflected the in-service was conducted by the ADM with the SA on 04/28/24 and signed in ink by both. Record review of the SA's time sheets dated 03/21/24-07/10/24 documented he was sent home on [DATE] at 2:44 pm. He returned to work on 04/30/24 from 7:01 am-7:16 pm. The record showed he worked Tuesdays, Thursdays, and Saturdays regularly and occasionally on a Monday or Friday. The SA was never suspended for his verbal abuse, he was only sent home early as reflected on his time sheets In an interview with Resident #1 on 08/07/2024 at 9:48 am she stated the SA specifically said, fuck you and she asked him, what did you say to me? and he said it again, louder. Resident #1 stated this happened on the smoking patio and lots of other people were out there. She stated she reported it immediately to the SW who sent her to the ADM, and she told him about the incident. She stated, First the SW and DON told her they fired him (the SA), then suspended him, but then he was back. Resident #1 stated, Since then, he (SA) either quit or got fired probably 3-4 weeks ago. She said did not speak to him, nor him to her when he came back. She stated she saw him around 3-4 times, and became very anxious each time. She said seeing him would ruin her day. She said she did not know what she was afraid of but felt unprotected. She said she spoke with the SW and asked the ADM why the SA was still around. She said she asked to see the report he (the ADM) sent because he had gone back & forth with her about when & if he called the state. Resident #1 stated the ADM told her if she kept causing trouble, she could find herself on the street. She stated HR had joined their conversation and told her, The state had more to worry about than her. She stated the ADM was not joking with her and had raised his voice to her. In an interview with HR on 08/07/2024 at 11:09 am she stated she (Resident #1) came to me about the smoke guy (SA) and said, who the F was I to let this MF clean the patio when we trying to smoke. HR stated she had never had any situations with the SA, that he was a good guy. HR stated the SA just stopped coming to work on July 10, 2024, and that was the day she terminated him. She stated she tried to call him, but he never answered her calls. HR stated the SA came to pick up his check and he told her his truck broke, and that was that. She stated the ADM had to tell Resident #1 she could not speak that way to them. In an interview with the ADM on 08/07/2024 at 11:34 am he stated he was not at the facility during the first encounter Resident #1 had with HR because he was at lunch. He stated Resident #1 wanted to speak to him in his office and she said she told the SA he should not be doing that (washing the smoking patio) right then and that he (the SA) cursed at her. The ADM stated he suspended the SA immediately then reported it to the state for verbal abuse. The ADM stated the SA was allowed to return after his suspension and was moved to a different role (light maintenance and painting) so he would not have any contact with Resident #1. The ADM stated the SA ended up leaving/quitting. In an interview with Resident #1 on 08/08/24 at 9:41 am, she stated that she felt embarrassed and anxious because she did not like being talked to by the SA in such a negative way in front of other residents. She stated that she felt fear and anxiety seeing him (the SA) around the facility after the incident. The resident stated that when they did not get rid of him right away, she felt like the facility did not care to protect her. In an interview the ADM on 08/08/24 at 10:53 am, he stated, The findings were inconclusive because the man (SA) never admitted to saying fuck you to the resident. He said signing the 1:1 was not an admission of guilt, it only meant he received the 1:1 training. The ADM repeated that the SA never admitted to it. He said a teachable moment (the 1:1 training) was just a record of a verbal reprimand. The ADM said there was no policy that stated what the punishment was for abusing a resident. The ADM said his conclusion of his investigation was inconclusive. He stated the allegation met the definition of verbal abuse, but his findings were inconclusive. The ADM refused to answer whether the incident had reasonable suspicion of a crime (verbal abuse) if the smoking attendant said fuck you to the resident. The ADM stated, In my opinion verbal abuse does not reach the threshold of needing to call the police (meaning he did not notify local law enforcement). If you want to get me for not following my policy, then that is fine. The ADM stated he did not know if the social worker did wellness checks on Resident #1 after the incident. In an interview with the DON on 08/08/24 at 1:25 pm, she stated she talked with Resident #1 a few weeks after the incident, and she was concerned about the SA still working in the facility. She stated, I eased her concerns and said he would not bother her. I reported this to the administrator and the social services director. She stated she did not know if the ADM or SW spoke to Resident #1. In an interview with the ADM on 8/9/24 at 4:00 PM, he stated, The SA was suspended for 3 or 4 days, then he had some days off behind it, making it seem longer. The ADM had no comment regarding the SA's timesheets. Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance. Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. Record review of the facility's Abuse Prevention policy and procedure undated. Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided for the resident's immediate care and needs for 1 of 5 residents (Resident #3) reviewed for physician services. The facility failed to ensure there were orders for R#3's type 2 diabetes mellitus with hyperglycemia. On 12/22/23 at 3:55 PM an Immediate Jeopardy (IJ) was identified., while the IJ was removed on 12/23/23 at 6:30pm, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death. The findings included: Record review of R#3's Face Sheet, dated 12/22/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus ( a chronic condition that affects the way the body processes blood sugar ) with hyperglycemia (high blood sugar), cerebral infarction (damage to tissue in the brain due to disrupted blood supply and restricted oxygen supply) unspecified, Osteomyelitis (infection of the bone), unspecified and urinary tract infection (infection in any part of the urinary system, the kidneys, bladder or urethra), site not specified. Record review of R#3's undated baseline care plan revealed a section titled DIABETES, with a goal of Efforts will be made to ensure symptom control without complication, Documentation in this section was comprised of check of questions and areas to be filled in. First line checked had a FSBS q (fingerstick blood sugars to be each/every) printed with AC/HS (before meals and at bedtime) written in. Third line was checked off and had Sliding Scale? printed with As ordered 12/15/23 written in. The 5th line that stated Monitor for S&S (signs and symptoms) of hypo/hyperglycemia (Low and high blood sugar) was not checked off and had no written documentation noted. Record review of R#3's undated MDS (Minimum Data Set) assessment received on 12/22/23 revealed R#3 had a BIMS score of 10 which meant the resident was moderately cognitively impaired. R#3's MDS also revealed he had clear speech, was able to make self-understood, and understood others. Record review of R#3's hospital's Discharge summary dated [DATE] stated, T2DM (type 2 diabetes melilotus), SSI (sliding scale insulin), Continue glargine (insulin) 10 units and Monitor closely for worsening hyperglycemia (high blood sugar) in the context of Solu-Medrol (steroid). Record review of R#3's discharge home medication list from the hospital dated 12/05/23 did not include any diabetic medication, injection, or blood sugar checks. Record Review of R#3's Admission/readmission data summary dated 12/06/23 and completed by LVN A stated R#3 had a diagnosis of Diabetes Mellitus and hyperosmolar hyperglycemic (life threatening complication from diabetes, happens when blood sugar is too high for long period of time, leading to severe dehydration and confusion). R#3 was documented as alert and able to make self-understood and understand others. LVN A documented that she verified medication with nurse from the hospital due to the improper list sent from the hospital and had the orders documented as verified with NP C (nurse practitioner) by LVN A. Record review of R#3's orders revealed he had no orders for any diabetic medication, injection, or blood sugar check until 12/15/23. Record review of R#3's orders revealed an order for CBC (complete blood count), CMP (comprehensive metabolic panel), ESR (erythrocyte sedimentation rate), CRP (c-reactive protein) Q (every) week while on ABT (antibiotic therapy) IV (intravenous) dated 12/06/23. Record review of R#3's laboratory results date collected 12/09/23, revealed R#3's glucose result of 288mg/dL (reference range 70-100) and was flagged as high, no A1C (blood test that shows what your average blood sugar (glucose) level was over the past two to three months) was noted as ordered. Written note on this document stated Physician D was notified on 12/11/23 but did not indicate by who. Record review of R#3's nursing note dated 12/14/23 at 7:40pm by RN B stated R#3 appeared confused and agitated. R#3's speech was impaired and was unable to be understood and was unable to answer simple questions. Vitals were documented however there was no fingerstick blood sugar completed. Record review of R#3's transfer form completed by RN B on 12/14/23 at 7:40pm stated R#3 was sent to the emergency room due to a change in LOC (level of consciousness). Record review of R#3's hospital document titled Patient Visit Information dated 12/14/23 stated R#3 was seen for hyperglycemia, UTI, and dehydration. This document also included Dr's instructions to Make sure that you are checking your blood sugars and having them taken care of with your medicines. You were found to have a urinary tract infection. There is no evidence of diabetic ketoacidosis today. During interview with hospital staff member on 12/21/23 at 12:34pm, hospital staff member reviewed R#3's hospital stay information from 12/14/23, she stated blood sugars taken by the EMS who transported resident read high and did not provide a numerical reading. R#3's blood sugar was taken at the hospital on [DATE] at 8:51pm and it was at 647. R#3 was given 15 units of insulin. R#3 was found with a primary impression of hyperglycemia, a secondary impression of UTI, and dehydration with discharge instructions provided on 12/14/23 at 11:57pm. R#3's hospital documentation has been requested but not yet received as of 01/04/23. During an interview with NP C on 12/20/23 at 4:43pm, he stated he did not recall if he had ordered an A1C for R#3. He stated an A1C should have been ordered. NP C stated diabetic patients should be put on monitoring and did not know why R#3 was not. NP C stated R#3 should have been put on insulin per protocol with a sliding scale, blood sugar check, and lab work. NP C stated he was at the facility on 12/09/23, 12/10/23, and 12/11/23 and he reviewed R#3's medications and chart. He stated, for whatever reason it went right over my head and there was a decrease in observance in this one particular item. During an interview on 12/22/23 at 2:45pm with LVN A, she stated she was the admitting nurse when R#3 was admitted . She stated when R#3 came into the facility the medication list she received was not the same one they usually receive. LVN A stated she called the nurse at the hospital to go over the medications and to check if it was correct. LVN A stated the only changes made was to the blood pressure medication. LVN A stated she did not recall if she asked the hospital nurse about insulin. LVN A stated she asked the hospital nurse if anything else needed to be added and she told her no. LVN A stated R#3's admission paperwork did state he had diabetes but did not have orders for insulin or blood sugar checks. LVN A stated she called NP C and went over the medications. LVN A stated when she asked about the labs, NP C stated he would go over the hospital labs and would see R#3 when he was at the facility. LVN A stated she had told NP C about R#3's diagnosis of hyperglycemia and NP C did not add any new orders. LVN A stated she did not recall if she asked NP C about blood sugar checks. During an interview with RN B on 12/27/23 at 8:47am she stated on 12/14/23 she had been rounding on R#3 and he was in bed acting normal. RN B stated right before 8:00pm R#3's family went to RN B and told her they thought something was wrong with R#3. RN B stated when she entered R#3's room she noted him to be all over the bed and he looked completely different. RN B stated R#3 was flopping about the bed but not purposely, and he appeared anxious and unable to focus. RN B stated R#3 looked at her like a stranger and she knew he was checked out. RN B stated she took one look at his pupils and called 911. RN B stated R#3 had a serious change in LOC (level of consciousness). RN B stated she had no idea what happened to him. RN B stated she took R#3's vital signs. She stated they were not horrible or wonderful. She stated at the time R#3's blood pressure was running high and was not unexpected. RN B stated she did not take blood sugar reading for R#3,she did not know R#3 was diabetic, but later in the interview she stated she knew he was diabetic. RN B stated R#3 did not have any orders for blood sugar checks, diabetic medication, or insulin. RN B stated when the EMS staff (emergency medical service) arrived R#3 had a blood sugar reading greater than 500 per EMS. RN B stated she never asked NP C or Physician D about orders for blood sugar checks or diabetic medication/insulin. During an interview with NP C on 12/27/23 at 9:10am, he stated the process for medication reconciliation upon admission was the staff should call him to review the medication discharge list with him. He stated, to see if they want to keep the medications, add, or subtract medications. NP C stated he could not recall if someone called him to go over R#3's medications. NP C stated everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. NP C stated he did not know if he knew R#3 was diabetic on 12/06/23. NP C stated he was aware R#3 was a diabetic when they told him R#3 had elevated blood sugars and they treated him immediately. NP C stated protocol for a regular diabetic would be to start them back on medication, sliding scale insulin, to monitor daily blood sugars throughout the day, and get lab work completed. NP C was asked about R#3's lab results from 12/09/23 and he stated a glucose level of 288 was considered elevated. NP C stated he usually does not treat unless glucose is over 150 and it depended on the patient's compliance. NP C stated he did not remember if any staff from the facility including the DON, or nursing staff asked him or physician D about adding blood sugar checks and/or diabetic medication/insulin. NP C stated he did not know why nothing was put in place for R#3 until 12/15/23. When asked about the facilities policy regarding monitoring, supervising, and getting orders for diabetic medication, insulin, and blood sugar checks NP C stated he did not know. He stated they had protocols but not everyone got blood sugar checks. NP C stated a resident would have to be assessed to see the circumstances before testing them. NP C stated he monitored residents to ensure appropriate orders were in place for their needs by rounding on them multiple times a month, reviewing their medications, looking at notes, and speaking with nursing about any incidents or concerns that may have occurred between his visits. He stated he also visits with the residents. NP C was asked how not monitoring blood sugars or not administering diabetic medication/insulin to a diabetic can negatively impact them, and he stated it was not that the resident was not monitored. He stated when he received the elevated sugars he was treated immediately. NP C stated he reviewed R#3's medications and stated he managed medication and symptoms as they presented themselves. During an interview on 12/27/23 at 9:51am with LVN A, she stated depending on the orders, the admitting nurse or anyone such as the ADON or the DON who checked the admission afterwards, would be responsible for identifying if a resident was diabetic and required blood sugar checks. LVN A stated when working and receiving a new patient with a diagnosis of diabetes, she usually looked for any oral diabetic medications, insulin, or sliding scales. During an interview with Physician D on 12/27/23 at 10:51am, he stated the process for medication reconciliation upon admission was for the admitting nurse to discuss whether to continue or hold medications with the mid-level professional (NP C). If the mid-level (NP C) was not available the admitting nurse would discuss medications with Physician D. Physician D stated he did not get the initial admission so it would have been his mid-level, NP C. Physician D stated all of us were responsible for ensuring residents had the appropriate orders to meet their needs and maintain their safety. Physician D stated he had reviewed R#3's hospital information and the note he saw on the discharge summary stated R#3 was diabetic and hyperosmolar hyperglycemia state. He was aware R#3 had been given 10 units of insulin and on a sliding scale due tohis sugar level that went up to 600 and required an increase of insulin to 20 units. Physician D stated he read where it stated to monitor and watch for hypoglycemia when tapering the steroid (Solu-Medrol). Physician D stated the way it was written, was as if R#3's blood sugars were rampant due to the steroid he was taking, and saw it as R#3's increase in sugar levels were steroid induced. Physician D stated when R#3 was discharged from the hospital his discharge medication list had no diabetic medications. Physician D stated he checked with the DON to see if anything was communicated from the hospital nurses to facility nurses about blood sugar checks, insulin, diabetic medication, or if R#3 was diabetically fragile and the DON stated no. Physician D stated they were monitoring R#3's labs and there was 1 lab done on admission. He stated the blood sugar was trending down after the initial admission labs. Physician D was asked about R#3's lab results from 12/09/23, Physician D stated he thought he saw those lab results on 12/13/23 or 12/14/23. Physician D stated glucose of 288 was high but not critical and stated R#3 still had the steroid in his system. Physician D stated he did not give any new orders at that time for blood sugar checks or diabetic medication or insulin. Physician D stated they had discussed blood sugars and previous steroids and decided they would continue to monitor and see how it was trending. Physician D stated ideally, yes, a diabetic would get fingerstick blood sugar checks and an A1C. He stated they did not get communication, so the transition of care was poor, and took a little long for them to pick up on the issue. Once it was picked up, they acted immediately. Physician D stated R#3 went to the hospital and ended up having a UTI. Physician D stated R#3 did not have any orders for blood sugar checks or diabetic medication/insulin because they were not aware. He stated if they knew they were diabetic then blood sugar checks, A1C, and diabetic regimen based off labs would be protocol. Physician D stated no staff asked him or NP C about adding blood sugar checks or diabetic medication/insulin. Physician D stated he was not personally notified of R#3's change in level of consciousness on 12/14/23. He stated that would have gone through NP C. Physician D stated based on facility policy if they knew 100% the resident was a diabetic and depending on their needs, would require various monitoring such as more frequent blood sugar checks, sliding scale, and A1C several times a year to adjust regimen. Physician D stated he monitored residents to ensure appropriate orders were in place for their needs through the DON. The nursing staff look at the resident and communicate anything that had come up with himself or NP C during their visits. Physician D stated, this was a one off because from the hospital side what transpired and their lack of whatever. Physician D stated not monitoring blood sugar checks, A1C's, and not administering diabetic medication and insulin to a diabetic resident could negatively impact to become hypoglycemic or hyperglycemic. During an interview with the DON on 12/27/23 at 3:55pm, she stated the process for medication reconciliation upon admission was for the admitting nurse to review medication with the nurse practitioner or physician. The DON stated on 12/07/23 she reviewed R#3's chart thoroughly and went over it with Physician D and they agreed to stay with the medication and regimen the way it was. The DON stated she was aware R#3 was a diabetic in the context of Solu-Medrol (steroid) and had not read the part in the hospital discharge summary that stated to continue with blood sugar monitoring due to high sugars. She stated she did not go based off that because it was from 12/05/23 and he was discharged [DATE]. The DON stated R#3 was not sent with any insulin and when LVN A reviewed medications with the nurse from hospital she did not say anything. The DON stated Physician D received R#3's updated chart on 12/07/23 when she reviewed it with him. She stated NP C got the information in their general admission email. The DON stated LVN A had documented that she went over the medication list with NP C. The DON was asked about R#3's lab results from 12/09/23 and stated a glucose level of 288 was considered high. The DON stated when she spoke to Physician D on 12/11/23, about labs from 12/09/23, they also reviewed labs from 12/06/23 in the hospital and stated they noted a lower glucose than his hospital labs on 12/06/23. The DON stated she received a call back on 12/11/23 at 11:32am and received no new orders for diabetic interventions, insulin, or blood sugar checks. The DON stated she followed the physicians' orders and stated Physician D was convinced R#3's blood sugars were in the context of Solu-Medrol (steroid). The DON stated she reviewed with Physician D and he was saying they were going in the right direction that the Solu-Medrol was going out of R#3's system and his glucose was decreasing. The DON stated the nurse (LVN B) on 12/14/23 documented that R#3 had a change in level of consciousness and told her R#3 could not get his words out correctly. The DON stated they do diabetic protocol as ordered by the physician. The DON stated she monitored residents to ensure appropriate orders were in place for their needs by collecting all orders from medical records every morning and making sure they were in place. She stated she will run order audits, especially with labs stating she would note any abnormal labs and if physician was notified. The DON stated normally they were on their diabetic residents, stating it was just this one case that was different because of the Solu-Medrol. The DON was asked how not monitoring blood sugars, not administering diabetic medication/insulin to a diabetic can negatively impact them and she stated they could go into diabetic keto acidosis (DKA- A serious diabetes complication where the body produces excess blood acids). During an interview on 12/27/2 at 4:50pm with R#3, he stated on 12/14/23 his sugar was too high. R#3 stated when he was in the hospital prior to arriving at the facility they were giving him shots (insulin) and when he arrived at the facility the shots stopped. R#3 stated when he was at the facility he was not on insulin and took his medications and thought he was on Metformin (diabetic medication). R3# stated at time of incident on 12/14/23 he was not having his blood sugar checked at the facility. Record review of the facility's Policy titled, Resident Assessment admission Orders with an effective date implemented 11/28/2017 stated, The facility must have physician orders for the residents immediate care. Record review of the facility's Policy titled, Physician Services/Physician Supervision with an effective date implemented 11/28/2017 stated, A physician must supervise the medical care of each resident. This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 3:55 PM. The administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 12/22/23 at 4:08pm The following Plan of Removal (POR) submitted by the facility was accepted on 12/23/23 at 12:06 PM: PLAN OF REMOVAL F710 The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of physician services: Regional Director of Operations re-educated Administrator on ensuring residents were receiving necessary and accurate physician services on new admissions on 12/22/2023. Regional Nurse Consultant for facility educated Director of Nursing on receiving practitioner's intended protocols for alleged deficient practice as related to physician services on 12/22/2023. Licensed facility personnel to perform audit on all current residents to assess diagnoses that could require order for diagnostics and present to practitioner for evaluation and orders as determined by primary care practitioner or designee. 12/23/2023. DON/designee to have complete re-education of licensed nursing personnel on new admission orders, including communication with the practitioner about diagnostics and diagnoses as ordered by practitioner by 12/23/2023. Facility DON and administrator discussed findings from survey allegations with medical director and practitioner responsible for resident care in question with understanding of allegation noted and medical director implementing standing orders for labs to indicate further monitoring needed upon MD, and practitioner under his/her direction, assessment of findings from labs drawn. Orders to be given by MD and/or practitioner under his/her direction, based on their clinical expertise and licensing, with facility to follow orders as indicated. 12/22/2023 Protocol to be initiated for lab and diagnostics on new admissions as facility practitioner designates and orders by 12/23/2023. Interventions and Monitoring Plan to Ensure Compliance Quickly: oThe Director of Nursing/Designee educating all licensed nursing staff on documentation in the clinical record of new admission verification and reconciliation of orders to include labs and diagnostics per resident practitioner orders. Initiated: 12/21/2023 Completion: 12/23/2023 oStanding orders for admission labs received from medical director with follow up orders on continuation of labs to be determined by practitioner according to findings and evaluation of individual resident needs. Initiated: 12/22/2023 Completed: 12/22/2023 oNew admission order assessment and completion audits will be completed 3 times a week for 4 weeks and then weekly from thereafter by DON/ADON/Designee. Initiated: 12/22/2023 Completion: 12/23/2023 oImmediate action to notify physician and receive new orders on residents identified through audit findings for potential adverse notations in diagnostics with appropriate documentation at such time of notification. Initiated: 12/22/2023 Completion: 12/23/2023 oStaff that are on leave from the facility will be re-educated by DON/ADON/Designee on documentation in the clinical record of new admission verification and reconciliation of orders to include labs and diagnostics per resident practitioner orders before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 12/22/2023 Completion: 12/23/2023. oFacility will initiate weekly admission meeting with interdisciplinary team to review previous week admissions to include physician and/or designee for re-verification of orders. Initiated: 12/22/2023 Completion 12/23/2023 oAudit sheets for admissions to be reviewed by DON/ADON/Designee for completion at least weekly during facility admission meeting. Initiated: 12/22/2023 Completed: 12/23/2023 oThe policy and procedure already in place for orders and physician services was reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with no changes to policies to be implemented. Continue to follow policy on physician services as previously implemented, to include any new procedures as ordered. Initiated: 12/22/2023 Completed: 12/23/2023 oFacility Administrator will ensure implementation and completion of interventions through individual communication with team members and medical practitioners, as well as weekly CAR meetings and QAPI meetings as indicated below. Initiated: 12/22/2023 Completed: 12/23/2023 The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate physician services, including new admission orders, are followed and maintained per current facility policy on physician services. The Medical Director was notified of Immediate Jeopardy on 12/22/2023 and will be part of the QAPI intervention meetings. Procedures on new admissions and physician services to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress. The state surveyor confirmed the facility's Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy that included: Interview with the Administrator on 12/23/23 at 12:45 PM revealed he was responsible for ensuring all POR interventions were implemented. The Administrator said he implemented a meeting with all IDT every morning Monday-Friday (initiated 12/22/23) to discuss corrective action plan coordination, completion, and follow-up for 3 weeks. The Administrator said he would review all in-services and along with IDT, would review all new admission orders for maintenance of the facility's physician services policy. The Administrator said the IDT, including himself, would discuss and review POR/POC status monthly for the next 3 months. Interview with the DON on 12/23/23 at 12:59 PM revealed she acknowledged she received training and provided her nursing staff training on: Standing Laboratory Orders (new procedure implemented after IJ) to include: CBC, CMP, HA1C, TSH, Lipid Panel (blood test to measure amount of cholesterol and triglycerides in your blood), Pre-Albumin (a protein that's made by the liver) for all new admissions to get a baseline of each resident. The DON said she also provided in-servicing for her licensed staff regarding admission documentation to include medication reconciliation, known history, diagnostics, and assessments. The DON said she informed/reminded her licensed staff on immediate notification of physician upon new admissions, reviewing of medications, orders, and history of diagnoses. The DON said she and her ADON conducted 100% of chart reviews which included 49 residents with a history of or current diagnosis of diabetes. The DON said 9 residents did not have a HA1C, or diabetic blood glucose monitoring ordered so their physicians were called and lab and monitoring orders were received. The DON added that 9 residents receiving hospice services did not have any labs ordered which the physicians were contacted, and orders remained the same. The DON said she implemented a Monitoring Tool - admission Audit Form which she and the ADON were responsible for conducting audits of every new admission to ensure: consent for treatment were received, Notify Physician of Admission, Diagnosis, Meds, Diagnostics, Lab Standing Orders initiated, Documentation of medications, dx, diagnostics .The DON stated the audits would continue for at least 3 months and results would be reviewed by IDT monthly in QAPI meetings. Interview with the following staff on 12/23/23 revealed they were able to verbalize the procedure for reporting a change in resident condition which included to immediately notify the nurse of any change in condition: 1:05 PM - CNA E (6A-2P shift) 1:15 PM - CNA F (6A-2P shift) 1:27 PM - CNA G (6A-2P shift) 1:35 PM - CNA H (6A-2P shift) 2:00 PM - CNA I (2P-10P shift) 2:13 PM - CNA J (2P-10P shift) 2:22 PM - CNA K (2P-10P shift) 2:28 PM - CNA L (10P-6A shift) 2:33 PM - CNA M (10P-6A shift The following staff (from different shifts) were interviewed on 12/23/23 and revealed all staff were trained on 12/22/23 regarding admission Standing Lab Orders, Physician Services, admission Documentation, Contacting Physician of New Admissions, Diabetic Monitoring. All staff were aware and verbalized the procedures per the facility's policy and procedures. 2:48 PM - LVN N (7P-7A shift) 3:20 PM - LVN O (11P-7A shift) 3:32 PM- LVN P (7P-7A shift) 3:40 PM -LVN Q (7A-3P shift) 3:56 PM -RN R (Weekend/PRN shift) 4:10 PM -LVN S (7A-3P shift) 4:29 PM -LVN T (7A-3P shift) 4:40 PM -RN B (7P-7A shift) 4:57 PM - LVN U (3P-11P shift) Record review of the facility in-services provided by the Regional Nurse Consultant reflected the DON received education on 12/22/23 Regarding Physician Services specifically addressing oversight by the DON of monitoring adherence to current policies and procedures for physician services and order reviews to include lab monitoring for specific diagnoses and documentation of physician or practitioner preferences and orders. Understanding of all education verbalized with plan for QAPI utilization and involvement as well as audits in place for monitoring of adherence. Record review of the facility in-services provided by the Regional [NAME] President of Operations reflected the Administrator received education on 12/22/23 Regarding the importance of physician services specifically addressing oversight and monitoring adherence to current policies and procedures for physician services and order reviews. Record review of the facility in-services provided by the Administrator reflected the Physician D and NP C received education on 12/22/23 Regarding Physician Services, specifically the indication of monitoring of diagnoses to be addressed on a case-by-case basis. Both individuals acknowledged their understanding of monitoring of said diagnosis. Interview with NP C on 12/23/23 at 5:14 PM revealed he acknowledged he received training regarding physician orders, specifically ordering lab, monitoring, and treatment for specific diagnoses: Diabetes. The NP said moving forward he will ask every nurse who call and/or report to him of any resident if the resident was diabetic and if Hemoglobin A1C and daily monitoring was ordered. Record review of the following resident records revealed they had a diagnosis of diabetes mellitus and had a HA1C and an order for diabetic glucose monitoring; Care plans were current and reflected diagnosis: -R#3 -R#6 -R#7 -R#8 The Administrator was informed the Immediate Jeopardy (IJ) was removed on 12/23/23 at 6:30PM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure services were provided using proper safety techniques to prevent accidents for 1 of 3 resident reviewed for accidents, Resident #2 (R #2) in that: The facility failed to ensure the Dietary Aide checked temperature of soup given to resident resulting in R #2 sustaining a second degree burn injuries. The non-compliance was identified as Past Non Compliance. The Immediate Jeopardy (IJ) began on 05/12/23 and ended on 05/17/23. The facility corrected the non-compliance before the investigation began. This failure could lead to the injury of residents that are served hot foods/beverages/liquids. The findings included: Record review of Resident #2's (R#2) clinical file revealed a [AGE] year-old male, with an original admission date of 3/21/2019. Diagnoses included, Heart Failure, lack of expected normal physiological development in childhood, Cellulitis (bacterial infection of the skin), Edema (swelling caused by too much fluid trapped in the body's tissues), Shortness of Breath, Bilateral Osteoarthritis of hip (cartilage in the hip joint gradually wears away), Idiopathic Aseptic Necrosis of Femur (death of bone tissue due to interruption of the blood supply), Type 2 Diabetes (insufficient production of insulin causing high blood sugar), local infection of the skin and subcutaneous tissue, Morbid Obesity(chronic disease in which a person has a body mass index of 40 or higher), Hypertension (high blood pressure), and Gastroparesis (delayed gastric emptying consisting of weak muscular contractions of the stomach). Record review of R #2's Minimum Data Set assessment dated [DATE] revealed R#2 had a BIMS score of 12 (Moderate Impairment), required supervision with eating (Oversight, encouragement, or cueing. Coding 1: Setup help only. Coding 0: Independent: no help or staff oversight at any time), limited supervision with personal hygiene, and extensive assistance with bed mobility, dressing, and toilet use. Record review of R #2's Care Plan dated 5/12/2023 revealed R#2 sustained blisters to lower abdomen, upper thigh and right groin while eating soup. Record Review of R #2's orders dated 5/12/2023 stated: burn to right groin, cleanse with normal saline, pat dry with 4x4 gauze, apply Silvadene cream 1%. Apply twice a day for 7 days. burn to right upper thigh, cleanse with normal saline, pat dry with 4x4 gauze, apply Silvadene cream 1% twice a day for 7 days. Order Dated 5/25/2023 burn wound of the right lower lateral abdomen, cleanse with normal saline, pat dry with 4x4 gauze, apply Silvadene cream 1%, cover with ABD (abdominal) pad and dry dressing daily until resolved. burn wound of the right anterior upper thigh, cleanse with normal saline, pat dry with 4x4 gauze, apply Silvadene cream 1%, cover with ABD (abdominal) pad and dry dressing daily until resolved. Interview on 8/1/2023 at 2:18 pm with Dietary Manager revealed she was not working the day of the incident but was aware of the situation. Dietary Manager stated R#2 asked for soup in-between meals, which was rare and the dietary aide, took it upon herself to heat up the soup on the gas stove, put it in a bowl once heated, and served it to the resident. Dietary Manager stated there was no temperature record of what temperature the soup was at the time it was served to the resident. Dietary Manager stated, a dietary aide is not supposed to handle hot foods and should only be handling cold foods and dessert like foods. Dietary Manger stated on that day, dietary aide just thought she could heat up the food and serve the soup to R#2, not thinking it would cause an accident. Interview with R#2 on 8/1/2023 at 3:32 pm. revealed he was lying in bed and was sick with pneumonia on the day of the incident when R#2 asked staff for some chicken soup. R#2 stated someone brought him soup and did not ask for him to check to see if soup was hot. R#2 did state that the staff member told him it was hot, and to be careful, and staff member placed the soup on R#2's bedside table, and staff member walked out of room. R#2 then picked up bowl of soup and attempted to drink it while semi-sitting up in bed, when he spilled it on his abdomen, and leg area, causing him to burn himself. R#2 stated he had blisters on lower abdomen and groin/leg area, but they (staff) were taking care of his wounds. R#2 pulled down bed sheet to reveal area of injury. Resident stated he refused to go to hospital because he felt too ill to be moved around at that time. Observation of injury site on 8/1/2023 at 3:38 pm of R#2 revealed no noted blisters at that time but some redness to the skin. A cream-like substance was applied to lower right abdomen area as per orders. Interview with Dietary Aide on 8/2/2023 at 10:00 AM revealed a housekeeper came to her and told her R#2 wanted chicken soup because his stomach was hurting. Dietary Aide stated she took some soup and heated it up on the stove burner. Dietary Aide stated, she usually did not prepare hot foods and his was her first time to prepare hot foods. Dietary Aide stated she did not check the temperature of the chicken soup before giving it to R#2. Dietary Aide stated that the cook available that day was busy and was told to, just heat it up and was not aware she had to check the temperature prior to serving. Dietary Aide went to the R#2's room, told R#2 the soup was hot and put it on the bedside table and told R#2 to be careful, the soup is hot. Dietary Aide stated that when she left R#2's room, she heard R#2 yell out ouch. Dietary Aide stated an in-service was conducted and she now knows dietary aides are not supposed to heat up hot foods and she was just trying to help the R#2 by making soup and should not have done that (heat up food) but did not think it would result in an incident. Interview with DON on 8/1/2023 at 3:03 pm. revealed the incident occurred on the weekend and R#2 was not feeling well and requested soup from staff. DON stated, R#2 was a larger man and bedside table does not fit over him while he is in bed, so the bedside table stays to the side of the bed. DON stated, R#2 can eat on his own but just needs to have meals opened for him. DON stated in-services were conducted with kitchen staff to avoid further incidents in the future and is aware that Dietary Aides should not be preparing hot foods. MD and family were notified of incident. Interview with Administrator on 8/1/2023 at 3:10 pm revealed sometimes it was okay for the dietary aides to heat up foods but depends on what the food is. Administrator stated at the time of incident, it was ok for dietary aide to heat up the food as R#2 was requesting soup. Administrator was unable to describe the job role and duties of a Dietary Aide but did state, Dietary Aides are no longer allowed to heat up hot foods. Interview with wound care doctor on 8/16/2023 at 10:37pm revealed he was informed how the incident occurred and stated the injuries were consistent with a spill. Wound care doctor provides wound care to R #2 every week and initially, he would have described the wounds as being consistent with a second-degree burn (partial thickness burns that affect the outermost layer of the skin and extend to the middle skin layer below). Wound care doctor stated the wounds are almost healed and R #2 had responded remarkably well to treatment. Interview with Primary Physician on 8/16/2023 at 10:46am revealed he was aware of how the incident occurred and though R #2 denied going to the hospital, he ordered wound care to begin immediately, and R #2 has responded to wound care treatment well and wounds are almost healed. Primary Physician stated he did not officially diagnose the level of burn, but injuries were consistent with second-degree burns (partial thickness burns that affect the outermost layer of the skin and extend to the middle skin layer below). Interview with various staff members (different shifts) RN, Cook/Dietary Aide, LVN, CNA A, and CNA B, on 8/16/2023 revealed if a resident was to request hot foods like soup, they would check the orders to see if it is within their dietary limitations, and notify dietary staff of request. If staff were asked to heat up food, all staff stated they have a microwave in the breakroom used to heat up residents' food, they must check the temperature, so it does not exceed 165 degrees Fahrenheit and log the temperature down in the log book in the breakroom. Record review of in-services conducted on Food Service and Distribution dated 5/17/2023 which states; All reheated/precooked food should reach 165 degrees Fahrenheit for 15 seconds. Record review of in-service conducted on Food Temperature and Abuse and Neglect dated 5/12/2023 conducted by DON, Administrator and Dietary Manager. The following staff were verified to have received and understood the above trainings: RA A Dietary Aide Dietary Manager RN A LVN A CNA A Cook/Dietary Aide CNA B Record Review Dietary Aide Job Role revised on 6/1/2011 documented: Position summary: The overall purpose of the dietary aide position is to provide assistance in the delivery of dietary services. Incumbents may prepare and/or serve food items, set up tables and trays, wash tableware and cooking utensils, perform general cleaning tasks, and deliver soiled linin, etc. to the laundry. Essential Functions: Assures that sanitation and quality standards are met. Scrapes, stacks, loads, washes according to instructions, unloads and stores tableware and utensils. Sanitizes food cars and dishwashing counters after meal and keeps dishwashing area clean at all times. Logs/records wash/rinse temperatures. Neatly arranges tray and/or table setting with proper tableware, condiments, and tray card. Performs various food preparation tasks, and assists in apportioning servings. Prepares and serves beverages per menu/recipe. Cleans beverage dispensers according to manufacturer's instructions. Performs other cleaning tasks according to established schedules. Must be able to perform moderate to heavy lifting. Must be able to walk or stand for extended periods of time. May prepare and/or deliver nourishments/supplements identified with resident name room number date and time. May maintain or assist in maintain, dry storage areas by logging temperatures daily and handling the unpacking, dating, and rotating the food and non-food supplies. Identifies and corrects safety hazard. Performs other duties/tasks as may be assigned. Record Review of Food Preparation and Service Policy dated 7/2014 states; Food Service/Distribution 4. Prior to the point of service, the temperature of coffee or hot beverages will be checked to ensure temperature is 155 degrees Fahrenheit or below. If above 155 degrees Fahrenheit, ice will be added to the coffee or hot beverage until at or below 155 degrees Fahrenheit. On 08/17/23 at 4:08 pm, the Administrator was notified of a Past Non-Compliance Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the Administrator at this time.