**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the residents' right to be free from mental abuse/verbal abuse/ and physical abuse by a staff member for four residents, (Resident #5 (R5), Resident #7 (R7) Resident #20 (R20) and Resident #177 (R177)) out of a survey sample of 20 residents, which resulted in psychosocial harm for R20. Immediate jeopardy (IJ) and substandard quality of care in the area of abuse was identified. The findings included: 1. For R5 and R20, the facility staff failed to protect the resident's right to be free from physical abuse, mental abuse and verbal abuse. On 10/29/24, a clinical record review was conducted of R5's chart, which noted she had been discharged and was no longer a resident of the facility. Therefore, an interview could not be conducted with R5. On 10/29/24 at 9:08 a.m., an interview was conducted with R20. R20 said, [Certified nursing assistant #1 (CNA 1)'s name redacted] treated me like slapping the pigs. I reported it to the social worker and talked with her about it. R20 said, The aide was rough with me, and I didn't like it. R20 stated they [facility staff] were responsive to her concern, and she never saw CNA1 again after the incident. R20 said, I am limited to what I can do due to my broken leg. On 10/30/24 at 11:00 a.m. an interview was conducted with the social service director (SSD). The SSD stated she had interviewed R5 and R20, who were roommates. SSD stated that R20 had stated that CNA1 was rough with her during daily care and in the shower room. The SSD stated that R5's complaint was that CNA1 was being rough with her during morning care while applying her back brace. The SSD said, [R5's name redacted] and [R20's name redacted] verbalized that they were not scared or nervous, just didn't want [CNA1's name redacted] as an aide anymore. On 10/31/24 at 8:40 a.m. another interview was conducted with the SSD. The SSD stated she documented her interviews with R5 and R20 in a word document but was unable to locate the document. When asked if other residents had complained about CNA1, the SSD stated she was unable to recall the names of the other residents, but others had complained previously about CNA1 and reported the residents were on the same hallway as R5 and R20. The SSD had no evidence of any interviews she conducted with any of the residents nor a record of their concerns and confirmed she had not documented any of the information in the resident's clinical record. The SSD said, [Administrator name redacted] asked me to interview the other residents who had complained about [CNA1's name redacted] being rough with them with care. The SSD stated that she reported the interviews to the administrator, and she was unaware of what was done about the additional complaints. The SSD stated that the complaints and interviews with other residents were prior to the complaints received about R5 and R20's incident. On 10/30/24, the facility administrator was asked to provide all information/evidence they had with regards to R5 and R20's allegation of abuse. On 10/31/24 at 9:15 a.m. an interview with the administrator was conducted. The administrator was questioned about the facility documentation provided to the survey team with regards to R5 and R20's allegations of abuse. Included in the documents was evidence of staff education with regards to customer service, not abuse. The administrator said, Not all nursing staff is on the in-service, we are missing two part-time college students and some from the third shift that's not on this education. The administrator stated that after she came into work on 10/1/24, a dayshift aide, CNA#7 (CNA7) approached her and reported the allegation of abuse. The administrator stated CNA7 was a new aide and was scared and tearful over the incident. The administrator then stated that CNA7 came to her after breakfast to report the allegation of abuse. The administrator stated that she discussed the allegation with her supervisor and then CNA1 was pulled off the nursing unit. The administrator said, [CNA1's name redacted] could be abrupt with communication when she is upset. [CNA1's name redacted] was terminated for her behavior toward us [staff/administration]. When [CNA1's name redacted] was leaving, she was disruptive in the hallway on the nursing unit and in front of the residents. ***On 10/31/24 a clinical record review was conducted of R5 and R20's charts. There was no documentation within the clinical records with regards to the resident's allegation of abuse or having been interviewed. According to the activity of daily living (ADL) documentation, it indicated that CNA1 continued to provide care and documented in R5 and R20's charts on 9/30/24 and on 10/1/24 until 10:00a.m. According to CNA1's timecard she clocked out at 10:45 a.m. on 10/1/24. On 10/31/24 at 11:30 a.m. an interview was conducted with the MDS (minimum data set) coordinator, who was a registered nurse. The MDS coordinator had written a witness statement on 10/1/24 that read, While reviewing baseline care plan with resident, [R5's name redacted] on 9/30/24, she told me that her nurse's aide that morning had been rough with her. She stated that while putting her TLSO (thoracic-lumbar-sacral orthosis) brace on, she was rough. When asked, the MDS coordinator identified the CNA as CNA1. The MDS coordinator said, I told her I would talk to the person who supervises the CNAs about it, and she expressed fear of retribution from the CNA. I assured her that she was safe. The MDS coordinator stated that she reported this to the administrator on 9/30/24. According to the facility documentation and fax confirmations, R5 and R20's allegation of abuse was not reported to the regulatory agencies and adult protective services until 10/1/24 at 3:34 p.m. On 10/31/24 at 5:00 p.m. a follow-up interview was conducted with R20. R20 said, Early morning I like to go out and watch things come to life and [CNA1's name redacted] came out stood by me just looking at me and never spoke to me and I did feel intimidated by her. Then R20 said, During the bed bath [CNA1's name redacted] took a washcloth and slapped me, like you would take a mop and sling it down. I have dogs and would not wash them like that. Then R20 said, When she hit me with this washcloth, I felt I wasn't human, subhuman and I cannot understand anyone doing this to someone! This verbiage you can tell is coming from a teacher. R20 stated that the acting DON did complete a skin assessment and found two small bruises on her legs and back. Then R20 said, I cried and was trying to catch my breath. I was appalled that someone would be that way. The social worker let me talk and I reported it and thought it would end there, but the social worker said no. I wish the aide still had a job but not with humans. I cried when I told the social worker the story and didn't see any reason for this, over a bath. It was like a nightmare. On 10/31/24 a review of witness statements in CNA1's personnel file about the allegation of abuse was conducted. The first witness statement was from CNA7. CNA7's witness statement read in part, .this morning two residents stated to me that [CNA1's name redacted] has been very rough and hurting them during her care. The two residents were [R20's name redacted] and [R5's name redacted]. I brought [R5's name redacted] to the dining table for breakfast she was trying to talk to me about [CNA1's name redacted] and [CNA1 name redacted] said to the resident Do you have something you need to say to me, in a smart tone. The administrator had written a witness statement on 10/1/24 that read in part, .This writer had to suspend [CNA1's name redacted], pending an investigation after complaints from two separate residents regarding her care for them. The SSD wrote a statement and read, This writer spoke with [R5's name redacted] and [R20's name redacted]. [R5's name redacted] reported that [CNA1 name redacted] was 'rough' with her during morning care yesterday morning. She had to have a brace on while lying down and [CNA1's name redacted] wouldn't put it on, getting her dressed instead and was rough with her. [R20's name redacted] reported that [CNA1's name redacted] was rough with her during shower care, not gentle, slapping the washcloth on her and she felt intimidated by her standing there. On 10/31/24, CNA1's personnel file was reviewed. According to the document titled, Performance Counseling and Improvement Plan for Correction Action, read in part, .Termination Written. Reason for Counseling 1. Policy/company rules not followed: Abuse or neglect of a resident, Date and Time: [DATE]. 2. Policy/company rules not followed: Failure to work in a cooperative manner. Date and Time: 9/26/24 . This document was signed by the administrator, the general manager and a witness on 10/7/24. On 11/1/24 at 9:09 a.m. another interview was conducted with the SSD. The SSD said, The resident [R20] was tearful when telling me the story about what happened with the aide. The SSD stated that she never asked R20 how the actions from CNA1 made her feel. On 11/1/14 at 10:28 a.m. an interview was conducted with a physical therapist. The physical therapist said, [R5's name redacted] was more subjective and was guarded with her language. She [R5] stated to me that her roommate was upset about being struck in the shower which indicated physical contact to me. The physical therapist stated she questioned R5 about R20 striking the aide and R5 stated no, it was the other way around, the aide struck her. The physical therapist said, I told [R5's name redacted] I needed to report this to my supervisor, and she may want to speak with you to get your feedback. Facility documentation also revealed that on 10/1/24, Resident #20 (R20) and Resident #5 (R5) reported to facility staff, that CNA #1 was rough and hurting them during care. Following this, the administrator suspended CNA #1 at 10:45 am, reported the incident to regulatory agencies that afternoon, and initiated an investigation. The investigation included staff witness statements that confirmed that CNA #1 was verbally abusive, and statements from both R20 & R5 that alleged physical abuse by CNA#1. On 10/31/24 a review of facility documentation was conducted. The incident summary read in part, .based on the assessments and investigation, the allegations were unsubstantiated. The facility administrator failed to complete a thorough investigation, no additional resident or staff interviews were conducted, and concluded that the allegation of abuse had been unfounded. 2. The facility staff failed to report an allegation of abuse for R7, after it was reported by a surveyor to the acting director of nursing. On 10/29/24 at 10:47 a.m., during an interview with R7 she reported the staff are rough when they help you to stand up or change your diaper. When R7 was asked about the bruising to her right wrist, the resident said, they are very rough. On 10/29/24 at 10:51 a.m., following the above interview with R7, the surveyor was unable to locate the facility administrator to report the allegation. The surveyor then made the acting director of nursing (DON) aware of the allegation. On the evening of 10/29/24, a clinical record review was conducted of R7's chart. There was no documentation with regards to the bruising on the interior of R7's right wrist and the bruising noted. There was a progress note entry dated 10/29/24 at 11:14 a.m., by the DON that read, ADNS [acting director of nursing services] was asked to follow up on resident statement that when she was asked how she got the bruise on her wrist, she stated staff was sometimes rough with her during care. ADNS approached resident in her room; she was observed lying in bed with eyes closed. I asked her how she was feeling and she responded sleepy. When I asked her how she got the bruise on her wrist, she hesitated to answer and said, I don't know . I asked her if she wanted any covers and she said, No. I just want to rest. I ensured bed was in low position, fall mat on floor beside bed, wheelchair in locked position, and call bell within reach prior to leaving the room. Will follow up with resident when she is awake. On 10/30/24 at 11:12 a.m., a follow-up interview was conducted with the DON. When asked about any follow-up with regards to R7 and the allegation reported by the surveyor, the DON said, I think I put a note in, I went in and she had put herself to bed, I was trying to make sure she was centered on the bed better, she is very hard of hearing, I asked if felt ok, she said yes, I asked if she was sleepy she said yes. I asked her, can you tell me how you got that bruise? She said, I don't know, she was very tired and very lethargic, I left it alone, I lowered the bed and put the fall mat down. I went and checked on her later and she was in a meal. I talked to her, she was up this morning, she wasn't answering questions appropriately, she had a fall again last night, they are talking to hospice to see what else we can do to help her . On 10/30/24 at 3:17 p.m., an interview was conducted with the administrator. The surveyor asked the administrator if she was aware of the allegation reported by the surveyor to the DON involving R7, the administrator said, She [the DON] did say you [the surveyor] had talked to her about an area on [R7's name redacted]'s wrist or hand and she went and talked to [R7] and got a very different answer. I believe she went back and talked to her again and she had no complaints of staff. She brought all that to me. The administrator acknowledged that nothing involving R7 had been reported to the required agencies and nothing was in process. On 10/31/24 at 11:30 a.m., the survey team reviewed facility documentation, which indicated R7's report of an allegation of abuse was reported as an injury of unknown origin following the surveyor questioning the facility administrator about reporting the allegation of abuse involving R7 on 10/30/24. 3. The facility staff failed to respond to and report an injury of unknown origin for R177's skin tear to her left hand. On 10/31/24 at 11:13 a.m. an interview was conducted with a staff member who expressed a desire to remain anonymous. The anonymous staff (AS1) verbalized that she was called into R177's room by certified nursing assistant, CNA1. AS1 stated, I reported an incident with a resident to the Administrator, the resident had two skin tears to her left extremity. AS1 then stated, the skin tears were new. AS1 said, [CNA1's name redacted] said to the resident, I don't want to hear that apology, and the resident began to cry. On 10/31/24 at approximately 3:00 p.m. a clinical record review was completed. On 7/28/24 a physician order for treatment was noted. The order read, clean skin tear to left elbow and left hand with normal saline pat dry apply border gauze until healed. On 7/28/24 a skilled note was written and there was no mention of an incident or the skin tears. On 7/30/24 a weekly skin note was completed by RN1 and read in part, .skin tear to left hand steri strips applied and foam dressing applied. On 7/30/24 a doctor's progress note was written. The note read in part, the skin tear on the left elbow happened by rubbing on the arm of the wheelchair. The note did not mention the skin tear to the left hand. On 10/31/24 an employee that wanted to remain anonymous showed the surveyor a text message that was sent to the administrator on 7/28/24 and the text message read, I really need to talk to you. The anonymous employee stated, I reported the incident of [R177's name redacted] skin tears and of her complaining that CNA1 was rough with her. The employee stated that the administrator response was, to be careful of what you are saying and accusing people of. The anonymous employee then stated, I never heard anything else about the incident and assumed nothing was done. On 10/31/24 and again on 11/1/24 a request was made by the surveyor for the facility to provide evidence of an investigation for the skin tear that R177 obtained, or how the facility determined it was caused. On 11/1/24 the surveyor had not received any information. Another request for it was made to the administrator. Prior to the survey team's departure from the facility, no information was provided to the survey team. On 10/31/24, prior to calling IJ, the skilled nursing staff members were interviewed, and three out of six staff members interviewed knew who the abuse coordinator for the facility was. On 10/31/24, a facility document was reviewed. The titled document was, Abuse, Neglect and Exploitation-Prevention, Reporting and Investigation, read in part, .It is the policy of the community that: a) each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Team members must not engage in, nor permit anyone else to engage in, abuse, neglect, or exploitation of any resident. b) team members of the community are mandated reporters and have a duty to report known or suspected abuse, neglect and/or exploitation to local, state, and/or federal authorities in accordance with applicable law and regulations. c) in addition, team members who know of or suspect abuse, neglect, or exploitation of any resident must immediately notify the Executive Director/designee, to ensure appropriate action is timely taken for the safety of the resident and those potentially impacted .Training, the department coordinator/designee educates team members, through on-boarding and on-going training sessions on the prevention, reporting, and documentation of abuse, neglect, and exploitation. Training includes a) all team members are mandated reporters and are required to report allegations or known episode of abuse, neglect, and/or exploitation to applicable state authorities within the time frame established by law. h) steps to take to ensure the safety and protection of residents in situations of known or suspected abuse, neglect and/or exploitation, including escalation to the Executive Director/designee .Duty to report. Every team member is a mandated reporter and has a duty to report known or suspected abuse, neglect, and/or exploitation to local and state authorities in accordance with applicable law and regulation. a) these authorities may include law enforcement, the licensing regulator, the ling term care ombudsman, and/or adult protective services. The report of abuse, neglect or exploitation must be made within the timeframes and through the format required by applicable law and regulation. b) allegations of or suspicions of abuse, neglect and/or exploitation are to be reported .Protecting the resident. In addition, to initial Mandatory reporting, to ensure the safety and protection of residents, any team member who know of or suspect abuse, neglect or exploitation of a resident must also immediately notify the ED/SNA/designee. The SNA/designee: a) upon receiving notification of any known or suspected abuse, neglect, or exploitation of a resident contacts the licensed nurse who evaluates the resident and provides the necessary intervention, for example, calls 911 if emergent. b) Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area. i. ensure that any team member alleged to be involved in the abuse, neglect or exploitation is placed on administrative leave, pending the results of the investigation. ii. Ensures that non-team members alleged to be involved in the abuse, neglect or exploitation will be asked to leave the resident area and await further instructions. c) ensures that the resident's (i) physician, (ii) legal representative and (iii) family member or other individual regularly involved in the residents day to day care are notified as soon as practicable within timeframes established within laws/regulations .Investigation: The SNA/designee: Validates that the mandatory report of known or suspected abuse, neglect or exploitation has been made to the applicable authorities in accordance with state/federal requirements. The SNA/designee manage and directs the investigation of all abuse, neglect and/or exploitation. The SNA/designee implements corrective actions as indicated by the results of the investigation. If a written report of the investigation 1findings is required by applicable law or regulation, the SNA completes such report and ensures that it is submitted timely. On 10/31/24 at 4:30 p.m., the survey team identified the facility was in immediate jeopardy (IJ) in the care area of Freedom from Abuse, Neglect, and Exploitation. The facility staff failed to implement interventions to prevent, protect, and respond to allegations of physical and verbal abuse. The survey team met with the facility administrator, acting director of nursing, social service director, the general manager and the regional director of resident care and reviewed the IJ findings and a copy of the IJ template was provided to the facility administrator. On 10/31/24 at 10:25 p.m., the facility administrator provided the survey team with an accepted IJ removal plan. The facility's plan to remove IJ read as follows: A. With respect to the specific resident/situation cited: On 10/31/24 upon notification of citation, the administrator and current on shift skilled team members will be educated by the regional director of resident care/designee to prevent, protect, respond to abuse reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy. On 10/31/24 the administrator will complete a facility reportable incident for an allegation of abuse of Resident #7 to required agencies. B. With respect to how the facility will identify residents/situations for the identified concerns: On 10/31/24 the administrator and/or designee will interview resident #7 and have a nurse complete a physical assessment. An assessment will be conducted for current residents in skilled nursing by the administrator and/or designee who are alert and oriented for safety and care concerns in the community to include abuse. Beginning 10/31/24 the administrator and/or designee will place additional signage around the community advising of the abuse coordinator and grievance coordinator. 10/31/24 the regional director of resident care and/or the acting director of nursing will re-educate all skilled team members on how to prevent, protect, and how to respond to abuse reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy. All skilled team members will be trained prior to them being able to work. Any concerns identified will be addressed as per our policy and procedures. The facility alleged they would have the IJ removal plan completed on 11/1/24 at 10:00 a.m. On 11/1/24 the survey team verified the removal of IJ. The survey team conducted interviews with all skilled team staff working how to prevent, protect, and how to respond to abuse as reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigating Policy. Interviewable resident interviews were reviewed, and no additional concerns of abuse were identified. Non interviewable resident families were interviewed. The interviews were reviewed, and no additional concerns were noted. Skin assessments conducted on non interviewable residents were reviewed. The skin assessments had no indication of when they were conducted, who conducted them and if the findings were areas of new concern or exiting issues. The facility staff were notified of the concern about the skin assessments and that the survey team would be unable to abate the IJ. The facility staff conducted new skin assessments on non interviewable residents. No new areas were noted, and all assessments had the initial date of identification. The survey team reviewed the revised skin assessments and confirmed that no new skin issues were identified. A sample of 20% of the skin assessment findings were verified through clinical record reviews to ensure skin impairments had been previously documented by the facility staff. The survey team reviewed and confirmed that the family of non interviewable residents were interviewed with no abuse related concerns noted. The survey team reviewed resident interviews, and no new areas of concern were identified. The survey team confirmed that the facility completed and reported R7's allegation of abuse. On 11/1/24 at 1:30 p.m. the survey team was able to confirm that the immediacy had been removed and IJ was abated. Following the removal of immediate jeopardy, the scope and severity was lowered to a level three isolated. No additional information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards and failed to assess residents to determine who was at risk, having the potential to affect multiple residents on one of one nursing units. Two residents (Resident #105 and Resident #109) spilled coffee onto their lap, which resulted in R105 requiring first aide intervention, which constituted harm. Immediate Jeopardy (IJ) and substandard care was identified. Once IJ was abated, the scope and severity was lowered to a level three, isolated. The findings included: For all of the residents residing on the one nursing unit in the facility, the facility staff had not assessed the residents ability to manage hot liquids, when hot coffee was available and accessible to residents in the lobby, and the facility failed to maintain a consistent system in place to monitor temperatures of hot liquids being served in the dining room, which resulted in two residents spilling coffee and one resident (Resident #105) sustaining redness that required first aide treatment. On 1/7/25 at 2:30 p.m., during a review of facility documentation, it was noted that on 12/22/24, Resident #105 (R105) spilled hot coffee onto her lap, which required medical treatment to include first aide (application of cold compress). According to the nursing note dated 12/22/24 at 12:37 p.m., it read, It was reported to writer that patient spilled hot coffee on her lap during lunch. Assessed guest skin and redness noted to thighs. Cold compress applied. Resident denies pain/discomfort when asked. Resident's son [name redacted] notified and Dr. [physician's name redacted] is made aware. Will continue to assess patient for any blister s/sx [signs and symptoms] of skin irritation. Patient is now to have cup with lid for all meals. According to R105's physician orders, the physician ordered occupational therapy to evaluate for upper extremity strengthening. On 12/24/24, occupational therapy (OT) initiated therapy for R105 to work on self-feeding and alternate cup options. According to a dietary employee (Other Employee #2-OE2), the dietary manager (Other Employee #6-OE6) and a registered nurse (RN #3), R105 had been previously identified with issues/concerns in her ability to feed herself. According to the dietary manager/OE6 and R105's clinical record, the previously identified concern prompted on 8/10/24, a physician order that R105 was to have light weight mugs at meals. On 1/7/25 at 2:40 p.m., an observation was conducted of the kitchenette where the coffee is prepared. The dietary aide (other employee #1- OE1) said that the coffee temperature is checked once it's prepared, but they let the coffee sit and cool down before serving it. The dietary aide also stated that sometimes ice must be added, prior to serving. As requested, the dietary aide measured the temperature of the coffee from the dispensing machine, and it was observed that the temperature measured 173 degrees Fahrenheit. The dietary aide then said that the service technician had just come and turned it down, as it previously was around 179 degrees. According to the meal service temperature logs from 12/30/24-1/7/25, there were multiple omissions that demonstrated that the temperature of the hot liquids was not recorded during each meal. When questioned about the prior temperature logs on 1/8/25, the dietary manager and dining director stated that the prior monitoring form did not include beverages, and they had not been recording or monitoring the temperature of hot liquids. On 1/8/25, approximately 8:15 am, an interview with a licensed practical nurse (LPN #2), it was identified that Resident #109 had also had an incident where she spilled coffee. Review of the clinical record revealed that on 12/27/24, R109 spilled lukewarm coffee into her lap and sustained no injury. On 1/8/25, interviews were conducted with LPN #2 and a certified nursing assistant (CNA #1), both of whom stated that if residents want coffee between meals, they obtain it from the lobby coffee station. On 1/8/25 at approximately 8:50 a.m., the dietary manager measured the temperature of the coffee in the lobby, which was noted to be 156 degrees Fahrenheit. On 1/8/25 at 3:20 p.m., an interview was conducted with two dietary staff (OE#1 and OE #2). Both of whom stated when they arrive, they obtain coffee from the coffee machine, fill the coffee dispensers, and take them to the front lobby around 7:30 a.m. Both dietary staff stated that they do not take the temperature of the coffee that is placed in the lobby, and it is not cooled down prior to placing in the lobby. At this time, the temperature of the coffee was again obtained, directly from the coffee machine as it would be put into the dispensers in the lobby and was measured at 165 degrees Fahrenheit. Both the dietary aides and dietary managers confirmed that the repair technician was onsite and had decreased the temperature of the machine on 1/7/25. On the afternoon of 1/8/25, an interview was conducted with the facility's interim administrator, interim Director of Nursing (DON), and general manager, to identify the facility response to the spilled coffee incidents. The facility DON reported that they had initiated a PIP (performance improvement plan) which included that all residents with a BIMs (brief interview for mental status score) of 12 or less, and those who are visually impaired, were evaluated by therapy for hot liquids and were actively working to develop an assessment tool to be used to assess resident's ability to safely manage hot liquids. The DON stated that the PIP was still in process and had not been completed. On 1/8/25, in the afternoon, an interview was conducted with the therapy director (Other Employee #9- OE #9). As of 1/8/25, there were three residents with a BIMs of 12 or less, that had not yet been evaluated for their ability to handle hot liquids safely. There was no evidence that the facility made any attempt to identify residents at risk with causative factors, other than cognitive or visual impairments, were evaluated for their ability to manage hot liquids safely. On 1/8/25 at 5:15 p.m., Immediate Jeopardy was identified and was noted to have begun on 12/22/2024, when R105 spilled her coffee, and first aid had to be provided. A meeting was held with the facility's interim administrator, interim director of nursing, and general manager to notify of the immediate jeopardy. On 1/8/25 at 7:40 p.m., the facility submitted an accepted IJ removal plan. The plan read as follows: Residents #105 and #109 were assessed for hot liquid safety and referred to Occupational Therapy. On 1/8/25 the Director of Nursing will conduct an assessment of all current residents for accident hazards such as risk of burns from hot liquids. Residents identified at risk; nursing will initiate a care plan with interventions to mitigate hazards such as risk of burns from hot liquids. Residents identified at risk will be evaluated by occupational therapy. Director of Nursing will educate all current team members on hazards such as the risk of burns from hot liquids and appropriate serving temperature prior to being permitted to work. Dietary manager will educate dietary team members on the importance of completing and documenting temperatures on hot liquids during each meal prior to being permitted to work. New admissions will be assessed for hazards such as risk of burns from hot liquids, with interventions initiated and a referral to occupational therapy. Hot beverage station located at the concierge's desk will be removed. Any concerns identified will be addressed as per our policy and procedures. Completion Date: 1/9/25 11:00 a.m. On 1/9/25 at 11:05 a.m., interviews were conducted with both certified nursing assistants (CNA #1 and CNA #2) working, the licensed practical nurse (LPN #2), a registered nurse (RN #3), the activity assistant, a housekeeper, the medical records employee, two therapy staff, and the two dietary employees. Each of the employees were able to verify they had received education and were able to answer questions with regards to the serving temperature of hot liquids, how to obtain coffee for a resident outside of mealtimes, and how to know what precautions had to be taken for residents identified to be at risk for burns from hot liquids. The two nurses were also able to verbalize knowledge of when and how the assessment of residents with regards to hot liquids would be completed. An audit was conducted which included comparison of the daily census, to ensure that 100% of residents had been screened/assessed for the risk of injury from hot liquids. The care plan was reviewed for the eleven residents identified to be at risk to ensure interventions had been implemented in the care plan. The therapy evaluation for each of the eleven residents noted to be at risk was reviewed to ensure that therapy had assessed the residents. The staff education was reviewed and the sign in sheet was compared to the as worked schedule to ensure that all staff were trained. Interviews were conducted with various staff to confirm they received education and had knowledge of the risks, interventions, etc. The education for the dietary staff was reviewed and compared to the as worked schedule to ensure that the dietary staff working had been educated. The temperature logs for breakfast were reviewed to ensure that that temperatures had been taken and were noted to be in the facility's acceptable serving range of 140-155 degrees Farenheight. The dietary staff were then interviewed to confirm receipt of the education and to verify their knowledge of the risk, importance of ensuring appropriate temperatures and the interventions for residents identified to be at risk. The census was reviewed to identify if any new admissions had been admitted since IJ was identified. No admissions had been received at the facility. On 1/9/25 at 12:10 p.m., observations were conducted in the kitchenette. Dietary staff were observed to obtain the temperature of all food items to include hot water and coffee. All temperatures were verified by the surveyor to ensure they were within appropriate serving temperature. Observations were conducted of the entire meal delivery to residents in the dining room. It was noted that none of the residents in the dining room received any hot liquids. The meal set-up and delivery of meals to residents eating in their rooms was observed. It was noted that Resident #106 (R106) was served hot coffee in a disposable cup with a lid. According to R106's meal ticket which was on the tray and accompanied the food into the resident's room was observed and was noted to read, . Preferences: Handled cup & lid for hot [NAME] [beverage] . At 1:30 p.m., R106 was served the meal which included the coffee in the disposable cup. The surveyor then returned to the Administrator's office, reviewed R106's hot liquid assessment which indicated that the resident was at risk and the care plan intervention read, Handled cup with lid for hot beverages. The facility administrator and director of nursing services (DON) were asked to accompany the surveyor to R106's room. The surveyor notified them of the observations and findings. The DON then entered R106's room and confirmed the observation. The facility administrator and DON were made aware at 1:40 p.m., they had been unable to abate IJ. The facility then presented the surveyor with notification that they had re-educated all the staff and were ready for the surveyor to attempt to verify IJ removal as of 3 p.m. on 1/9/25. On 1/9/25 at the evening meal, observations were again made. The observations included dietary staff obtaining temperatures of the foods and hot liquids and verification that they were within appropriate temperature for service. The dietary staff were observed to record the temperatures obtained. Meal service/delivery to residents was observed. One resident, R106 received coffee at the meal, and it was served in a mug with a handle and a lid. IJ was abated at 5:40 p.m. on 1/9/25, and the scope and severity was lowered to a level three, isolated. No additional information was provided.