**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #47, the facility staff failed to ensure the resident was free of mental and verbal abuse as evidenced by being threatened with a 30 day notice of discharge. Resident #47 was initially admitted to the facility on [DATE]. Resident #47 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included but were not limited to, Major Depressive Disorder, Recurrent Moderate and Generalized Anxiety Disorder. Resident #47's Quarterly Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 05/03/2021 coded Resident #47 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #47 as independent with setup help only with eating, requiring extensive assistance of 1 with dressing and toilet use, extensive assistance of 2 with bed mobility and personal hygiene and total dependence of 2 with bathing. On 06/16/2021 at approximately 7:00 p.m., the surveyor entered into Resident #47's room. Resident #47 observed lying in bed awake. When asked how was he doing, Resident #47 stated, I'm not getting the care I think I should get. The resident stated that the facility is understaffed and he thinks that 12 to 15 residents are too many residents for a CNA (Certified Nursing Assistant) to have assigned to them to care for. Resident #47 then stated, The Administrator, (Name) or whatever his name is, told me if you keep this stuff up I will give you a 30 day notice and get you out of here. When asked why did he say that, Resident #47 stated, My wife died in April and I have been rude and abusive to the staff but I have changed. Resident #47 asked, Do I have to take therapy? Resident #47 stated, The Administrator told me I will write in the letter that you are abusive to the staff and refused to do therapy. Resident #47 stated, I'm working with a organization to get me out of here. (Name of Ombudsman) is suppose to visit me in the morning. I want to leave. On 06/17/2021 at approximately 11:58 a.m., requested that Regional Director of Clinical Services come to the conference room. On 06/17/2021 at 12:00 p.m., Regional Director of Clinical Services was notified of the Resident #47's statement made on 06/16/2021. Regional Director of Clinical Services stated, The first thing I have to do is get him out of here. On 06/17/2021 at approximately 1:00 p.m., review of Resident #47's clinical record was reviewed and revealed a Behavior Contract. Review of Behavior Contract revealed and is documented in part, as follows: BEHAVIOR CONTRACT Inappropriate Behaviors I, (Resident Name), spoke with the administrative staff at (Facility Name) on this date to discuss my recent behaviors. As a result of this conversation, I understand that effective immediately, and permanently I can no longer do the following. I am not permitted to curse, yell at, or treat staff with disrespect. If I have a problem with a staff member, I know I can speak with either the social worker or administrator about this issue. I understand that I have rights in my home. However, if my behavior infringes on any other resident's rights, it may be necessary for my rights to be altered or modified for the safety of others. I agree to stop all of these behaviors immediately. If any of these behaviors continue, I understand that Facility Name will issue a 30 Day Notice of Transfer and Discharge and I will be discharged from this facility. I also understand that I have rights to contact the state Ombudsman to assist with this matter. Resident #47 signature and wife's signature Date 3/12/21. Review of Resident #47's clinical record on 06/17/2021 revealed that the Behavior Contract was signed by the resident and his wife 3 months ago. The residents clinical record has documented behaviors towards staff but no documentation of danger to self or other residents. Received copy of Facility Reported Incident (FRI) on 06/17/2021 from the Regional Director of Clinical Services along with copy of fax confirmation to OLC (Office Of Licensure and Certification) and the Ombudsman. On 06/17/2021 received copy of Relias Learning Behavior Education Training Course and Accident Prevention and Management Course. On 06/21/2021 received a copy of the FRI investigation for Resident #47 dated June 18, 2021. Review of FRI investigation revealed and is documented in part, as follows: Actions: On June 17, 2021, (Name of Administrator) was suspended pending investigation for allegation of verbal abuse. (Name of Administrator) was asked to write a statement with (Regional Nurse Name), and not to return to premises until directed by RVPO (Regional [NAME] President of Operations) or RCDS. Education for abuse was started immediately with employees of the facility, and interviews of residents, staff and (Resident Name) were initiated. Facility also provided copies of Nurse Progress Notes with resident behaviors highlighted and Psychological Services Progress Notes. On 06/21/2021 at approximately 7:25 p.m., the [NAME] President of Operations and Regional Director of Clinical Services was made aware of finding at the pre-exit meeting. When asked is cursing a reason to give a 30 day notice of discharge, [NAME] President of Operations stated, Yes because of the Behavior Contract. The contract was written up in March and the 30 day notice is in the Behavior Contract. No further information was provided. Policy: Virginia Resident Abuse Policy Section: Abuse, Neglect and Exploitation Effective Date: May 2008 Last Revision Date: 7/14/2020 Policy: This facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Based on observations, clinical record reviews, staff, resident and family interviews, the facility staff failed to ensure two residents were free from abuse; one resident (R#185) who was intentionally restricted from movement by a tucked in top bed sheet on each side with the two top corners tied at the junction of the side rail and bed frame, and the bottom two corners of the top sheet tied to the bedframe; and, a second resident (R#47) to be free of mental and verbal abuse as evidenced by threatening a 30 day notice of discharge. The treatment of Resident #185 constituted harm. The findings included: 1. Resident #185 was admitted to the nursing facility on 7/12/19 for skilled services with a primary diagnosis of stroke with aphasia. She was discharged home on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident as having no problems with short and long term memory and moderately impaired (cues and supervision required) in the skills needed for daily decision making. The resident was not coded with having signs and symptoms of delirium or any mood and behavioral problems. Resident #185 was assessed unable to speak, rarely or never understood. The resident was coded to require extensive assistance of two staff for bed mobility, dressing, toilet use. She was coded on this assessment as requiring one staff for locomotion on and off the unit which occurred two times or fewer. The resident required extensive assistance of one staff for eating and also coded with a feeding tube. She was coded totally dependent on two staff for bathing. The MDS assessment continued to indicate that the resident had no impairments of upper and lower extremity and used the wheelchair as her primary mode of transportation. She was assessed always incontinent of bowel and bladder. This assessment did not code the resident as receiving antipsychotic, antianxiety, antidepressant, hypnotic or opioid medications. The resident was coded as receiving restorative nursing services. The resident was assessed not requiring physical restraints (manual, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). The assessment indicated the family or significant other participated in the assessment. The nursing restorative program dated 9/9/19 indicated that some of the goals were that the resident would be able to stand and pivot and transfer to the wheelchair, and to and from the bed and chair with one assist. The resident also had a range of motion restorative program dated 9/9/19 for all extremities with active participation from the resident 30-35 repetitions per session. There was no documentation to indicated that the resident did not tolerate the program. The care plan dated as initiated on 9/13/19 identified that the resident met the goal for transfers to be able to stand pivot transfer and wheelchair transfer with functional (active participation) tier. The care plan revised on 10/23/19 identified a potential for anxiety or feeling of fear. The goal set for the resident was that she would not display nonverbal indications of fear or anxiety related to care by the next review. The approaches the staff would implement to accomplish this goal included communication with the resident using yes/no questions and allow her time to respond and communicate needs, and monitor resident for non-verbal cues or indications of fear or anxiety. The care plan dated 9/13/19 also identified the resident met the goal for range of motion that included turning head from side to side, tilt head back, chin up, raise arms above head, raise arms straight out from shoulders, touch top of head, rotate feet in and out, up and down and rotate legs inward/outward. The care plan dated as initiated 7/12/19 identified Resident #185 was at risk for falls as characterized by history of falls/injury, multiple risk factors related to stoke, gait and balance problems. The goal set by the staff for the resident was that there would be no fall related injuries through the next review. Some of the approaches to accomplish this goal included apply concave sleeve to the air mattress, assist with mobility as needed, reinforce need to call for assistance and therapy to screen and treat as necessary per physician order. The care plan dated as initiated on 7/12/19 identified the resident required tube feeding related to stroke with difficulty swallowing. A speech therapy referral dated 9/19/19 was initiated related to a request for a swallowing study to inquire if resident could swallow. After speech evaluation, Resident #185 was able to take medication crushed in applesauce on 10/5/19 and fortified foods diet with pureed texture and nectar consistency. Enteral feedings, ordered on 10/25/19, in the evening for difficulty swallowing. Isosource 1.5 Cal 50ml/hr continuous x 12 hours AND in the morning for to stop tube feeding. The bed rail assessment dated [DATE] indicated that the resident had bed rails and the medical need listed for the side rails was to promote independence. There were no physician orders or signed consent to authorize the use of physician restraints. On 6/21/21 at 4:00 p.m., a phone interview was conducted with the medical power of attorney (POA) of Resident #185 who was also the resident's daughter. She stated that the resident had 6 strokes and on the 6th one she was left unable to speak, but was able to understand what was said to her and responded appropriately by nodding her head, raising her shoulders, gesturing with her hands and facial expressions. She stated the resident was able to move all extremities with some weakness in the right arm and was working with restorative for transfers and range of motion. She stated the resident lived with her for 13 years and when she was admitted to the nursing facility, she came in every day and stayed long hours. During the above interview, the POA stated that October 23, 2019 was a day she would never forget when she came into the Resident #185's room to find the resident with the top sheet tucked in tight on each side and the top corners of the top sheet knotted and tied at the base of the side rails to the bed frame. She stated, at the foot of the bed, each corner of the top sheet was knotted and tied to the foot of the bed frame. According to the PO, because the resident was not able to talk, she could see she was agitated and exhibited fear based on her facial expressions, eyes and head movements. She said the resident was trying to reach out to her, but she could not lift her hands or arms from under the top sheet. She stated, she asked the charge nurse, Licensed Practical Nurse (LPN) #4 was the resident okay because she found her tied to the bed to which the charge nurse told her she knew nothing about the incident and did not see the resident in that position when she gave medications. She said she located the Unit Manager, LPN #3 who literally ran down the hallway entering the resident's room in disbelief. The POA stated, the Unit Manager, LPN #3 called all Certified Nursing Assistants (CNA) into the resident's room to question and identify who tied each corner of the top sheet to the bed frame, but could not get a clear story. The POA stated, It was at that time she immediately untied my mother and we both had a few choice words to say. You cannot fake that kind of surprise on (name of Unit Manager #3). She stated once the resident was untied at the top corners, she immediately placed her hands on top of the sheets at her sides in a way to prevent the occurrence from happening again. The POA said, My mother is not a fighter. Yes, she would throw her covers off and try to get up and I would tell her she couldn't, but see what she wanted. It was mainly to go to the bathroom. Just because she could not tell you how she felt did not mean she was not bothered by being tied and restrained in the bed. I had to keep telling her she would be okay. I hated to leave her that day, but I was told by the current DON and Administrator, the CNA involved would no longer be working at the nursing home. As the interview continued, the POA stated the Director of Nursing (DON) at the time and the Administrator at the time took her to the office and shared that they identified the CNA (#5) who tied the sheets at each end and tucked the sides and that CNA #5 stated, I instructed and gave permission to secure my mother in bed that way to keep her from trying to get up. That was crazy that they would think I gave any such instruction and I told them I would never want my mother tied down. A phone interview was conducted with one of the CNA's (#4) that worked with the resident on 6/21/21 at 3:15 p.m. She stated she no longer worked there, but remembered the incident and the CNA (#5) who remained in the resident's room after she left to finish changing the resident and she did not return to the resident's room before she left for her shift. CNA #4 said, I heard the resident was tied tight like that by (CNA #5) to make sure she did not get out of bed and to be able to finish up for the shift without her (Resident #185) getting out of bed. She stated she would have never tied anything to or across a resident because, It is just not done like that and I think if she was able to talk she would have told them not to fix her sheets that way. I had nothing to do with that, (CNA #5's name) did it so she could finish her work with the other residents without having to deal with her trying to get out of bed. A phone interview was conducted with the previous Unit Manager, LPN #3 on 6/21/21 at 4:35 p.m. who not longer worked at the facility. She stated although the resident had gait disturbances and a fall history, she was able to move her arms and legs and was doing well enough with restorative in house. She stated one of the aides had left and did not stay employed because of an incident of restraining the resident with tying the top sheet corners. Unit Manager, LPN #3 stated the resident's daughter came to the nurse's station to tell her when she came in her room, she found her top sheet tied and tucked in over her. She continued to say, When I came into the room, I could see fear in her eyes. I released her and spoke to all CNA's. I found out who tied her sheet down and told her that we never do that! (CNA #5's name) said she tucked and tied her top sheet so the resident would not try to get up. I told her that we never do anything like that even if you think residents will try to get up. I told her we take residents to the nurse's station, find an activity for them or assist them to an activity session. I also told her you never do that because too many things could go wrong like getting entangled in the top sheet, choking from the tied part of the top sheet as she wiggled to set herself free. It technically was abuse! Unit Manager, LPN #3 said she went straight to the previous Administrator and informed her of the incident and she wrote a statement about how she found the resident and released the restraints. On 6/17/21 at approximately 4:00 p.m., the previous Administrator had arrived at the facility. She stated she sent an initial Facility Reported Incident (FRI) to the State survey and certification office on the date of the incident and also the 5 day follow-up report with all the details from a full and complete investigation was in the specific FRI folder for Resident #185. The FRI was reviewed by this surveyor which indicated on 10/23/19, Resident (name of R#185) was noted in bed with her sheets tied in such way that could prevent her from getting out of bed. Full investigation was started immediately. Resident is currently safe with no injury. Education on abuse policy, including use of restraints has begun. The FRI investigative folder indicated that in the charge nurse's, LPN #4 she flushed Resident #185's feeding tube at 2:00 p.m. and there were No difficulties at the time. This was the only statement that was written by LPN #4. The investigative folder did not include the written statement of the Unit Manager, LPN #3 as was indicated she wrote during the telephone interview above. On the back of the abuse and neglect tool that was used to complete the investigation was a written timeline, undated and not signed. The time line indicated that it was about 3:00 p.m. when Resident #185's daughter reported to Charge Nurse, LPN #4 informed Unit Manager, LPN #3. Both LPN #4 and #3 along with the daughter go into the resident's room and undo the tied sheet. At 3:15 p.m. the incident was reported to the Director of Nursing (DON) and the physician was made aware who was in the facility at the time. The timeline indicated the Administrator and DON initiated a FRI. The five-day follow up report to the FRI, dated 10/27/19, typed and submitted by the previous Administrator indicated that written statements were obtained from all, but CNA #5 who was the last person to care for the resident. The FRI indicated that numerous unsuccessful attempts were made by the facility to have the CNA come in and give a statement. The FRI further noted that the following day on 10/24/19, CNA #5 did not come back to work and on 10/25/19, the CNA was a no call, no show for her shift. The follow-up depicted that CNA #4's statement indicated that she and CNA #5 provided care to the resident at approximately 2:00 p.m. and that CNA #5 was left alone with the resident to straighten the bed while CNA #4 emptied the trash. The follow-up inaccurately indicated that both CNA #4 and #5 returned to the room and the two of them left together. This depiction was not recorded in CNA #4's written statement, nor was it verbally stated during the phone interview with this CNA conducted by this surveyor. The FRI also indicated they could not identify who was responsible for the incident, but due to the fact that CNA #5 refused to cooperate with the facility's investigation and failure to report to work as scheduled led to her termination of employment. CNA #5 was hired on 9/10/19 and completed abuse training during general staff orientation on 9/11/19 in accordance with the facility's policy. On the abuse and neglect quiz the CNA answered that the improper use of bedrails or other restraints was considered emotional abuse. The nurse's notes dated 10/23/19 at 3:35 p.m. indicated that the incident occurred, assessment was completed and inaccurately recorded Residents family/responsible party was notified of occurrence (Resident #185 daughter's name listed). As indicated above, it was the daughter who notified the charge nurse and the Unit Manager that the resident was tied to the bed. All nurse's notes indicated the resident was unable to verbally make her needs known, but was alert and oriented and understood without difficulty. The Adult Protective Services indicated in their letter to the previous Administrator dated 3/30/20 that a report was sent to them on 10/24/19 alleging that Resident #185 was a victim of abuse. The APS social worker indicated that the investigation was completed and their was a preponderance of evidence that Resident #185 was a victim of abuse while a resident at the nursing facility. On 6/21/21 at approximately 3:00 p.m., a phone interview was conducted with the Interim Administrator. She stated, It looks like this was a problem that she was tied in such a way to prevent movement. This was before my time here. I wish they would have never did that. She also stated that the facility staff is trained on abuse and use of restraints based on the facility's established policies. The facility's Abuse policy and procedure dated as effective on 5/2008 and last revised on 5/26/21 indicated that the facility would not tolerate abuse of a resident by anyone and that willful actions facilitated or enabled through the use of physical restraints was considered abuse without a physician's order, assessment and compliance with regulations and guidelines of the facility's restraint policy and procedures. Specific assessments are required along with a physician's order and if the device restricts The facility's Restraint policy and procedures dated 1/2011, 1/2014, 7/2015 and last revised on 3/2108 indicated a physical restraint was any manual method or physical or mechanical device, material, or equipment attached adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy identified specific assessments are required along with a physician's order and if the device restricts freedom of movement, it is a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to provide adequate supervision and failed to ensure heated beverage was served in a manner to prevent an avoidable accident for 1 of 59 residents in the survey sample (Resident #83), with known behaviors of throwing objects, food and beverages resulting in harm, a second degree burn, to Resident #74. The staff served Resident #83 a cup of hot coffee without a lid. Resident #83 threw the hot coffee onto Resident #74 resulting in a second degree burn to the resident's left upper thigh requiring physician intervention, medication and treatment. A second degree burn involves the first two layers of the skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Referenced from http://www.bt.cdc.gov/masscasualties/burns.asp The findings include: A Facility Reportable Incident (FRI), incident type Unusual Occurrence, was received at the State Agency on 1/23/19. The FRI evidenced that on 1/22/19, Resident #74 while in her wheelchair bumped into the wheelchair of Resident #83. This resulted in Resident #83 throwing her coffee at Resident #74. The hot coffee caused a second degree burn to Resident #74's left upper thigh. 1a. Resident #74 was admitted to the facility on [DATE] with diagnoses to include, but not limited to a stroke resulting in paralysis of the right upper and right lower extremities and anoxic (absence of oxygen) brain damage. The MDS (Minimum Data Set) prior to the unusual occurrence incident was a quarterly with an Assessment Reference Date of 11/21/18. The resident scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired decision making skills. Resident #74 was wheelchair bound. The Nursing Noted dated 1/22/19 written by the nurse who heated the hot water in the microwave to make the coffee and served it without a lid to Resident #83 read as follows: Patient sitting at nurses station at 1830 (6:30 p.m.) with a cup of hot coffee and another resident (Resident #74) in a W/C (wheelchair) was passing by and bumped into her and (Resident #83) threw her cup of coffee at the resident and it landed on her lap. The Nurse Practitioner note dated 1/23/19 evidenced the following documentation: .Today, was called by nursing to assess new skin concern noted to left upper thigh area. The area is raised, erythematous (red) and swollen. Two blisters are noted and intact. Wound nurse consulted. After further information obtained from staff, it was noted that another resident spilled coffee on (Resident #74) and this is the cause of the blistering . AP (Action/Plan): Left leg cellulitis/burn: Started on Keflex (an antibiotic) 250 (mg-milligrams) QID (four times a day) x 7 days, consulted with the wound nurse. Will add Silvadene ointment and xarafoam dressing to protect site. Will follow up in 48-72 hours. The wound nurse assessment dated [DATE] evidenced the following documentation: 1. Wound type-Burn. 2. Wound location- left upper thigh. The wound measured 2 cm (centimeters) length x 6 cm width and 0.1 cm depth. Small amount of drainage, wound bed pink in appearance, periwound (surrounding skin) pink. Pain level: 4. The Weekly Wound assessment dated [DATE] evidenced the burn wound measured 1.6 cm x 3.0 cm x 0.1 cm, scant drainage, periwound pink. The Weekly Wound assessment dated [DATE] evidenced the burn area had resolved. 1b. Resident #83 was admitted to the facility on [DATE] with diagnoses to include, but not limited to schizophrenia, bipolar disorder, Alzheimer's disease and combative behaviors. The MDS (Minimum Data Set) prior to the unusual occurrence incident on 1/22/19 was a quarterly with an assessment reference date of 12/8/18. The resident scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderately impaired daily decision making skills. The resident exhibited hallucinations, delusions and behaviors of rejecting care. Review of the clinical record evidenced Resident #83 had a history of known behaviors that had a potential to cause injury towards staff and other residents. The documented behaviors included: 4/28/18 while in the hallway the resident attempted to take the purse of another resident, when the other resident picked up the purse so that Resident #83 could not get it Resident #83 threw a magazine toward her; 5/20/18 threw ice while in the hallway, 5/23/18 threw things on her floor, 6/24/18 combative, throwing things at resident's family members as they were coming through the door, 7/1/18 threw a cup of water at a C.N.A. (certified nurse assistant) walking by her, threw a plate cover while at the nurses station towards a nurse, 7/13/18 while at the nurses station hit another resident in the chest. The Comprehensive Person-Centered Care Plan dated 11/2/17 identified a focus care area of mood and behaviors related to diagnoses of schizophrenia, bipolar, psychosis and dementia with behaviors. Identified behaviors included but were not limited to, throwing objects, throwing lunch and dinner trays, combativeness and impulsive behaviors. The care plan did not include interventions during meal times prior to the incident to prevent potential avoidable accidents of the resident throwing lunch and/or dinner trays, food and or beverages. The last psychiatric evaluation/consult was dated 1/9/18. The resident's mood was described as labile and combative at times. Insight and judgement were poor. (Labile/lability-excessive emotional reactivity associated with frequent changes or swings in emotions and mood referenced from Tabers Cyclopedic Medical Dictionary 19th Edition.) The five day facility follow up report to the FRI was received at the State Agency on 1/28/19. The report read in part: .The nurse on the unit made the coffee. She heated the water in the microwave for 1 minute and then added instant coffee and thickener. The facility replicated the making of the coffee; same type of cup, same amount of time and the temperature after heating was 124 degrees (Fahrenheit) . The facility will provide a sturdy cup with a lid for (Resident #83's name) .Care plans were updated on both residents . There is no evidence in the facility's report that the nurse obtained the hot beverage temperature at the point of service prior to serving the coffee. Table 1. Time and Temperatures Relationship to Serious Burns-Time Required for a 3rd Degree Burn to Occur at 124 degrees Fahrenheit is 3 minutes. Referenced from http://www.bt.cdc.gov/masscasualties/burns.asp On 7/25/19 the Comprehensive Person-Centered Care Plan dated 11/2/17 was reviewed for a second time and did not include the revision/ implementation of a sturdy cup per the five day follow up report. The care plan was revised on 1/22/19, the intervention was to educate staff and visitors that resident is not to receive hot beverages. On 7/26/19 at 5:53 p.m., the MDS Coordinator who revised the care plan on 1/22/19 was interviewed. She stated she failed to completely revise the intervention which should have read, Educate staff that resident is not to receive hot beverages unless it is in a cup with a secure lid. When asked if that was an important piece to have been left off the intervention she stated, Yes ma'am it sure was. On 07/25/19 at 11:48 AM, the resident's lunch tray was observed placed on top of the bedside drawer instead of the bedside table. A CNA approached the resident to inform her of the delivery of the tray. A mug of coffee was observed on the tray with a unsecured plastic cover. The resident removed the plastic lid and drank her coffee from the mug. The CNA did not place the coffee into the sturdy cup. 07/25/19 at 05:29 PM, the resident was asleep in a wheelchair in front of nurses station. The resident's dinner tray was delivered to the resident room. The tray was observed to have coffee and water as beverages. The CNA who delivered the tray left the coffee inside the coffee mug with an unsecured plastic lid instead of transferring it into the sturdy cup. The resident then wheeled herself slowly into her room and began to consume her dinner and drink her coffee from the mug. Observed on the bedside table was a black 14-16 ounce sturdy cup with a secure lid (travel mug) for use. On 7/25/19 at 5:45 p.m., Licensed Practical Nurse #3 and #4 were interviewed. LPN #3 stated, When I first got here she (Resident #83) was eating at the nurses station, she would have outbursts and push her trays onto the floor .this is why she now gets served in her room. When asked when was the last time the resident exhibited this behavior; LPN #3 stated, About 4-5 weeks ago. LPN#4, assigned to care for Resident #83 was asked if the resident was allowed to have hot beverages per the care plan. LPN #4 stated, I don't know, I am going to look that up. LPN #4 also stated the resident had coffee for all meals. On 7/26/19 at 10:58 am, the above findings was shared with the Administrator and the Interim Director of Nursing (DON). The Administrator provided this surveyor with a Corrective Action Plan in response to the unusual occurrence. The Administrator stated, We knew about her behaviors, combative with staff, throwing objects, throwing lunch and dinner trays .She has never been aggressive with other residents .it wasn't an issue with the temperature (the hot coffee), it was her behaviors . The DON stated the resident was, .very impulsive, she'll be quite and then she reacts according to what she hears in her head . They stated a thermometer to temp food and beverages was placed in the nourishment room, staff were educated, the resident was provided a sturdy cup with a lid for hot beverages, the resident was encouraged to eat at the nurses station to provide supervision, the DON stated, That's why we liked her at the nurses station and microwave heating instructions was added as part of general orientation. When asked if there was anything that could have been done differently to prevent this occurrence, the DON stated, The nurse not turn her back (after serving the resident hot coffee) and give her a lid (for the coffee). Review of the facility policy titled Hot Beverage Service effective date October 22, 2018 reads as follows: Policy: Facility will provide hot beverages to residents in a manner that promotes safety and meal satisfaction. Procedure: 4. Appropriate supervision will be provided as needed for residents with decreased safety awareness and/or self-feeding deficits that could place them at risk for burns/scalds 5. Staff will monitor for increased behaviors or agitation at meals and consider an alternative for hot beverages if a resident is at increased risk of burning themselves or others. 6. Staff will monitor hot beverage temperatures periodically at the point of service and make adjustments as needed. An inspection of the facility's one nourishment room was conducted on 7/26/19 at approximately 5:00 p.m., there was a sign posted above the microwave for the staff that read: Attention Staff-When heating liquids for consumption the temperature should never exceed 155 degrees. Please obtain temperature before serving and do not serve if over 155 degrees. Please sanitize thermometer before and after use. A thermometer was observed stored inside a plastic bag on top of the microwave.