Health inspection·March 3, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 5 of 5 residents (Resident #s 1, 2, 3, 4, and 5) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was assessed for safety regarding hot liquids resulting in Resident #1 sustaining 1st and 2nd degree burns on 02/23/2024 when he spilled his coffee on himself and was not assessed for hot liquids safety after the incident. The facility failed to have a system in place to assess for hot liquid safety and to ensure Residents #2, #3, #4, and #5 were being served hot coffee with safety interventions assessment or potential interventions in place. The facility failed to follow its policy and ensure the resident was assessed upon admission to the facility to determine risk factors for consuming hot liquids safely (coffee, tea, soups, etc.) and failed to have a policy or a practice that was appropriate for resident consumption of hot liquids. Resident #1 received both 2nd and 1st degree burns on his shoulder, chest and right forearm. On 03/01/2024 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/03/2024 at 12:01 PM, the facility remained out of compliance at a scope of isolated and a severity level with no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This deficient practice placed residents at risk of scalding, burns, pain, infection, and hospitalization. The findings were: Record review of Resident #1's face sheet, dated 02/26/2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure, muscle weakness, and congestive heart failure. Review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 7, suggesting severe cognitive impairment. Record review of the care plan for Resident #1, dated 03/03/2023, reflected the following: Resident Page 1 of 9 676364 676364 03/03/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #1 had frail skin and may need assistance with activities of daily living completion with intervention to follow safety protocols for protection of injury. Review of order dated 02/23/2024 revealed NP wrote an order for Resident #1 to have a no spill cup with his meals. Record review of Resident #2's face sheet, dated 03/03/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included ankle contractures, age related debility, muscle weakness, other reduced mobility, and other lack of coordination. Review of the care plan for Resident #2, dated 12/21/23 revealed Resident #2 was at risk for impaired skin integrity. Review of Resident #2's MDS assessment dated [DATE] reflected a BIMS score of 2, suggesting severe cognitive impairment. Review of Resident #2's MDS dated [DATE] reflected lower extremity impairments (hip, knee, ankle, and foot) and used a wheelchair. Record review of Resident #3's face sheet, dated 03/03/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (disrupted blood flow to the brain), paralysis to one limb of the body, speech and language deficit, hemiplegia(paralysis) to the right dominant side of the body, muscle weakness, and unsteadiness on feet. Review of the care plan for Resident #3, dated 01/26/2024 revealed Resident #3 was at risk for bruising, skin breakdown and skin tears related to his decline in mobility, frail skin and his need for increased assistance with activities of daily living completion. Review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 9, suggesting moderate cognitive impairment. Review of Resident #3's MDS assessment dated [DATE] reflected upper extremity impairments (shoulder, elbow, writs, and hand), used a wheelchair, and required supervision and touch assistance when eating. Record review of Resident #4's face sheet, dated 03/03/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's, muscle weakness, cognitive communication deficit, and mild cognitive impairment. Review of care plan for Resident #4, dated 11/20/2023 revealed Resident #4 had fragile skin and gets skin tears easily and Resident #4 has a diagnosis of dementia and will need to be re-oriented to person, place, time, and situation. Review of Resident #4's MDS assessment dated [DATE] revealed a BIMS score of 5 suggesting severe cognitive impairment. Record review of Resident #5's face sheet, dated 03/03/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, muscle weakness, cognitive communication deficit, and other psychotic disorder. 676364 Page 2 of 9 676364 03/03/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #5's MDS assessment dated [DATE] reflected a BIMS score of NA - not applicable, suggesting moderate cognitive impairment. Review of the care plan for Resident #5, dated 03/07/2023 revealed Resident #5 had the potential for skin damage Resident #5 has a diagnosis of dementia and will need to be re-oriented to person, place, time, and situation. Residents Affected - Few Review of Resident #5's MDS assessment dated [DATE] revealed she used a wheelchair. Review of NP progress note revealed on 02/23/2024 Resident #1 was seen this morning for an acute coffee burn. He was holding his coffee cup in the left hand and the left hand started shaking and he spilled the coffee over his far-right side of his chest, right auxiliary, right lower side, right shoulder, and right forearm. Second degree burn on the anterior right shoulder. Blistered skin. Blister posterior side right forearm. First degree burns on the right side, upper outer chest wall, and his right forearm. Observation and interview on 03/01/2024 with Resident #1 at 12:17 pm revealed that the resident said he was in his bed when he was served coffee in his room. He revealed he was not wearing a shirt and the coffee was placed on the bedside table in front of him. When asked if he was sitting up, he said he was lying as he was when the state surveyor observed him (slightly inclined in the bed). He said he picked up the coffee and his hand shook, and the coffee spilled on the right side of his body. The state surveyor observed an area on Resident #1's forearm about 3 inches in length and 3 inches in width red, dry, with white flaking skin and a scab in the center about 2 inches in length. Resident #1 revealed when the coffee spilled on him it hurt very badly and he yelled out. When the state surveyor asked Resident #1 to explain how it felt, he made a long expression in his face and a oh oh sound and grabbed his arm and said it hurt very badly. Observation on 03/01/2024 at 10:46 AM of coffee temperatures: Temperature when poured from the warmer into cup, temperature immediately taken - 164.3 degrees Fahrenheit. Coffee temperature taken after 5 minutes 150.02 degrees Fahrenheit. Coffee temperature taken 8 minutes after 144 degrees Fahrenheit. Observation on 03/01/2024 at 11:40 AM of Residents 2, 3, 4, and 5 being served coffee with no lid in the dining room. Interview on 03/01/2023 with CM A at 10:10 AM revealed she served Resident #1 coffee. She put it on his bed side table. As she left the room, she heard Resident #1 yell out in pain and saw that he had spilled his coffee on himself. Interview on 03/01/2024 with the NP at 10:30 AM revealed she was at the facility and assessed the resident at the time of the incident. She said Resident #1 did not have a history of involuntary hand movement or shaking. She said she wrote an order for Resident #1 to have a no spill cup with his meals. She said she had seen Resident #1 a lot of times with coffee. Interview on 03/01/2023 with the DM at 11:41 AM revealed there were not lids on coffee cups when 676364 Page 3 of 9 676364 03/03/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few they were serving in the dining room. The DM revealed that when a cup of coffee is taken to a residents' room, it has a lid, and it completely covers the top and has to be completely removed to drink the coffee. She said the facility began logging the temperature of the coffee after the incident with Resident #1. The DM revealed that the temperature was taken after it was brewed and in the coffee pot prior to serving. The DM revealed that when the state surveyor was in the dining room observing, she put ice cubes in the residents' coffee prior to it being served, but she did not take the temperature of the coffee in the cups when they were served to the residents. Interview on 03/01/2024 with the Administrator at 12:54 pm revealed she did not know at what temperature that hot liquids caused burns. She thought that hot liquids should be between served at a temperature between 140- and 150-degrees Fahrenheit. When shown the facility policy that reflected that one of the interventions to be implemented to minimize the risk from burns from hot liquids was to maintain a hot liquid serving temperature of not more than 180 Fahrenheit, the Administrator said she felt like this serving temperature was too high. After Resident #1 was injured by the coffee spill the Administrator revealed she did not conduct a hot liquids evaluation for Resident #1. The Administrator revealed no hot liquids safety evaluations were conducted for any of the residents in the facility. She did not conduct a hot liquids safety evaluation for Resident #1 or any other resident in the facility. Record review of a Google search revealed coffee and other hot beverages are usually served at 160 to 180 degrees Fahrenheit resulting in almost instantaneous burns that may require surgery. Facility policy safety of hot liquids dated October 2014 reflected: Policy Statement Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury. Policy Interpretation and Implementation 1. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. 2. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and it take longer to heal. 3. Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular hot liquids safety evaluations as 676364 Page 4 of 9 676364 03/03/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0689 indicated and document the risk factors for scalding and burns in the care plan. Level of Harm - Immediate jeopardy to resident health or safety 4. Once risk factors for injury from both hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include: Residents Affected - Few a. maintaining a hot liquid serving temperature of not more than 180°F. b. serving hot beverages in a cup with a lid; c. encouraging residents to sit at a table while drinking or eating hot liquids; d. providing protective lap covering or clothing to protect skin from accidental spills; and e. staff supervision or assistance with hot beverages. 5. Food service staff will monitor and maintain foods temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. This was determined to be an Immediate Jeopardy (IJ) on 03/01/2024 at 3:29 PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/01/2024 at 3:29 PM. The following POR was submitted by the facility and was accepted on 03/03/2024 at 9:10 AM. Plan of Removal for the Immediate Jeopardy F689 on 03.01.2024 On 03.01.2024 an abbreviated survey was initiated at the facility for an incident that occurred on 02.23.2024. On 03.01.2024 the state surveyor provided an Immediate Jeopardy (IJ) template notification that Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to the resident health and safety of 17 residents identified with the presence of risk factors on the hot liquids safety evaluation. The notification of immediate threat states as follows: The facility failed to provide hot liquids evaluation for resident #1. The deficient practice did result in harm to resident #1. Resident #1 was not evaluated at 676364 Page 5 of 9 676364 03/03/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0689 Level of Harm - Immediate jeopardy to resident health or safety admission, nor at any other time, for hot liquid safety. Resident #1 was served hot coffee with unacknowledged risk factors present on 02.23.2024. He was served hot coffee without a lid, while in bed with no shirt or gown on, nor a clothing protector. These risk factors contributed to resident receiving burns from hot coffee and harm resulting from the deficient practice. The Medical Director, as well as the APRN , were notified on 02.23.2024, the date of the incident. Residents Affected - Few The Medical Director, as well as the APRN, were notified of the deficient practice on 03.01.2024. Resident #1 will be reassessed with the hot liquid evaluation and updated in resident's plan of care, EMAR and paper chart. Initiated 03.01.2024 and completed by Assistant Director of Nursing on 03.01.2024. All staff in-serviced by the ADON and the MDS nurse for results of hot liquid assessment and interventions required for at risk residents. Initiated 03.01.2024 and completed 03.02.2024. Current and future residents will be assessed with the hot liquid evaluation and updated in residents plan of care, EMAR and paper chart. Initiated 03.01.2024 and completed by the Assistant Director of Nursing and the MDS Nurse on 03.01.2024. Seventeen at risk residents identified by hot liquid safety evaluations, and all staff in-serviced by the ADON and the MDS nurse for results of hot liquid assessment and interventions required for at risk residents. Initiated 03.01.2024 and completed 03.02.2024. Staff will be reeducated on the hot liquid evaluation, including but not limited to serving temperatures, fill capacity, placement, and identifying risk factors contributing to potential for spills. Initiated on 03.01.2024. The Administrator and the DON will continue reeducation with non-present/prn/agency staff and future staff. A posttest will be administered by the DON and the ADON to verify comprehension of the policy. Initiated on 03.02.2024 and will be completed for all scheduled staff 03.02.2024. Reeducation for current staff will be completed 03.02.2024. Reeducation for PRN/agency/future/non-present staff will be completed prior to staff starting their next shift and will be ongoing. Dietary supervisor in-serviced all dietary staff on safe holding and serving temperatures for hot beverages. Initiated 03.01.2024. Completed 03.02.2024. Dietary staff members will monitor safe temperature for beverages. Dietary staff will record hot beverage temperatures for every meal, and ensure they are within appropriate range of 140 to 155 degrees at service. Initiated on 03.02.2024 and will be an ongoing practice to ensure safety of residents with hot liquids. This task will be monitored by dietary supervisor daily to ensure compliance. Administrator will audit temperature logs daily ongoing. Ad Hoc QAPI meeting held 03.01.2024 with the Administrator, the ADON, the MDS nurse, and the Dietary Supervisor to discuss immediate jeopardy. This will be an ongoing discussion at monthly QAPI meetings indefinitely. A team of interdisciplinary professionals will review this policy and update as needed. Resident #1 will be reassessed with the hot liquid evaluation and updated in resident's plan of care, EMAR, and paper chart. Initiated 03.01.2024 and completed by Assistant Director of Nursing on 03.01.2024. Monitoring: 676364 Page 6 of 9 676364 03/03/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0689 Monitoring was initiated on 03/03/2024. Level of Harm - Immediate jeopardy to resident health or safety Surveyor reviewed Resident #1's Hot Liquids Safety Evaluation dated 03/01/2024. Resident #1's plan of care was updated to include that hot liquids given to Resident #1 will have a lid, will be given while he is sitting up at a table, wearing a clothing/lap protector, and staff will assist him with eating. During interview with Resident #1, resident showed the state surveyor the insulated cup with lid that was provided to him for hot liquids. Residents Affected - Few Reviewed staff in-services initialed by the ADON and the MDS nurse for results of hot liquid assessment and interventions required for at risk residents. Reviewed the facility hot liquids assessments conducted for all facility residents completed by the ADON and the MDS Nurse and the updates to the plan of care, EMAR, and paper chart for the seventeen residents identified by the hot liquid safety evaluations. Resident #1's Hot Liquids Safety Evaluation indicated risk factor other (2/23/24 hot liquid spill) and listed intervention for resident to use a cup with a lid. Resident #2's Hot Liquids Safety Evaluation indicated risk factors of cognition, mood and behavior, contractures, and mobility and listed interventions for resident to use a cup with lid, resident to drink hot liquids while sitting at table only and to wear clothing protective/lap protector. Resident #3's Hot Liquids Safety Evaluation indicated risk factors of strength, and mobility and listed interventions for resident to drink hot liquids while sitting at table only. Resident #4's Hot Liquids Safety Evaluation indicated risk factors of cognition, mood, and behavior and listed interventions for resident to use a cup with lid, resident to drink hot liquids while sitting at table only and to wear clothing protective/lap protector. Resident #5's Hot Liquids Safety Evaluation indicated risk factors of cognition and tremors and listed interventions for resident to drink hot liquids while sitting at table only and to wear clothing protective/lap protector. Reviewed Resident #s 1, 2, 3, 4, and 5 care plans to confirm Hot Liquids Safety Evaluation interventions are included in their care plans. Reviewed the staff in-services serving hot liquids that included serving temperatures, fill capacity, placement, and identifying risk factors contributing to potential for spills. Reviewed the post tests to verify comprehension of policy. Interviewed the Dietary supervisor who revealed she in-serviced all dietary staff on safe holding and serving temperatures for hot beverages and dietary staff members will monitor safe temperature for beverages. Dietary supervisor said dietary staff will record hot beverage temperatures for every meal and ensure they were within appropriate range of 140 to 155 degrees at service. Reviewed the current audit of dietary hot beverage temperature logs that revealed hot beverage temperatures for meals were served within the range of 140 to 155 degrees at service. The ADON and the MDS Nurse are responsible for conducting hot liquid safety evaluations as indicated in the POR and evidenced that the ADON and MDS Nurse conducted the hot liquids evaluation that revealed seventeen residents were identified with the presence of risk factors on the hot liquids safety evaluation. Observed on 03/03/24 at 11:45 am of 15 residents in the dining room. Several residents with interventions wearing thin plastic protective covering. 676364 Page 7 of 9 676364 03/03/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Reviewed Ad Hoc QAPI meeting held 03.01.2024 with the Administrator, the ADON, the MDS nurse, and Dietary Supervisor to discuss immediate jeopardy. Interview on 03/03/2024 with KS B at 10:29 am revealed she was in-serviced on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. She learned that hot liquids need to be between 140 and 155 degrees Fahrenheit and residents need to wear protective covering when drinking coffee. She needs to take the temperature of the coffee before it was served and if it was too hot it needs to sit and then the temperature taken again. Only a staff member should serve the resident coffee and the cups should only be ¾ full and placed on towards the center of the table on the resident's dominate side. Interview on 03/03/2024 with KS C at 10:42 who revealed he attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. He learned that coffee temperatures have to be between 140 and 155 degrees Fahrenheit before it was taken to the resident. If it was higher than that that, they cannot serve it, it has to cool down. He was told to use a thermometer to measure the temperature. He revealed they were now charting coffee temperatures and there was a list of residents who needed assistance with hot liquids. He said it was important to only fill the cup ¾ full of hot drinks and it was not acceptable to leave hot beverages in an area where a resident was alone. When serving hot beverages, the hot beverages should be placed away from the edge of the table and close to the resident's dominant hand. He said try and offer iced tea or iced coffee instead of hot beverages. Interview on 03/03/2024 with CNA D at 10:54 who revealed she attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. She revealed there was a list of all residents who needed interventions. She said hot beverages should be served to the residents at a temperature between 140 -155-degree Fahrenheit and to make sure it was not hotter. She will use a thermometer to check the temperature and make sure the temperature is correct before giving the beverage. She said that some residents have an intervention for clothing protectors and ice can be added to a beverage if it was too hot only if the resident agrees. She revealed the beverage cup should be filled to 75% capacity and hot beverages should be removed from the dining rooms or other areas where residents have accessibility without supervision. Residents could also be offered an insulated mug with a lid but only if the resident agrees. Interview on 03/03/2024 with CNA E at 11:05 am who revealed he attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. He said hot liquid temperatures should be 140 - 155-degree Fahrenheit and residents need to have protective apron if they were on the list of residents with interventions. He revealed the kitchen staff were to make sure the temperature was cool enough for the residents to drink the beverage. He said do not place coffee close to the resident and hot drinks can't be left in or around where the residents were not supervised. Residents who have cognitive issues or physical issues need to be offered assistance and supervised while consuming hot beverages. Interview on 03/03/2024 with RN F at 11:18 AM revealed she attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. She learned that hot liquids can't be served to residents if they were hotter than 140 - 155-degrees Fahrenheit and do not place hot drinks too close to the edge of the table but have them within residents' reach. She said some residents will wear protective clothing and they have already begun using the protective clothing with the resident. 676364 Page 8 of 9 676364 03/03/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Interview on 03/03/2024 with LVN G at 11:20 AM revealed he attended an in-service on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. He said he was going to use the thermometer from the kitchen to check that hot drinks were not hotter than 140 - 155-degrees Fahrenheit and serving mugs should be only filled to 75% capacity. Resident can have an insulated cup and lid. He was aware that there was a list of residents who need interventions for hot beverages and what those interventions are. Residents Affected - Few Interview on 03/03/2024 at 11:27 AM with the DM revealed the dietitian in-serviced her on interventions for residents and hot liquids including which residents needed interventions and the procedures for serving hot liquids. She revealed that the kitchen will be taking the temperature of all hot liquids to confirm they were served at a temperature between 140- 155-degrees Fahrenheit. She said that if the resident agrees, staff can drop a piece of ice to cool the beverage. She revealed hot drinks need to be placed away from the edge of the table but in resident's reach when it was served. Some residents have an intervention for protective clothing when they have been served hot drinks and some residents will have a lid on their beverages. She revealed that the list of residents who have hot liquid intervention was in the kitchen. The ADM was informed the Immediate Jeopardy was removed on 03/03/2024 at 12:01 PM. The facility remained out of compliance at a scope of isolated and at a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 676364 Page 9 of 9