Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the resident's right to make choices that are significant to the residents, as evidenced by not accommodating residents with their smoking choices/preferences of more than one (1) cigarette per break or more than two (2) smoke breaks per day for three (3) of three (3) sampled residents that smoke. Resident #15, Resident #21, and Resident #29 Findings include: A review of the facility's policy Resident Rights, undated, revealed . Policy Interpretation and Implementation . 2. Residents are entitled to exercise their rights to the fullest extent possible . A review of the facility's document Consent and Release for Smoking/Vaping, undated, revealed . We acknowledge and respect an individual's right to smoke/vape. A review of the facility's policy Smoking/Vaping Policy, undated, revealed . It is the intent of the facility . to allow those residents, who wish to smoke/vape the opportunity to do so . A record review of the facility's document Smoker Worksheet revealed there were five (5) residents who currently smoke in the facility and the smoking times were listed as 11:00 AM and 7:00 PM. During a Resident Council meeting on 11/07/23 at 10:05 AM, Resident #21 and #29 reported that the residents who smoke had met with the Administrator approximately one (1) month ago and had asked to have more than one (1) cigarette at smoke breaks because the facility allowed only two (2) smoke breaks daily. The residents expressed to the Administrator they wanted to have two cigarettes during the breaks because they had smoked for years and preferred more than one (1) or two (2) cigarettes daily. The Administrator had not responded to their request. Resident #21 stated that he saw facility staff going out to smoke several times a day. He commented if they can go out and smoke several times a day, why can't we? Resident #21 explained that he had smoked for years, and he specifically chose the facility because they allowed the residents to smoke. Resident #29 explained that she did not like nicotine gum or patches because she wanted to smoke cigarettes. She stated that she was told on admission that she could smoke, but it was not explained to her that the facility did not allow more than one cigarette per smoke break. Resident #29 also stated that the facility staff went out to smoke several times daily. On 11/07/23 at 11:00 AM, during an observation of a smoke break and interview with Certified Nursing Assistant (CNA) #1, she assisted Resident #15, Resident #21, and Resident #23 to the designated smoking area. CNA #1 explained that the staff are not allowed to smoke with the residents. She confirmed that the residents are allowed to smoke one (1) cigarette during the smoke breaks. She stated that the residents have complained about getting only one cigarette at each break and had spoken to the Administrator about it. CNA #1 explained that the scheduled breaks are at 11:00 AM and 7:00 PM, but before the COVID-19 pandemic, the residents had four (4) designated smoke breaks daily. CNA #1 commented that she was a smoker and would hate to be allowed only two cigarettes a day. On 11/07/23 at 11:30 AM, during an interview with Resident #15, she confirmed that she and the other residents who smoked had asked the Administrator for more than one cigarette per smoke break because it was important to them. Resident #15 stated that the Administrator never responded to their request. On 11/07/23 at 02:00 PM, during an interview with CNA #3, she explained she assisted with smoke breaks for the residents. She confirmed that the residents are allowed to smoke one cigarette per smoke break, which was at 11:00 AM and 7:00 PM. She said that she and the staff who smoked take smoke breaks whenever they can, which was usually more than two times a day. On 11/07/23 at 03:45 PM, during an interview with the Administrator, she confirmed the residents who smoke came to her and requested more cigarettes during smoke breaks and she explained to them it would be discussed. At a Quality Assurance Performance Improvement (QAPI) meeting on 10/18/23, the request was presented to the Medical Director, and it was determined that the facility would not allow residents to smoke more than one cigarette per smoke break and smoking would be against medical advice. She explained the facility had always allowed one (1) cigarette at each smoke break because it took 30 minutes to smoke one (1) cigarette and the facility did not have enough staff to allow more than two smoke breaks daily. She confirmed that she had not responded to their request since the decision was determined at the 10/18/23 meeting because she had been too busy. The Administrator also confirmed that she did not consider their concern a grievance, but more of a request, and she did not add the concern to the facility's Grievance Log At 08:55 AM on 11/08/23, during an interview with the Administrator, she confirmed that she completed the admission paperwork with the resident or the Resident Representative (RR). The admission paperwork included smoking/vaping consents, contracts, and the facility policy, but did not include or acknowledge the number of cigarettes allowed by the facility per smoke break or the number of smoke breaks allowed by the facility. The form included that smoking was against medical advice. Resident #15 A record review of the Face Sheet revealed the facility admitted Resident #15 on 10/21/15 and she had a diagnosis of Nicotine Dependence, Cigarettes. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/08/23 revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. A record review of the facility's Smoking Policy and Consent and Release for Smoking dated 05/05/21 revealed Resident #15 signed the forms which did not indicate or include information regarding the number of cigarettes allowed by the facility per smoke break or the number of smoke breaks allowed by the facility. Resident #21 Record review of the Face Sheet revealed the facility admitted Resident #21 on 07/06/23 with a diagnosis of Hemiplegia Following Cerebral Infarction. Record review of the admission MDS, with an ARD of 07/13/23, revealed Resident #21 had a BIMS score 15, which indicated he was cognitively intact. A record review of the facility's Smoking/Vaping Policy and the Smoking/Vaping Contract, dated 07/05/23, revealed Resident #21 signed the forms which did not indicate or include information regarding the number of cigarettes allowed by the facility per smoke break or the number of smoke breaks allowed by the facility. Resident #29 A record review of the Face Sheet revealed the facility admitted Resident #29 on 01/27/21 with a diagnosis of Type 2 Diabetes Mellitus. A record review of the Annual MDS, with an ARD of 12/26/22, revealed Resident #29 had a BIMS score of 15, which indicated she was cognitively intact. A record review of the facility's Smoking Policy, Consent and Release for Smoking, and Smoking Contract, dated 05/05/21 revealed Resident #29 signed the forms which did not indicate or include information regarding the number of cigarettes allowed by the facility per smoke break or the number of smoke breaks allowed by the facility.

Based on observation, staff interviews and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by-date, food items without an identifying label, and food items opened and exposed for one (1) of three (3) kitchen observations. Findings Include: A review of the facility's Food Storage Labeling Policy, revised 2/15, revealed, .The facility will ensure the safety and quality of food by following food storage and labeling procedures . 1. All food items that are not in their original containers must be labeled: 4. a. Common name b. Date of preparation or Use By Date c. Example: Food prepared on 2/01 must be used or discarded by 2/7 . On 11/6/23 at 9:41 AM, an observation of the kitchen and interview with the Dietary Manager (DM) revealed the contents of the refrigerator to include, (1) opened plastic container of chicken-flavored base with the facility's received by date of 8/2/23. There was no date indicating when the container was opened and there was no facility use by, or manufacturer's expiration date noted on the container. There were two (2) reusable squeeze bottles of ranch dressing and one (1) reusable squeeze bottle of French dressing that was dated by the facility on 10/20/23. There was no label indicating when the food items were prepared or when they should be discarded. The DM stated she did not know what the date of 10/20/23 indicated for those items. There was one (1) plastic food storage bag containing two (2) peeled, pre-boiled eggs, with the facility's received by date of 10/4/23. There was no open by date and no use by date to indicate when the eggs should be discarded. There were four (4) unopened plastic bags of liquid scrambled eggs that were not in their original container and were not labeled with the common name, date of preparation or a use by date. The DM revealed that whoever received the food and stocked the items was responsible for dating each item with the facility's received date. She reported that the [NAME] was responsible for labeling foods with an open date when the foods are opened. The DM explained that all staff are responsible for discarding food items that have reached the expiration or use by date and should be discarded within 3-5 days after opening. She reported the facility completed staff in-services on food safety every 2-3 weeks and acknowledged that her expectation was that staff would label all food items and immediately dispose of any expired foods. On 11/7/23, at 11:15 AM, an interview with [NAME] #1 confirmed that the [NAME] that opened a food item was responsible for putting an opened date on it item and kitchen staff should dispose of it within three (3) days. The [NAME] stated the ranch dressing was prepared from a packet and mixed with buttermilk and should have been dated and discarded within three (3) days. She confirmed that kitchen staff received in-service training three (3) times per month on various topics. On 11/8/23, at 8:06 AM, an interview with the Administrator revealed that she expected the residents to receive food from the kitchen that was safe for the residents to consume.