**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, review of the facility menus and spreadsheets for mechanical soft diets, review of facility policy for therapeutic diets, consistency modified diets, and tray card policy, the facility failed to ensure 10 residents on mechanically altered diets were provided food in the correct form assessed to meet their individual needs. This resulted in Immediate Jeopardy for Residents #6, #11, #19, #30, #31, #36, #37, #201 and #345 who were served whole, intact bone-in chicken by the dietary staff and nursing assistants. Residents #6, #27, #30 and #36 also were assessed to need their liquids thickened to nectar consistency and were served the wrong consistency liquids. The noncompliance to the mechanically altered diets placed them at risk for serious harm such as choking which could have resulted in death. The facility identified ten Residents (#6, #11, #19, #27, #30, #31, #36, #37, #201 and #345) who received mechanically altered diets. The facility census was 48. On 02/17/22 at 9:13 A.M. the Administrator and Regional Director of Operations (RDO) #549 were notified Immediate Jeopardy began on 02/15/22 at approximately 1:00 P.M. when Residents #6, #11, #19, #27, #30, #31, #37, #201 and #345 who were ordered mechanical soft diets were observed receiving whole, bone-in regular fried chicken legs. In addition, Residents #6, #27, #30 and #36 were served liquids at the wrong consistency contrary to their assessed needs for nectar thick liquids. Interview with [NAME] #516 and Dietary Manager #508 at 1:10 P.M. revealed [NAME] #516 did not prepare any mechanical soft meat for the meal. The Immediate Jeopardy was removed on 02/16/22 when the facility implemented the following corrective actions: • On 02/15/22 at approximately 2:20 P.M. the Regional Director of Operations (RDO) #549 educated DM #508 on diet spreadsheets including mechanical soft and pureed consistency, the tray ticket program and liquid consistency including nectar and honey thickened liquids and thin liquids. • On 02/15/22 at approximately 3:30 P.M. the Director of Nursing (DON) and Dietetic Technician Registered (DTR) #546 audited 48 of 48 resident diet orders to ensure the ordered diet texture and liquids consistencies matched the resident's assessed needs. • On 02/15/22 at approximately 3:45 P.M. Dietary Manager (DM) #508 educated two of six dietary staff working in the facility on the importance of dietary tray cards, the consistencies of nectar and honey thickened liquids, the consistencies of mechanical soft and pureed modified diets, the therapeutic diet policy, and examples of mechanical soft dietary items. The remaining four dietary staff were educated by DM #508 by 2:00 P.M. on 02/17/22. • On 02/15/22 between 4:30 P.M. and 5:30 P.M. the Administrator and DON rounded the floor during dinner and observed all meal trays being delivered with correct diet consistency including 10 of 10 mechanical soft diets and four of four nectar consistency liquids. • On 02/15/22 from 6:30 P.M. to 7:30 P.M. 10 of 10 residents ordered a mechanically altered diet and nectar thickened liquids had respiratory assessments completed by the DON and RN #537. There were no signs or symptoms of respiratory compromise. • On 02/15/22 between 7:30 P.M. and 8:00 P.M. the DON reviewed 10 of 10 mechanically altered and nectar thickened liquid diet orders with Medical Director (MD) #552 and verified the diet orders being implemented for the residents were accurate compared to the physician orders. • On 2/16/2022 beginning at 6:00 A.M. the DON and Administrator began to educate all available staff on shift on the meal tray preparation, meal tray service, the importance of checking dietary tray cards, proper consistency of thin, nectar and honey consistency thickened liquids, consistency of modified diets, the therapeutic diet policy, and examples of mechanical soft dietary items. All staff (42 out of 42 staff including 16 out of 16 STNA's, 4 out of 4 RN's, 3 out of 3 LPN's, 5 out of 5 housekeeping/laundry employees, 1 out of 1 activities aid, 6 out of 6 dietary staff, 7 out of 7 department heads) education was completed on 02/17/22 by 2:00 P.M. when DM #508 completed the education with the remaining four of six dietary department employees. • On 02/16/22 beginning at approximately 8:30 A.M. RDO #549 again reviewed for competency with DM #508 the importance of dietary tray cards, consistency of thickened liquids, consistency of modified diets, therapeutic diet policy and examples of mechanical soft items. RDO #549 monitored breakfast and lunch meal service to ensure compliance. • On 02/16/22 at 12:08 P.M. RDO #549 communicated with the contracted Registered Dietitian (RD) #547 to inform her of the recent review of dietary spreadsheets and mechanically altered diet extensions with related staff education. RDO #549 observed the lunch meal service. • The facility administrator or designee ( which may include the DON, ADON, RDO #549, DTR #546, DM #508 or RD #547) will continue to audit/observe the meal tray service line to ensure all tray items match the resident diet order/food consistency/liquid consistency all 3 meals for the next 3 days and then 1 random tray line service daily (5 days per week) x 4 weeks and then as determined by QAPI committee comprised of the administrator, DON, dietary manager, maintenance director, social service director, activity director, BOM/HR director, admissions director. • The facility DON or designee which may include the ADON, Charge Nurse, Administrator, RDO #549, Regional Clinical Nurse (RCN) #553, DTR #546 and RD #547 will observe meal tray delivery service to the rooms to ensure all tray items match the resident diet order/food consistency/liquid consistency all 3 meals for the next 3 days and then 1 random tray line service daily (5 days per week) x 4 weeks and then as determined by QAPI committee comprised of the administrator, DON, dietary manager, maintenance director, social service director, activity director, BOM/HR director, admissions director. Although the Immediate Jeopardy was removed on 02/16/22 the facility remained out of compliance at a severity level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) as the facility was still in the process of implementing their corrective action, monitoring to ensure on-going compliance, and evaluating their corrective action for further recommendations. Findings include: 1. Record review was conducted for Resident #6 who was admitted to the facility on [DATE] with diagnoses including stroke, multiple sclerosis, and oropharyngeal dysphagia (difficulty chewing and swallowing). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had no cognitive impairment, required extensive assistance of two staff for bed mobility and transfers and required set-up and one-staff physical assistance with eating. A physician order dated 07/21/21 indicted Resident #6 was to receive a mechanical soft diet with nectar consistency liquids. The plan of care with a revision date of 12/06/21 revealed the care plan indicated Resident #6 required a mechanically altered diet with nectar consistency liquids. The interventions included dietary staff and nursing staff would provide the diet as ordered and monitor the consistency of the diet served to the resident. Observation of and interview with Resident #6 in the dining room on 02/15/22 at 12:47 P.M. presented as dependent on a custom wheelchair with a head rest for mobility and positioning. Resident #6 required staff assistance to put his food on the table, set-up the meal and prepare his nectar consistency liquids. Resident #6 was alert and oriented to person, place, time, and conversation and had little eye contact with the surveyor during conversation. Resident #6 was able to verbally make his needs known to staff. 2. Record review was conducted for Resident #11 who was admitted to the facility on [DATE] with diagnosis including Alzheimer's dementia with behavioral disturbance. The MDS 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment, required extensive assistance of one staff for bed mobility, extensive assistance of two staff for transfers and set-up help only and supervision for eating. A physician order dated 01/07/21 indicated Resident #11 required a mechanical soft diet with thin consistency liquids. The plan of care with a revision date of 07/15/19 revealed Resident #11 was edentulous (no teeth) by choice and required a mechanically altered diet texture. The interventions included for dietary and nursing staff to provide the ordered diet. Observation and interview were conducted 02/14/22 at 11:00 A.M. in the Resident #11's room. He presented as alert with disorientation to time, place and was not able to provide reciprocal conversation with the surveyor often making limited comments of no relevance to the questions. 3. Record review was conducted for Resident #19 who was admitted to the facility on [DATE] with diagnoses including stroke, hemiparalysis of right side and dementia. The MDS 3.0 assessment dated [DATE] revealed Resident #19 had no cognitive impairment and required limited assistance of one staff to provide physical assistance for eating, extensive assistance of two staff for transfers and extensive assistance of one staff for bed mobility. A physician order dated 06/23/21 indicated Resident #19 required a mechanical soft diet with thin consistency liquids. The plan of care with a revision date of 02/15/22 revealed Resident #19 required a mechanically altered diet and the diet should be provided to him as ordered by the dietary and nursing staff. Observation and interview of Resident #19 in his room on 02/15/22 at approximately 6:00 P.M. revealed he was unable to use his paralyzed right arm to eat his meal, but he could feed himself with his left hand. Resident #19 was alert and oriented to person, place and conversation and was able to verbally make his needs known to staff. 4. Record review was conducted for Resident #30 who was admitted to the facility on [DATE] with diagnoses including stroke, right sided paralysis, and oropharyngeal dysphagia. The MDS 3.0 assessment dated [DATE] revealed Resident #30 had severe cognitive impairment, required extensive assistance of two staff for bed mobility, total assistance by two staff for transfers and extensive assistance with one-staff physical assistance for eating. A physician order dated 07/07/21 revealed Resident #30 required a mechanical soft diet with nectar consistency liquids and low concentrated sweets. The plan of care with a revision date of 04/25/19 revealed dietary staff and nursing staff should provide the diet as ordered. Observation was conducted of Resident #30 on 02/15/22 at approximately 5:59 P.M. revealing a vulnerable man with paralysis in need of extensive assistance by staff to ensure he ate his meal. Resident #30 was alert but unable to carry a conversation nor answer questions from the surveyor. 5. Record review was conducted for Resident #31 who was admitted to the facility on [DATE] with diagnosis including Alzheimer dementia. The MDS 3.0 assessment dated [DATE] revealed Resident #31 had severe cognitive impairment, required limited assistance of one staff for bed mobility and transfer and set-up with supervision for meals. A physician order dated 07/06/2020 revealed Resident #31 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 12/11/21 revealed Resident #31 had the potential for alteration in nutrition and hydration status due to a poor appetite and need for supplements. Interventions included for dietary and nursing staff to provide the diet as ordered and monitor diet consistency. Observation was conducted on 02/15/22 at 12:49 P.M. of Resident #31 sitting in her wheelchair in the main dining room. She was alert, able to state her name but disoriented to place and time. Resident #31 could answer simple questions with a one word reply with limited ability to express her wants and needs. Resident #31 was unable to verbalize understanding of her mechanical soft diet. 6. Record review was conducted for Resident #36 who was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance and schizophrenia. The MDS 3.0 assessment dated [DATE] revealed severe cognitive impairment, extensive assistance of two staff for bed mobility and transfers and set-up with supervision for eating. A physician order dated 12/10/2020 indicated Resident #36 required a mechanical soft diet with nectar thick liquids. The plan of care with a revision date of 12/11/21 revealed Resident #36 required mechanical soft texture with nectar thick liquids and interventions included to give the diet as ordered and monitor the consistency of the diet. Observation was conducted on 02/14/22 at approximately 11:00 A.M. of Resident #36 in his bed. He was alert but completely disoriented. When asked if the staff provided good care to him, Resident #36 gave unrelated comments about catching a bus. 7. Record review was conducted for Resident #27 who was admitted to the facility with diagnosis including dysphagia. The MDS 3.0 assessment dated [DATE] revealed severe cognitive impairment, and Resident #27 was totally dependent on two staff for bed mobility, transfers and needed extensive assistance of one staff for eating. A physician order dated 06/08/21 revealed Resident #27 was receiving palliative care services from hospice. On 10/24/21 her diet order was mechanical soft with pureed meats and nectar thick liquids. On 02/08/22 she was ordered a chest x-ray to rule out cough and aspiration. On 02/15/22 she was ordered speech therapy for dysphagia. Review of the chest x-ray revealed Resident #27's lungs were clear. Review of the Speech Therapy Evaluation and Treatment Plan dated 02/15/22 authored by Speech Therapist (ST) #545 revealed Resident #27's current diet texture was appropriate, and she was able to feed herself without staff assistance and with proper positioning for the meal. Observation and interview were conducted on 02/15/22 at 5:57 P.M. of Resident #27 sitting upright in her bed with her tray table at breast level and within her reach. Resident #27 presented with good positioning and demonstrated an ability to feed herself using a divided plate, double handled, lidded sip cup and built-up handled utensils. Resident #27 was alert and oriented to herself, the meal and conversation capable of giving appropriate answers to simple questions by the surveyor. Resident #27 smiled, made good eye contact with the staff and was able to verbally make her needs known to staff when they asked her what she would like to drink. 8. Record review was conducted for Resident #201 who was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance and unspecified psychosis. The MDS 3.0 assessment dated [DATE] revealed Resident #201 was cognitively impaired, needed limited assistance of one staff for bed mobility and transfers and supervision and set-up for meals. A physician order dated 10/10/2018 indicted Resident #201 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 06/11/21 revealed Resident #201 required mechanical soft consistency due to difficulty chewing with an intervention for dietary and nursing staff to monitor the consistency served to him and provide the ordered diet. Observation was conducted on 02/15/22 at 1:10 P.M. of Resident #201 sitting up on the side of his bed with his meal tray in front of him. He presented as alert and oriented to person, place, and conversation. Resident #201 was visually impaired but able to point to the food on his plate, identify it and feed himself with standard utensils. He could carry on reciprocal conversation and verbally make his wants and needs known to staff. 9. Record review was conducted for Resident #345 who was admitted to the facility on [DATE] with diagnoses including quadriplegia. The MDS 3.0 assessment dated [DATE] revealed he had no cognitive impairment, was totally dependent on two staff for bed mobility and transfers and totally dependent on one staff for eating. A physician order dated 12/12/19 indicated Resident #345 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 01/08/22 indicted Resident #345 was edentulous, required a mechanical soft diet and dietary and nursing staff should offer diet as ordered. Observation was conducted on 02/15/22 at approximately 6:00 P.M. of Resident #345 who presented as highly vulnerable with limited body movement. He needed the staff to feed him and was alert and oriented to the meal. Resident #345 was able to verbally make his wants and needs known to the staff. 10. Record review was conducted for Resident #37 who was admitted to the facility on [DATE] with diagnoses including moderate intellectual disability, dysphagia, and dementia with behavioral disturbances. The MDS 3.0 assessment dated [DATE] revealed Resident #37 had cognitive impairment, required extensive assistance of one staff for bed mobility, transfers and supervision and set-up for meals. A physician order dated 02/14/22 and revised on 02/16/22 revealed Resident #37 required a mechanical soft diet with thin liquids. The plan of care with a revision date of 06/12/19 indicated Resident #37 had dysphagia. The nutrition risk portion of the care plan with a revision date of 01/23/22 revealed Resident #37 required a mechanical soft diet due to dysphagia and thickened liquids. The interventions were to provide the diet as ordered and monitor the consistency of the diet served to him. Observation was conducted on 02/14/22 at approximately 11:00 A.M. of Resident #37 in his bed. He was alert with disorientation and unable to answer simple questions from the surveyor. Record review was conducted of the menu for 02/15/22 and 02/16/22 along with the mechanical soft spreadsheets, therapeutic diets policy, and consistency modified diets policy. The mechanical soft spreadsheet for 02/15/22 revealed ground pork loin, diced oven potato, and green beans should have been served for lunch. Dinner was garden vegetable soup, three packs of saltines, ground turkey for the sandwich and pineapple chunks. The therapeutic diet policy stated crackers were allowed if softened in soups. Observation and interview were conducted on 02/15/22 at 8:51 A.M. with DM #508 who was sitting in her office writing diet orders and resident names on white pieces of paper. She informed the surveyor it was her first week on the job and the former dietary manager took the computer, so she had no computer program to print tray tickets for the residents. Observation was conducted on 02/15/22 from 12:47 P.M. to 1:13 P.M. of the lunch meal service. State Tested Nurse Aide (STNA) #527 was passing trays in the main dining room. The resident tray tickets had been handwritten on approximately four-inch-wide by eight-inch-long white paper. The residents name and diet type were written in red ink on the tickets. The tray tickets for Residents #6 and #31 stated mech soft on the ticket in red ink. The ticket gave no specific instructions on the types or portions of food to be served for the meal. The meal served to both residents was diced potato, cooked green beans and a whole, regular texture, bone-in, breaded, fried chicken leg. Resident #31's lips were sunken around her gum lines presenting as edentulous and when asked by the surveyor if she could eat the chicken, she said she did not know if she could. Resident #6 said he wanted to eat the chicken. The surveyor intervened and brought the concern to the attention of STNA #527 who had been passing trays to other residents. She verified the findings. She did not attempt to offer them any alternative foods of mechanical soft consistency instead she began trying to cut the meat off the bone for Resident #31 saying the meat was dry and hard to cut up. She shredded the meat into large stringy pieces and the resident declined to eat it. In addition, Resident #6 required drinks thickened to nectar consistency. The only drink on his tray appeared too thick. STNA #527 verified the finding as she stirred his drink to check the consistency, she said it was too thick more like honey not nectar. Observation and interview on 02/15/22 at 1:10 P.M. of the kitchen tray line with [NAME] #516 and DM #508 revealed she did not make any mechanical soft chicken or other mechanical soft meat for the lunch meal. When asked what she served the 10 mechanical soft diets in the facility she pointed to the bone-in fried chicken pieces in the steam table pan and said that was what she served. When asked what mechanical soft consistency chicken should look like she replied it was chopped meat and she was not able to make it that way because she did not have any other chicken without bones. The surveyor proceeded to the 100 unit to check other mechanical soft meal trays and encountered the same concerns. Observation on 02/15/22 at 1:13 P.M. of Resident #36 was found sitting on the side of his bed taking a bite out of the bone-in fried chicken leg. He was unable to verbalize understanding he was ordered a mechanical soft diet and said he wanted to eat the chicken leg. STNA #541 appeared in the doorway after the surveyor had entered the room and verified the findings including the cranberry juice on his meal tray was not thickened at all but should have been thickened to nectar consistency. STNA #541 said Resident #36 did not need supervision with eating, so she had just set up his tray and he ate alone in his room. She verified the paper on his tray said mech soft nectar liquids. Interview was conducted on 02/15/22 at 3:38 P.M. with DTR #546 who revealed he was contracted to come to the facility every other week and meal rounds were not part of his contract. He verified a bone-in, regular consistency chicken leg should never be served to any resident who needed a mechanical soft diet. He said he had not done any staff education on therapeutic diets within the last year because the former dietary manager was a seasoned dietary manager and he had never noticed any problems in the facility when she worked there. He said his supervisor was RD #547 who did not come to the facility but reviewed his work with him via telephone. Interview was conducted on 02/15/22 at 4:47 P.M. with ST #545 who said she worked at the facility per diem. Her only resident on case load was Resident #27 who she was seeing because the staff told her she was having some coughing episodes. When asked what her expectation was for any resident in need of a mechanical soft diet, she explained the meat should be ground or at least chopped into small, bite sized pieces. She said she had not provided any diet guidance for mechanical soft diets to the facility, nor had she been asked to provide any. She verified Resident #27 had not aspirated and her current diet texture of mechanical soft with pureed meat and nectar thickened liquids was appropriate for her. She stated with proper positioning Resident #27 did not need to be supervised or assisted with eating her meals. Observation was conducted with the DON on 02/15/22 from 5:57 P.M. to 6:15 P.M. of the dinner trays for Residents ##6, #11, #19, #30, #31, #36, #37, #201 and #345. All residents except Resident #27 where served a ground turkey sandwich on white bread, tomato soup with three packs of whole saltine crackers and canned pineapple. None of the resident's saltine crackers had been added to their soup. Resident #27 was served pureed turkey sandwich, mashed potato, and applesauce even though her diet was mechanical soft with pureed meat and nectar thick liquids. STNA #527 brought her in a cup of red drink and said it was not thick enough because the thickener had settled to the bottom. She proceeded to add 2 scoops of thickener to the cup which made it present as more of a honey thick liquid. When asked if she followed the recipe on the can for thickening liquids, she said she does it all the time so she knew how much to add without looking. When asked if a staff member would stay with Resident #27 throughout the meal, STNA #527 expressed she did not need to be fed because she could feed herself, so they just check on her a few times. Interviews were conducted on 02/17/22 from 9:45 A.M. to 10:00 A.M. with Occupational Therapy Assistant (OTA) #548, Licensed Practical Nurse (LPN) #518, STNA #526, STNA #527, STNA #515 and STNA #506 who reported the kitchen occasionally sends out the wrong texture foods, but it did not happen often. They offered no specific dates on when wrong textured foods were sent from the kitchen. Review of the policy titled Consistency Modified Foods, dated January 2019, stated the mechanical soft diet included ground moist meats, poultry and fish without bones, canned fruits and vegetables, well cooked vegetables, soft breads, and desserts. Review of the policy titled The Importance of Dietary Tray Cards, dated 2009, indicated the tray card must be completely accurate to ensure the correct diet was served to each resident. The tray card should include the residents name, room number, diet type, portions, likes/dislikes, supplements, allergies, beverage preferences, adaptive devices, and thickened liquids order. Review of the policy titled Therapeutic Diets, dated October 2017, indicated hard crackers are to be served softened in soup or liquid.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interviews with residents and facility staff and review of facility smoking policy, the facility failed to provide adequate supervision and interventions with cigarette smoking and oxygen use for one resident (Resident #43). This resulted in the likelihood of actual harm that is Immediate Jeopardy on 06/06/19 when Resident #43, who utilized continuous oxygen therapy via nasal cannula and was assessed to require supervision when smoking, was found smoking in his room with the oxygen concentrator in use. This affected one of twelve residents reviewed for smoking and accident hazards. The facility identified eleven additional residents (Resident #4, #9, #12, #17, #19, #29, #30, #31, #37, #41, and #149) currently residing in the facility, who smoked. The facility census was 47. In addition, deficient practice that did not rise to level of Immediate Jeopardy was identified when the facility failed to ensure seven residents (Residents #4, #12, #30, #37, #31, #41 and #149) were assessed for smoking safety; followed smoking policies and procedures to ensure resident safety and properly disposed of smoking materials. On 08/21/19 at 2:37 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 06/06/19 at approximately 2:38 A.M. when Resident #43, who utilized continuous oxygen therapy via nasal cannula and was assessed to require supervision when smoking, was found smoking in his room with the oxygen concentrator in use. The Immediate Jeopardy continued on 06/19/19 at 8:20 P.M. when Licensed Practical Nurse (LPN) #502 noted a burning smell upon entering Resident #43's room and removed the oxygen tubing and oxygen concentrator from the room. Resident #43 was educated on 06/21/19 with a video on the dangers of smoking around oxygen. The Immediate Jeopardy was removed on 08/22/19 when the facility implemented the following corrective actions: • On 08/20/19 at 3:00 P.M. the DON and Social Services Designee (SSD) #619 reviewed all residents in the facility and identified 12 residents who were smokers (Resident #4, #9, #12, #17, #19, #29, #30, #31, #37, #41,43 and #149). It was confirmed the only smoker who used oxygen was Resident #43 and no other smoking residents had roommates who used oxygen. • On 08/20/19 at 3:15 P.M. the facility updated their smoking policy to indicate any resident who failed to comply with the smoking rules and policies would be discharged immediately because they placed all residents at risk for serious harm. • On 08/20/19 at 3:30 P.M. the DON, Administrator, Corporate Administrator (CAD) #650 and Admissions Director (ADM) #600 began in-servicing staff members on the smoking policy and responsibilities of staff members during smoke breaks as well as the change to the smoking policy. All facility staff, including eight administrative staff (Administrator, DON, the assistant director of nursing Registered Nurse RN #707, admission Director AD #600, Business Office Manager BOM #601, Social Services Director SSD #619, Dietary Manager DM #602, Maintenance Director #603), four Registered Nurses (RNs) #705. #706, #708 and #711; nine Licensed Practical Nurses (LPNs) #503, #508, #509, #510, #512, #513, #514, #515 and #516; twenty-five State Tested Nurse Aides (STNAs) #409, #410, #411, #412, #413, #414, #415, #416, #417, #418, #419, #420, #421, #422, #423, #424, #425, #426, #427, #428, #429, #430, #431, #432 and #433; three activity staff members (AS) #604, #605 and #606; five dietary staff members (DS) #607, #608, #609, #610 and #611; one physical therapy assistant (PTA) #618 and six housekeeping/laundry/maintenance staff members (HK) #612, #613, #614, #615, #616 and #617 were in serviced either in person or by phone by 08/22/19 at 10:14 A.M. • On 08/20/19 from 4:30 P.M. to 5:00 P.M. the DON and SSD #619 ensured all twelve smoking residents had assessments in place for smoking capabilities. Residents who did not have assessments (Residents #4, #12 and #149) were assessed and Residents #9, #17, #19, #29, #30, #31, #37 and #41 were reassessed. The assessment included cognition, vision, dexterity and smoking frequency. The assessment also included a safety assessment including if the resident could light their own cigarette or needed adaptive equipment such as a smoking apron, cigarette holder, supervision or one-on-one assistance. The assessment indicated if the residents' lighters and cigarettes needed to be stored by the facility. Additionally, the assessment indicated if a plan of care would be developed to include individualized interventions related to resident safety during smoking. • On 08/20/19 from 5:30 P.M. to 6:00 P.M., the DON completed an entire facility sweep to ensure all oxygen equipment was secured in a safe manner and all smoking materials were secure. The DON checked the rooms of all residents who smoked to ensure there was no evidence of smoking in the room, such as burn holes, smell of smoke or cigarette butts. No issues were identified. • On 08/20/19 at 5:30 P.M. SSD #619 completed a smoking assessment for Resident #43. The resident indicated he would no longer smoke in the facility. A safety assessment of Resident #43's room was completed to check for smoking materials, with none found. • On 08/20/19 at 6:00 P.M. the DON assessed the smoking area for appropriate ashtrays, approved smoking receptacles, a fire blanket and smoking aprons. All items were present and accessible. • On 08/20/19 at 6:00 P.M. the Assistant Director of Nursing, RN #707 reviewed and revised, all 12 smokers' care plans to ensure they indicated what type of assistance was required and identified all safety/adaptive equipment needed by each resident. • On 08/20/19 at 6:00 P.M. the DON observed the smoke break to ensure all residents were following their plan of care regarding smoking. The 9:00 P.M. smoke break was observed by RN #707 with no concerns • On 08/20/19 at 7:00 P.M. the DON placed list of smokers that required adaptive equipment in the box of smoking materials for all staff to review when taking residents out to smoke. • On 08/21/19 at 10:00 A.M. SSD #619 educated Resident #43 on the smoking policy and obtained his signature indicating he understood and agreed with the policy. • On 08/21/19 at 10:30 A.M., SSD #619 educated all residents who smoke on the smoking policy and obtained a signature from each to indicate they understood and agreed with the policy. • On 08/21/19 from 3:00 P.M. to 10:00 P.M. facility nurses (RNs #405, #406 and #407 and LPN #403) physically assessed all smokers head to toe to ensure no evidence of unsafe smoking. No issues were identified. • On 08/21/19, at 6:00 P.M., the interdisciplinary team (IDT) comprised of the Administrator, DON, RN #707 (ADON), AD #600, BOM #601, SSD #619, DM #602, and Maintenance Director #603 began audits of the entire facility to identify any unsafe smoking or violations of the smoking policy, including observations of smoke breaks. This would be completed daily for two weeks, then two times weekly for four weeks then as determined by the Quality Assurance Committee (QA). • Beginning 08/21/19, at 6:00 P.M., the DON began audits of the records of all smoking residents to identify any unsafe smoking or violations of the smoking policy. This would be done daily for two weeks, then twice weekly for four weeks then as determined by QA. • Beginning 08/21/19, at 6:00 P.M., RN #707 began audits of smoking assessments to ensure they were up to date and smoking care plans to ensure they matched the smoking assessment. The audits will continue weekly for four weeks then as determined by QA. • On 08/22/19 at 4:00 P.M. the facility developed a new procedure for smoking assessments to indicate that all residents would be assessed on admission for smoking habits by the admitting nurse, with a smoking assessment to be completed for residents who wished to smoke. The nurse would also add the resident's name and any interventions to the list in the box of cigarettes. Smokers would be re-assessed with a change in condition, or if a resident started or stopped smoking. The belongings of all new admissions would be checked for smoking materials with any materials removed and stored at the nursing station. • On 08/22/19 at 4:40 P.M., the DON began in-service of all nurses on the new procedure for smoking assessments. By 08/24/19 at 7:00 P.M., four RNs (#705, #706, #708 and #711) and nine LPNs (#503, #508, #509, #510, #512, #513, #514, #515 and #516) were in serviced either in person or by phone. • On 08/22/19 at 9:00 A.M., 1:00 P.M. and 3:30 P.M. and on 08/23/19 at 9:00 A.M., 1:00 P.M. and 3:30 P.M. observation of smoke breaks by the surveyor revealed staff were present. Staff handed out cigarettes one at a time to the residents. No residents exhibited unsafe behaviors or attempted to keep smoking materials in their possession. • On 08/22/19 and 08/23/19, LPN #508, RNs #705 and #707 and STNAs #409, #410, #411 and #428 were all interviewed and indicated they had participated in the in-service regarding smoking breaks and verbalized knowledge of the smoking break procedures. Although the Immediate Jeopardy was removed on 08/22/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan, including their new policy and procedure and were monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including encephalopathy, opioid dependence, nicotine dependence, major depression, anxiety and chronic obstructive pulmonary disease. Review of the admission nursing note dated 04/11/19 at 5:15 P.M. revealed the resident did not use oxygen. Resident #43 was started on oxygen after a fall on 06/02/19. Resident #43 had been admitted to the hospital and on his return to the facility on [DATE] was utilizing oxygen at three liters, However there was no physician order for the oxygen noted in the medical record until 06/12/19 when an order was written for oxygen at five (5) liters with delivery by nasal cannula. Review of the medical record revealed Resident #43 was assessed on 04/12/19 at 3:49 P.M. for smoking. He was cognitively intact with no visual deficit or dexterity problems, smoked five to ten cigarettes throughout the day and could safely light his own cigarette. The assessment indicated he did not need adaptive equipment to smoke but did need the facility to store his lighter and cigarettes for him. The assessment indicated a plan of care would be developed to ensure the resident was safe while smoking. Review of the resident's record did not reveal a care plan for smoking. The resident was not assessed for smoking safety when he was started on oxygen on 06/04/19 until 07/02/19. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/18/19 revealed Resident #43 was assessed to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. He required supervision of one staff member for his activities of daily living, including bed mobility and transfer and mobility in his wheelchair. Medical record review revealed Resident #43 signed a smoking consent form on 04/27/19 which indicated he had received the facility's smoking policy and list of scheduled smoking times and agreed to abide to the policies. A nursing note dated 5/20/19 at 11:23 A.M. by LPN #509 revealed Resident #43 was given a cigarette for smoke break. He only smoked half, put it out and placed the remainder of the cigarette in his pocket. Resident #43 initially denied having the half cigarette but did eventually give it to the staff member. The nurse also noted another cigarette sticking out of his pocket and placed it in a pouch at the nursing station. Review of a nursing note written by LPN #501 on 06/06/19 at 2:38 A.M. revealed Resident #43 was smoking in his room. The note indicated the resident had an oxygen concentrator in his room that was in the on position. Resident #43 was educated about the importance of not smoking in his room and the seriousness of it. The note indicated Resident #43 denied smoking, but the resident's roommate complained about him smoking in their room. The note indicated the DON and RN #707 were notified and after the incident, Resident #43 went outside (to smoke) with his cigarette and lighter that were in his room that he denied having. A note from SSD #619 on 06/06/19 at 2:57 P.M. revealed she educated Resident #43 on 06/06/19 on the importance of not smoking in his room and the seriousness of it. He stated OK and that he understood. SSD #619 said that was all she could remember about educating Resident #43, and she could not provide any documentation of the education. There was no evidence the resident was educated about oxygen use and smoking. Review of Resident #43's care plans revealed a care plan for non-compliance was originated on 06/14/19 and updated on 07/01/19 through 10/08/19. The care plan indicated the resident refused medications, care and services, and refused safety measures, especially related to smoking and had a history of trying to smoke in his room. The interventions included educating the resident and the family or responsible party on negative outcomes of non-compliance, explain all procedures and the benefits of them before starting the procedures, document educational attempts made with the resident and notify the physician or nurse practitioner of non-compliance. Review of a nursing note written by LPN #502 on 06/19/19 at 8:20 P.M. revealed she noted a burning smell upon entering Resident #43's room. She asked the resident if he had any cigarettes or had been smoking in his room, which he denied. The note indicated Resident #43 had oxygen via nasal cannula applied to his face and the oxygen tank was running. LPN #502 indicated she turned off the tank and removed it from the room and the resident self-propelled out of the room. The note indicated a short time later, another resident told LPN #502 Resident #43 was outside on the patio with two cigarettes and was asking for a light. The nurse and an STNA went out to investigate and found the resident with two cigarettes. He was informed of the facility rules regarding smoke breaks and the need for staff to supervise smoke breaks. The nurse's note indicated Resident #43 became angry, stating he would check himself out of the facility the next day. The note indicated the nursing supervisor was notified and instructed LPN #502 to check Resident #43's room for cigarettes or lighters. No smoking materials were found. Review of a note dated 06/21/19 at 10:48 A.M. written by SSD #619 revealed Resident #43 was educated on the dangers of smoking around oxygen with a video. The note indicated he was alert and oriented. There was no evidence found the resident was educated about the dangers of smoking around oxygen from 06/06/19, when he was first found smoking with oxygen, until he was provided the education by video on 06/21/19. A smoking assessment was completed again on 07/02/19 at 9:45 P.M. The assessment indicated the resident had cognitive loss at the time of the assessment and could no longer light his own cigarette. He was assessed to need a smoking apron and supervision for smoking. No other items on the assessment had changed from 04/12/19. Review of Resident #43's care plans did not reveal a care plan specific to smoking was completed after the assessment on 07/02/19. LPN #501 no longer worked at the facility. Attempts to contact her by phone were made on 08/21/19 at 3:50 P.M. and 4:10 P.M. and on 08/23/19 at 8:45 A.M. She did not answer the phone, messages were left, no return call was received. An attempt was made to contact LPN #502 by phone, as she was no longer employed by the facility, however, her phone had been disconnected. The nursing assistant mentioned in the note could not be identified by the facility. Observation and interview with Resident #43 on 08/20/19 at 2:45 P.M. revealed him lying in bed. The resident said he had not smoked in about four days because he did not feel well. He was asked about reports of him smoking in his room in the past, but became irritated when asked, stopped talking, and did not answer the question. When asked if he was permitted to keep smoking materials in his room or if he had any cigarettes or lighters in his room, he waved his hand in dismissal and closed his eyes. An interview with the DON on 08/20/19 at 4:00 P.M. revealed she was made aware of the resident smoking in his room by the nurse on the night shift on 06/06/19. She stated she told the nurse to check the resident's room for cigarettes. She did not have interviews of staff or the resident's roommate or any investigation about the incident. She verified the record indicated the resident had been educated after the incident, but also verified he was cognitively intact and had been educated on admission. She could not provide any evidence of any other interventions put in place to ensure the resident did not have access to smoking materials when he had his oxygen on or that changes were made to supervision when he was smoking to ensure he did not keep extra cigarettes. The DON stated he had been roommates with Resident #19 at the time of the incident and she thought she remembered that Resident #43 may have taken cigarettes from his roommate that night. She stated she remembered making sure both residents were educated about the dangers of smoking in their rooms. Review of a printed text conversation between the DON, RN #707 and LPN #501 revealed on 06/06/19, LPN #501 texted at 2:37 A.M. indicating Resident #43 was smoking in his room and has an oxygen concentrator in there and his roommate (Resident #19) was complaining about him smoking to staff and he is putting everyone at risk. The text continued by LPN #501 (Resident #7, who resided in the room next door) is on oxygen as well. The DON responded to the text at 5:03 A.M. to ask if the nurse had searched his room and removed cigarettes and lighters and LPN #501 indicated she got the lighter and cigarette because he wanted to go outside after the incident and smoke but gave the items to her when he came back in. The text indicated he used his roommate's lighter. The DON responded to take the roommate's lighter as they aren't supposed to have them, and LPN #501 indicated it was in the box. An interview with Resident #19 on 08/20/19 at 4:45 P.M. revealed he remembered an incident involving his prior roommate, who he identified as Resident #43. He stated he did not know exactly when the incident occurred but that he could not sleep and could smell cigarette smoke coming from the bathroom in their room. He stated Resident #43 was in the bathroom and he called for the nurse. He stated he thought the resident was wearing oxygen. He did not remember any specific actions taken by the nurse, and stated he thought Resident #43 was smoking cigarette butts. An interview with SSD #619 on 08/22/19 at 10:50 A.M. revealed she did not recall specific details about Resident #43's actions, other than he used oxygen in his room and had reportedly smoked in his room. She said she educated him on the dangers of smoking near oxygen. An interview with RN #707 on 08/22/19 at 11:25 A.M. revealed she remembered receiving the text from LPN #501 but stated since the DON responded, she did not respond. She stated she did not remember any additional details about the incident. An interview with the DON on 08/23/19 at 12:00 P.M. confirmed she was notified of the burning smell in Resident #43's room by phone on 06/19/19. She stated she talked with the nurse and then replied to the nurse by text. Review of printout of the text dated 06/19/19 at 8:39 P.M. revealed the DON texted the nurse to check the resident's oxygen saturation after he has been off the oxygen for 20 to 30 minutes and if he does well, take the oxygen out of his room and put it in the clean utility room so it's close if he needs it. She verified there was no further evidence of interventions. Interview with the DON on 08/23/19 at 4:02 P.M. confirmed she did not know if the resident's oxygen was held just for that night or for longer. She verified the resident's record did not contain an order from the physician to indicate the oxygen could be discontinued as an intervention to prevent him from smoking with the oxygen in use. She verified the resident had not been smoking recently due to a decline in medical condition, but that the condition was expected to improve. She verified if the resident wanted to smoke, he currently could, with assistance of staff to transfer out of bed and that his mobility and independence could improve to a point of independently transferring out of bed. The DON verified there had been no interventions put in place after the incidents to ensure Resident #43 remained safe with smoking materials and smoking habits while ordered oxygen therapy. An interview with SSD #619 on 08/22/19 at 10:50 A.M. revealed she showed Resident #43 a video about the dangers of smoking around oxygen. She stated other residents who smoked also watched the video. An interview with the facility medical director who was Resident #43's personal physician on 08/23/19 at 12:20 P.M. revealed he was aware Resident #43 was non-compliant with smoking. He verified Resident #43's behavior of smoking with oxygen in place was dangerous and although it was difficult to control, the facility policy of keeping resident smoking materials at the nursing station should be enforced. Review of the facility Smoking Policy and Procedure, dated 08/09/18, revealed all residents who smoke would be assessed for needed assistance upon admission, quarterly and with a significant change. The policy indicated facility staff would supervise residents while smoking, if they were indicated to need supervision. Staff members were also to light all smoking products and provide other assistance and protective devices as needed. Smoking was only allowed in designated smoking areas and all smoking materials were to be kept in a secured area and distributed by staff for all residents. The policy indicated failure to comply with the rules places others at risk for injury, and the facility may find it necessary to assist a resident in finding alternative placement if smoking and safety rules are not followed. 2. Observation of smoking break at 1:05 P.M. on 08/20/19 revealed four residents outside in the smoking area unsupervised. The residents were identified by RN #405 at 1:10 P.M. as Residents #4, #12, #30 and 37. RN #405 verified the residents were all smoking in the smoking area and were not supervised by a staff member. She stated the residents kept cigarettes on them and probably had cigarettes and lighters that they utilized on their own. RN #405 walked with the surveyor toward the nurses' desk, still in view of the smoking area, and after checking the assignment book, stated STNA #410 was supposed to be outside with the residents during that smoke break. As the surveyor and RN #405 were talking, the four residents in the smoking area came back into the unit and an employee identified as STNA #410 went out the door at 1:15 P.M. with three other residents, identified by RN #405 as Resident #'s 31, 41 and 149. STNA #410 lit cigarettes for the residents in the smoking area. She did not pass cigarettes out to them or have the box of cigarettes in her possession. On 08/20/19 at 1:18 P.M. interview with STNA #410 in the smoking area revealed she had told the residents at 1:00 P.M. she had to help another employee and would be a little late to supervise the smoke break. She stated she did not give any residents cigarettes and did not know where they had gotten them. STNA #410 said sometimes they have extras, but she said many residents kept their own cigarettes and some kept them at the nurse's station. Medical record review for the seven residents observed during smoke break on 08/20/19 revealed the following. Review of the medical record of Resident #4 revealed he was admitted to the facility on [DATE] with diagnoses including hemiplegia, chronic obstructive pulmonary disease and unspecified dementia with behavioral disturbances. The record revealed he had not had a smoking assessment completed since his admission to the facility and did not have a smoking care plan. He was not named on the list of smokers provided to the surveyors on entrance to the facility. Review of the medical record of Resident #12 revealed she was admitted to the facility on [DATE] with diagnoses including convulsions, asthma, vascular dementia, anxiety and psychosis. The record did not reveal a completed smoking assessment since her admission to the facility and the resident did not have a care plan for smoking. Review of the medical record of Resident #30 revealed he was admitted to the facility on [DATE] with diagnoses including alcohol induced dementia, chronic obstructive pulmonary disease, muscle weakness and difficulty walking. His most recent smoking assessment was completed on 04/12/19. He was marked to need supervision for smoking and needed to leave his smoking materials at the nursing station. Review of the medical record of Resident #37 revealed he was admitted to the facility on [DATE] with diagnoses including schizophrenia, depression, and cognitive impairment following cerebral infarction. His most recent smoking assessment was completed on 04/12/19. He was assessed to need supervision for smoking, was to wear a smoking apron and needed to leave his smoking materials at the nursing station. Review of the medical record of Resident #31 revealed she was admitted to the facility on [DATE] with diagnoses including paraplegia, anxiety, schizoaffective disorder and history of substance abuse. Her most recent smoking assessment was completed on 04/12/19. She was not indicated to need any adaptive equipment for smoking but needed to leave her smoking materials at the nursing station. Review of the medical record of Resident #41 revealed he was admitted to the facility on [DATE] with diagnoses including schizophrenia, mild cognitive impairment and chronic obstructive pulmonary disease. His most recent smoking assessment was completed on 04/12/19. He was not indicated to need any adaptive equipment for smoking but needed to leave his smoking materials at the nursing station. Review of the medical record of Resident #149 revealed he was admitted to the facility on [DATE] with diagnoses including anxiety, and alcohol abuse. The record revealed he had not had a smoking assessment completed since his admission to the facility and did not have a smoking care plan. He was not named on the list of smokers provided to the surveyors on entrance to the facility. Observation of the smoke break on 08/20/19 at 3:30 P.M. revealed STNA #412 with several residents in the designated outdoor smoking area. She had a large box with her from which she obtained cigarettes which she passed out to the residents. Resident #37 was smoking, but was not wearing a smoking apron, as indicated in his smoking assessment. An interview with STNA #412 on 08/20/19 at 3:45 P.M. after the completion of the smoking break, revealed an apron was in the box of smoking materials that she had taken out with her. She stated the only resident she knew of that used an apron was Resident #17, who had not gone out for the smoke break. She stated she was unaware of any other residents who needed an apron. She stated she did not know of a list of residents who required aprons to smoke, but stated she was just told about Resident #17 by other staff. Review of the medical record with RN #705 on 08/20/19 at 3:50 P.M. confirmed Resident #37 was assessed on 04/12/19 to need a smoking apron. RN #705 stated she was not aware Resident #37 needed to wear a smoking apron. An interview with the DON on 08/20/19 at 4:00 P.M. confirmed the observations of the smoking breaks. She verified she was not aware Resident #4 or #149 were smokers and had not been assessed. She stated she thought the assessment for Resident #37 must have been a mistake, as the resident had no indication she was aware of that would necessitate a smoking apron but did verify the assessment indicated the apron should be used. The DON also verified the facility did not have a system to easily identify residents who needed adaptive smoking equipment. In addition, the DON verified she knew some residents kept cigarettes in their rooms. She stated the policy indicated the smoking materials should be stored at the desk but stated family members bring in new supplies of cigarettes or residents hang on to extra cigarettes if they don't smoke them during a break. The DON verified all residents should be supervised during smoke breaks and should not be smoking in the smoking area without staff supervision. The DON indicated all residents should be assessed as to their safety prior to smoking at the facility with a care plan in place to ensure assessed interventions were put in place to prevent possible injury. 3. Observation of the front entrance to the facility on [DATE] at 10:55 A.M. by two surveyors revealed countless numbers of cigarette butts along the curb, sidewalks and near two tall smokeless cigarette butt discarding receptacles. One of the smoking receptacles had a broken foot pedal that did not allow the can to be opened hands-free. Observation by the life safety code surveyor during tour with Director of Maintenance (DM) #603 on 08/22/19 at 8:30 A.M. revealed cigarette butts in the landscaping adjacent to the building, on the sidewalk and driveway at the facility's main entrance. Interview with DM #603 indicated he was unaware of the butts being disposed of improperly and that housekeeping handled disposal of cigarette butts. DM #603 verified the above findings at the time of the observation. An observation on 08/26/19 at 7:00 A.M. revealed continuing observations of cigarettes butts near the front entrance. This observation was verified with the DON on 08/26/19 at 8:30 A.M. She verified cigarette butts should be disposed of properly to prevent accidental fires.