**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/21/25, an Immediate Jeopardy (IJ) was determined to exist related to the facility's failure to ensure the safety of Resident #1. The facility did not have a care plan which reflected smoking on admit. The facility failed to ensure interventions were in place when Resident #1 continued to smoke in their room. On 02/05/25 at 3:29 p.m., facility staff noted a fire had started in the trash can in Resident #1's room. Resident #1 had lit a cigarette and had disposed of the cigarette in the trash can in their room. Staff extinguished the fire. At the time of the fire Resident #1 was wearing oxygen. Staff extinguished the fire and evacuated other residents safely. The fire department was called and came to the facility. Resident #1 was sent to the ER for possible smoke inhalation. On 02/21/25 at 5:06 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 02/21/25 at 5:12 p.m., the administrator and ADON were notified of the IJ situation and the IJ template was provided. On 02/24/25 at 4:36 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal showed the total number of residents at risk for the same deficient practice was 59. It showed the actions to remove the immediacy of the alleged deficient practice were the following: a. on 02/05/25, Resident #1's care plan was updated to show the one-on-one intervention implemented, b. on 02/21/25 and 02/22/25, all staff were educated in person and by phone on the updates to the smoking policy put into place, the changes made to what staff could supervise smokers outside, and steps staff were to take if lighters and cigarettes were found in residents' room, and c. all smoking residents were counseled on the smoking policy and the changes made. It showed all smokers care plan interventions were updated for smoking supervision. The plan of removal showed the action taken to prevent recurrence of the alleged deficient practice were the following: a. on 02/24/25, the facility smoking policy would be located at the staff time clock and in the staff break room for review at any time. It showed the master list for smokers would be in a binder kept at the nurses desk, b. the ADON and MDS nurses were re-educated in the process of smoking assessments and smoker safety care plans, c. the director of nursing/ADON/administrator/designee would make routine rounds of smokers' rooms to ensure there were no smoking materials in rooms. The plan of removal showed they would also check with smokers when returning from outings to have them surrender any smoking materials/lighters, d. new residents admitted to the facility would be assessed upon admission and their smoking status determined. It showed a smoking evaluation would be completed and the care plan would be updated quarterly or with significant change in condition, e. the administrator/designee would review the smoking policy with residents who wished to smoke and ensure understanding of all aspects of the policy, f. smoking policy updated showing smoking was not allowed inside the facility and/or any resident room or bathroom under any circumstances, and h. the interdisciplinary team would meet monthly, and review the list of smokers, and address any concerns noted. The IJ was lifted, effective 02/24/25 at 5:27 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on record review, and interview, the facility failed to ensure the safety of a resident who smoked for 1 (#1) of 3 sampled residents reviewed for smoking. The administrator identified 59 residents resided in the facility and 21 residents whom were current smokers in the facility. Findings: An undated facility Smoking policy, read in part, this facility will establish and maintain safe resident smoking practices .smoking is only permitted in designated resident smoking areas, which are located outside the building, smoking is not allowed inside the facility and (or in any resident room or bathroom) under any circumstances. Resident #1 had diagnoses which included anxiety, nicotine dependence, and chronic obstructive pulmonary disease. A care plan, date initiated 10/25/23, showed no focus regarding Resident #1 being a smoker. A behavior note, dated 12/26/23, read in part, resident continues to smoke in [their] room and bathroom. Resident continues to not abide by the smoking rules. A Quarterly Smoking Evaluation, dated 01/12/24, showed the resident was safe to smoke with supervision. A quarterly MDS assessment, dated 01/24/25, showed the resident's cognition was intact. An incident note, dated 02/05/25 at 3:29 p.m., read in part, staff called to room by staff member yelling fire down the hallway. Upon entering room, fire alarm was sounding, flames observed coming from area surrounding O2 [oxygen] concentrator, flames also noted coming from trash can in sink. Resident noted sitting in power chair in between two flames but was not attempting to remove [themselves]. An incident note, dated 02/05/25 at 3:55 p.m., read in part, resident was in room when staff observed a fire flamed coming from residents trash can. Staff explaining to resident they needed to get out of the room so we can put the fire out, resident would not leave at first and then staff manually pulled resident out of room from back of electric wheel chair. Resident sent to ER for evaluation. An initial state reportable incident report, dated 02/05/25, showed a fire was found in Resident #1's room. The incident showed the fire was caused by a cigarette that was improperly extinguished in Resident #1's trash can in their room. The report showed Resident #1 was sent to the ER on [DATE] at 3:55 p.m. for evaluation of possible smoke inhalation. A care plan, date initiated 02/10/25 and revised 02/10/25, showed the resident was one-on-one with staff monitoring related to the incident with the fire in their room on 02/05/25. A Quarterly Smoking Evaluation, dated 02/20/25, showed the resident was safe to smoke with supervision. On 02/20/25 at 10:31 a.m., Resident #1 was asked what was the facility smoking policy. The resident stated they could not have lighters in their room and could not smoke in their room. The resident stated last summer they smoked in their room and staff caught them. On 02/21/25 at 10:37 a.m., MDS coordinator #1 was asked what the policy was for residents smoking. They stated to keep all cigarettes and lighters in a locked box until smoking times which were every two hours. MDS Coordinator #1 was then asked how staff was keeping Resident #1 safe from having cigarettes or lighters in their room. They stated if it was known the resident had such items they were to be surrendered to the administrator or nurse. MDS Coordinator #1 was then asked to review Resident #1's admit care plan. After review, MDS coordinator #1 was asked if the care plan reflected Resident #1 being a smoker and Resident #1 would hide cigarettes and lighters in there room. They stated, No. MDS Coordinator #1 was then asked to review the care plan and asked if the care plan was updated after the behavior note on 12/26/23 regarding Resident #1 was continuing to smoke in their room and/or bathroom. They stated no it was not. On 02/21/25 at 1:48 p.m., the administrator was asked what was the policy for residents smoking. They stated residents could only smoke outside in the designated area with staff during the designated smoke times. The administrator was then asked what the facility had put in place for Resident #1 to ensure another incident would not occur regarding lighting a cigarette in the resident's room. They stated Resident #1 was placed on one-on-one monitoring with staff 24 hours a day until the facility could find proper placement for them at another facility. On 02/24/25 at 4:38 p.m., CMA #3 was asked the facility policy for smoking. The CMA stated all residents that smoked had to be supervised at the designated smoking times. The CMA was asked where the residents kept their cigarettes and lighters. The CMA stated those items were locked up in a smoke box that was locked up in the medication room. The CMA stated CMAs and nurses had access to unlock the medication room to remove the box. The CMA stated staff would light cigarettes for the residents.

On 06/29/22 at 12:18 p.m., the OSDH confirmed the existence of an immediate jeopardy related to the facility failed to ensure a resident was provided a physician ordered puree diet with restriction for use of straws for Resident #57 who had a diagnosis of Dysphagia and Oropharyngeal phase. Resident #57 was observed being assisted to eat food that was not pureed and assisted to drink with a straw, when the Resident #57 began to cough and clear their throat. Staff were interviewed and were unable to verbalize why straws should not be used when assisting Resident #57 with fluid intake. Resident #57's dietary card did not document a diet change to puree. On 06/29/22 at 12:30 p.m., the Administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. On 06/29/22 at 3:28 p.m., the Administrator provided a plan of removal. On 06/29/22 at 4:09 p.m., the plan of removal was accepted by the OSDH. The plan of removal was as follows: .Step #1 DON/ADON/Designee made rounds upon notification of incorrect diet served on Resident #57 to ensure no other resident were served incorrect diet, with no further negative findings. Step #2 Resident #57 tray card was update upon notification of incorrect diet to reflect correct prescribed diet with proper utensils . Step #3 All Nurses, CNA/CMA and Dietary staff educated on Interdepartmental Notification of Diet (including changes and reports) along with utilization of communication forms from nursing department and dietary department. Dietary manager/Designee and Dietary staff educated that when changes come from nursing department regarding changed in diet, utensils, and preferences, reporting nurse will be updating tray cards and educating all dietary staff of these changes, as well as removing old tray card from the kitchen. Nurses, CNA/CMAs educated to match tray card diet to actual meal sent to resident upon serving. If any aspects of the meal provided are not correct, they are to return to kitchen to correct immediately to match prescribed diet. Step #4 Complete audit of all resident diet orders completed and compared to tray cards to ensure no further inappropriate diets or utensils in use with no further negative findings. Interdepartmental Notification of Diet (including changes and records) policy was printed and given to survey team with plan of removal. Step #5 Upon receiving new orders for dietary changes, nursing staff will fill out dietary communication form and take to dietary manager or place in designated area in dietary managers office. At this time old tray card is removed and given to nursing, nursing will fill out new tray care with updated diet information. DON/Designee will report all diet changes and special utensil use to Administrator after ensuring MD order is correct and care plan is updated. Administrator will take changes to dietary manager to ensure changes were made timely to tray cards and dietary staff is educated. Upon approval of plan of removal, a current staff in the facility will be in-serviced immediately to ensure safety of all resident on 06/29/22 by 7 pm. All other staff will be in-serviced prior to reporting for next shift . On 07/05/22 at 4:35 p.m., after all the components of the plan of removal had been completed, the Administrator was notified the immediacy had been lifted as of 06/30/22 at 3:46 p.m. The deficiency remained isolated with more than minimal potential for harm. Based on observation, record review and interview the facility failed to ensure A. A puree diet was served as ordered by the physician, B. Ensure dietary cards were updated to reflect the current diet, and C. Ensure staff did not use a straw for a resident who had a dietary restriction for the use of straws for one (#57) of six sampled residents reviewed for nutrition. The Resident Census and Condition of Residents identified 59 residents lived in the facility. The clinical director identified two residents received nutrition via enteral feedings and did not receive dietary services from the kitchen. Findings: A policy and procedure, titled, Interdepartmental Notification of Diet (Including Changes and Reports), read in part, .Nursing services shall notify the food and nutrition services department of a resident's diet order, including any changes in the resident's diet, meal service, and food preferences .or a diet has been changed, the nurse supervisor shall ensure that the food and nutrition services department receives a written notice of the diet order .The food and nutrition services department will be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal . Resident #57 had diagnoses which included dysphagia, oropharyngeal phase, dementia, other symptoms and signs concerning food and fluid intake. A care plan, last updated 05/17/21, read in parts, .Mechanical Soft diet as ordered with thin liquids and no straws. Med pass/Healthshakes with all meals as ordered. (History of eating with her hands, no sandwiches, eats in dining room - will get up from table and then later return during mealtimes.) . A document titled, ST-Therapist Progress and Discharge Summary, dated 12/23/19, read in parts, a.Safely Consume Liquids .GOAL MET - 12/20/2019 .The patient safely consumes thin liquid consistency utilizing cup while facilitating chin tuck exhibiting modified independence(1-10%impairment; diet may be modified due to medical and/or dental status) . b.Safely Consume Solids .Goal met-on 12/20/2019 .The patient safely consumes mechanical soft consistency utilizing spoon while facilitating chin tuck exhibiting minimal impairment (10-25% impairment; risk of trace aspiration, diet may need modified due to medical/dental status) .Area of treatment provided per treatment Plan: Treatment of swallowing dysfunction and/or function for feeding . An ST Clarification Order dated 01/06/20 read in part, . ST recommends change in diet consistency to mechanical soft foods with ground meats, continue finger foods when available. Continue thin liquids, no straws . A Physicians Order, dated 01/08/20, read in part, .Regular diet, Mechanical Soft texture, Regular consistency No Straws/ Ground meat /Finger Foods .related to DYSPHAGIA, OROPHARYNGEAL PHASE . A Physician's Order Summary Report, dated 05/31/22, read in part .Regular diet mechanical soft texture, Regular consistency, No Straws/Ground meat/Finger Foods Dinner related to dysphagia, Oropharyngeal Phase . A Nutrition/Dietary Note, dated 06/15/22, read in part, .Good PO intake on regular mech (sic) soft diet with ground meat .monitor and continue POC . An Annual assessment, dated 06/19/22, documented Resident #57 had severe cognitive impairment, required extensive assistance of one person for eating, and had no signs and symptoms of possible swallowing disorder. A physician's progress note, dated 06/25/22, read in part, .[Resident] diet was changed to pureed .[Resident]seems better with a pureed diet so I am ordering a diet change to pureed .Assessment and Plan .Dysphagia change diet to pureed . A Physician's Order Summary Report, dated 06/25/22, read in part, .Regular diet, pureed texture, Regular consistency. No Straws related to DYSPHAGIA, OROPHARYNGEAL PHASE . A Health Status Note, dated 06/25/22 at 6:02 p.m., read in part, .[doctor name] here to see resident. N.O. to change diet to pureed . Documented by the DON. On 06/28/22 at 12:01 p.m., staff was observed feeding resident chopped mandarin oranges, chopped ham, smashed sweet potatoes, and pieces of fried green beans. The diet card documented, ground meat, finger foods, no straws or plastic ware. Staff was observed assisting resident to drink fluid with a straw. On 06/29/22 at 8:10 a.m., CMA #1 was observed feeding Resident #57 chopped sausage, scrambled eggs, blueberry muffin/cake, and orange juice with a straw. The continued observations included: a. Staff was observed giving resident a drink of orange juice with a straw. CMA #1 left room to obtain a small glass of apple juice, and put a straw in glass. CMA #1 fed Resident #57 bites of chopped sausage, scrambled, egg, and blueberry muffin, then provided a drink of Apple juice with the straw. b. Resident #57 had a small cough/cleared throat. c. CMA #1 gave Resident #57 a bite of egg, sausage, drink of apple juice with a straw, and a bite of sausage. d. Resident #57 had audible sounds to clear throat. e. CMA #1 provided a bite of egg, f. Resident #57 began to cough. g. CMA #1 gave drink apple juice with a straw. CMA #1 gave a bite of muffin. h. Resident #57 coughed. On 06/29/22 at 8:40 a.m., Resident #57 was observed seated in a recliner, coughing. CMA #1 was asked to show #57's diet card. The card documented .regular diet, ground consistency, thin liquids, regular portions. ground meat, finger foods if possible, no straw or plastic ware On 06/29/22 at 10:17 a.m., CMA #1 was asked, did you assist Resident #57 with fluids using a straw. CMA #1 replied, yes. On 06/29/22 at 10:17 a.m., CMA #1 was asked what diet is Resident #57 supposed to be on. CMA #1 replied, ground. On 06/29/22 at 10:17 a.m., CMA #1 was asked what did her diet card say regarding straws. CMA #1 stated, I don't know why they put straws on there, the straw is the only way [resident] drinks good. CMA #1 was asked why is the resident not allowed to have straws. CMA #1 stated, My guess, because of the plastic, when I saw that on the card. I been meaning to ask the nurse. On 06/29/22 at 10:17 a.m., CMA #1 was asked if the resident had a diet change recently. CMA #1 stated, Not that I am aware of. CMA #1 was asked when the resident was eating/drinking, did Resident #57 cough or clear throat. CMA #1 stated, Yes, I gave her a drink. On 06/29/22 at 10:20 a.m., CNA #2 was asked how do you know what diet to serve to residents. CNA #2 stated each resident has a meal card on the tray at every meal, and knows the residents. CNA #2 was asked who is responsible to ensure the cards are up to date. CNA #2 stated the nurse and therapy decide and if aides see the resident is having a cough or trouble to eat/drink they tell the nurse and the nurse gets the information to therapy. On 06/29/22 at 10:22 a.m., CNA #1 was asked how the nurse aides help to ensure residents receive the diet ordered by the physician. CNA #1 stated the nurses make cards for dietary and each resident has a card on the meal tray. CNA #1 was asked who is responsible to ensure the cards are current. CNA #1 stated the charge nurse. On 06/29/22 at 10:25 a.m., LPN # 1 was asked why Resident #57 is not allowed to have straws. LPN #1 stated, [resident] clamps down on them with .teeth, it's not necessarily the straw's, [resident] bites plastic silverware. LPN #1 was asked what was the residents' current diet. They stated [resident] was on regular with ground, but is now on puree. LPN #1 was asked who ensured the resident gets the correct meal as ordered. LPN #1 stated, we give dietary the order and the aide on the hall getting the tray should check the card. LPN #1 was asked if scrambled eggs, ground sausage and a blueberry muffin is a pureed diet. LPN #1 stated, No. On 06/29/22 at 10:30 a.m., the ADON was asked who is responsible to ensure residents receive the correct physician ordered diet. The ADON stated the charge nurse do the final check of the orders and the orders and the card should match. The ADON was asked if the meal card and/or order stated no straws, should the staff use straws to offer liquids. The ADON stated, No. The ADON stated, when there is an order (verbal/written) they completed/update the dietary card. The ADON was asked if anyone ever completed an audit to ensure the order/diet served was correct. The ADON stated they did approximately 1 ½ months ago and dietary has completed one since and made new cards. The ADON was asked why Resident #57 had an order for no straws. The ADON stated, Resident #57 could not have straws because they needed to slow [resident] down from drinking too fast. The ADON stated if Resident #57 was provided fluid through a straw, [resident] would drink all of the liquid without getting a breath, so no straws. The ADON was asked what is Resident #57's diet order. After review of the computer orders, stated regular/pureed texture, thin liquid, which was a new order on 6/25/22. ADON was asked if Resident #57 could be served fried green beans. The ADON stated, not if they are not pureed. The ADON was asked if the Resident #57 could be served sausage, they stated no. On 06/29/22 at 10:37 a.m., DA #1 was asked how it is determined what food was served to a resident. The DA #1 stated, I just know the residents, it is in my memory. DA #1 was asked if they utilized the dietary card system. They stated, we should. DA #1 was asked how new (diet) orders were communicated. They stated, nurses will bring the information and the diet is changed. They were asked if anyone does an audit of the orders/cards to ensure they are correct. DA #1 did not know. They were asked who would be responsible, they stated the dietary manager. On 06/29/22 at 10:40 a.m., the DM was asked how dietary ensured residents receive the correct diet. The DM stated, We use cards with the diet orders, supposed to look at with each meal but I have them memorized. The DM was asked what if the resident has a diet change. The DM stated, nursing will bring another card and get the tray card changed. The DM was asked who was responsible to audit orders/diet cards to ensure accuracy. The DM stated I did one a couple of weeks ago. The DM was asked if dietary puts straws on the trays served. The DM stated, no, nursing has access to straws. The DM was asked if any of the residents have an order for no straws. The DM stated, No. On 06/29/22 at 11:50 a.m., the DON was asked for a policy/procedure on diet changes. The DON stated the nurse should give a copy to dietary. The DON was asked who makes the cards. They stated, dietary should but since they haven't been, the ADON has been doing them. The DON was unsure if there was a policy, but would look for one. On 06/30/22 at 8:07 a.m., the DON was asked why the doctor had made the diet change for Resident #57. The DON stated, staff said [resident] was coughing. The DON was asked if there was a copy of the dietary communication change. The DON stated, on Saturday I took it to the kitchen staff.