**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 16 residents (Residents #9 and #63) reviewed for accidents and hazards. 1. Resident #9 was observed with her own smoking paraphernalia which included a lighter (a self-contained ignition source used to lite cigarettes) and was observed smoking on the facility property without supervision and or at the assigned agreed upon times for supervised smoking. 2. Resident #106 was discovered with smoking paraphernalia which included a lighter and cigarettes, and was actively smoking, while receiving oxygen therapy, in his bathroom twice, once on 8/12/2025 and again on 8/21/2025. The noncompliance was identified as PNC. The IJ began on 6/13/2025 and ended on 8/25/2025. The facility had corrected the noncompliance before the survey began. These failures could have exposed residents to harm by neglecting to provide supervision. The findings included:The findings included: 1. A record review of Resident #9's admission record dated 8/29/2025 revealed an admission date of 6/2/2025 and a discharge date of 8/27/2025 with diagnoses which included chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause airflow obstruction and breathing difficulties), left lower leg amputation, intermittent explosive disorder (recurrent episodes of impulsive, aggressive, and violent behavior that is disproportionate to the triggering situation), and diabetes mellitus II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin and results in high concentrations of sugars in the bloodstream with potential negative outcomes). A record review of Resident #9's quarterly MDS dated [DATE] revealed resident #9 was a [AGE] year-old female admitted for long term care with supports for safe supervised smoking. Resident was assessed with a BIMS score of 15 out of 15 which indicated no cognitive impairment. A record review of Resident #9's care plan dated 8/27/2025 revealed, problem; resident is a smoker . instruct Resident about smoking risks and hazards and about smoking cessation aids that are available . instruct residents about the facility policy on smoking locations, times, safety concerns, . notify charge nurse immediately if it is suspected resident has violated facility smoking policy . observe clothing and skin for signs of cigarette burns . A record review of Resident #9's nursing progress notes revealed on 6/13/2025 at 4:16 AM LVN F documented, patient noted going into (another residents) room multiple times throughout the night and taking patient out to smoke. A record review of Resident #9's nursing progress notes revealed on 6/15/2025 at 11:47 AM LVN X documented, resident observed outside in courtyard smoking with another Resident, resident was redirected. When nurse asked for lighter and cigarette, resident refused and stated she could smoke outside. Resident nurse notified. During an interview on 8/30/2025 at 1:51 PM LVN F stated Resident #9 would often smoke unsupervised and at unassigned time. LVN F stated Resident often had her own cigarettes and lighter and would surrender the lighter when asked but would often obtain another lighter, most likely from when she would sign herself out on pass. smoked out in the courtyard unsupervised and reported to the ADON and previous DON. LVN F stated there was a risk for burns. LVN F stated he recalled his documentation on 6/12/2025 at 4 AM when he observed Resident #9 in the facility courtyard smoking cigarettes. LVN F stated he reported the incident at the change of shift to the previous DON and the ADON. 2. Record review of Resident #63's admission record dated 8/30/2025 revealed an admission date of 5/14/2025 with diagnoses which included malnutrition, anxiety, pain, hypertension (high blood pressure), muscle spasms / weakness, reflux, and chronic obstructive pulmonary disease. A record review of Resident #63 quarterly MDS dated [DATE] revealed Resident #63 was a [AGE] year-old male admitted for long term care with supports for safe supervised smoking. Resident #63 was assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #63's physicians order dated 5/14/2025 revealed the physician prescribed for Resident #63 to receive continuous oxygen therapy every shift every day and night. Record review of Resident #63's care plan dated 8/30/2024 revealed that he was an intermittent smoker (start date 5/14/2025) with a revision on 8/12/2025 indicating that he was noncompliant with the smoking policy and smoking in his bathroom and was educated/acknowledged smoking agreement. A record review of the facility's event report dated 8/12/2025 revealed at 4:00 PM the Social Worker and LVN A discovered Resident #63 in his bathroom smoking while receiving oxygen therapy via a nasal cannula and an oxygen concentrator. A record review of the facility's event report dated 8/21/2025 revealed at an unknown time prior to 4:00 PM LVN A and CNA B discovered Resident #63 was in his bathroom smoking while receiving oxygen therapy via a nasal cannula and an oxygen concentrator. During an observation and interview on 8/28/2025 at 1:40 PM revealed Resident #63 was in his room and was assisted to pack and gather his belongings to discharge to another facility. Resident #63 stated he was discharged related to his episodes of smoking in his rooms' bathroom. Resident #63 stated he did not participate in the supervised assigned smoke breaks due to his inability to participate in the smoke break without his oxygen therapy. Resident #63 stated he could not endure very long without his oxygen because of his COPD. During an interview on 8/28/2025 at 1:50 PM LVN A stated she and the SW discovered Resident #63 smoking in his bathroom twice in August 2025. LVN A stated the ADON, the DON, and the Administrator were aware of Resident #63's smoking incidents. LVN A stated Resident #63's smoking could have had serious injury potential to include fires and or burns. LVN A stated the incidents were reported to the facility's leadership who implemented safety measures which included assessing peer residents who smoke for smoking paraphernalia and monitoring Resident smokers for safe smoking practices. LVN A stated Resident #63 was monitored and reviewed for safety every 2 hours every day until he was discharged . During an interview on 8/28/2025 at 4:10 PM the ADON stated she was aware of Resident #63's smoking incidents while he was on oxygen therapy and had reviewed the incidents in the morning IDT meetings with the DON and the Administrator and could not recall anyone discussing a report to the state agency for the incidents. During an interview on 8/28/2025 at 5:00 PM the Administrator stated she had received a report from nursing staff that Resident #9 and Resident #63 had a history of smoking unsupervised and at unassigned times. The Administrator stated LVN A and the SW reported that Resident #63 had been caught smoking in his bathroom on 8/12/2025 and again on 8/21/2025. The Administrator stated the facility could no longer meet Resident #63's and Resident #9's needs for safe smoking and non-compliant behavior and discharged the Residents. The Administrator stated the IDT and herself had not considered the incidents as incidents which were reportable to the state agency and had not reported the incidents to the state agency. During an interview on 8/29/2025 at 4:40 PM NP C stated he was the NP for the MD and was responsible for Resident #63's medical care. NP C stated Resident #63 had a need for oxygen therapy related to his poor gas exchange and should never be able to smoke while receiving oxygen therapy. NP C stated the practice was dangerous not only to Resident #63 but to the public to include a potential for fires and explosions. A record review of the facility's smoking policy dated 2017 revealed It is the policy of this home that: All residents who smoke will be supervised. Smoking will be permitted in designated safe area(s) only. Oxygen equipment is not permitted in the smoking area(s). The minimum safe distance for oxygen equipment from the smoking area is 50 feet. Residents not complying with the home's smoking policy may be discharged from the home. PNC verification A record review of the facility's Ad Hoc QAPI meeting documentations titled AD Hoc QAPI Meeting / Four Point Plan of Correction Agenda and Summary revealed the Ad Hoc committee members met which included the Medical Director, the Administrator, the DON, the ADON, the Maintenance Director, the Housekeeping Supervisor, the Social Worker, and the Business Manager. Further review revealed an action plan which included:1. Corrective actiona. What specifi9c action would you take for the identified residents? i. Identify residents who smoke ii. Provide re-education regarding safe smoking practices completed (policies.) iii. Proper notification to administration regarding non-compliance with smoking policy. iv. Monitoring of system to ensure compliance.2. Identification of othersa. What other residents might be a risk in the same deficient practice and why? All smokers could be potentially at risk for committing deficient practice. Therefore, continued reeducation of smoking policy has been implemented. Smokers were invited to resident council meeting to discuss smoking practices and ensure compliance with smoking policy.3. Systemic changesa. what changes would you make based on the results of your root cause analysis? Administrator, director of nursing, and assistant director of nursing will closely monitor smoking system and ensure compliance. Admissions - to identify smoker status prior to administration and communicate status with nursing team. Nurses have been in service on ensuring safe smoking practices are followed based on smoking policy and transparent communication will be required of non-compliance with administration and nursing administration teams.b. How will changes be communicated to staff? In services and one-on-one education on updated policies will be provided by the administrator and nurse managers including the director of nurses.c. Identification of non-compliant residents who smoke must be communicated to the administration team for interventions and safety practices put in place.4. Monitoringa. How will you sustain compliance? By making compliance monitoring rounds, education of staff and residents as appropriate.b. How do you plan to monitor corrective action? When and how long will monitoring occur? Monitoring will be ongoing. It will be monitored by all department managers to ensure compliance and reviewed monthly during QAPI meetings until further notice.c. Resident council will be included to provide smoking policy and ongoing education regarding safe practices. A record review of the smoker's club Resident council meeting dated 8/18/2025 revealed 10 residents which included Resident #9 and #63 received a review of the facility's smoking policy, It is the policy of this home that: All residents who smoke will be supervised. Smoking will be permitted in designated safe area(s) only. Oxygen equipment is not permitted in the smoking area(s). The minimum safe distance for oxygen equipment from the smoking area is 50 feet. Residents not complying with the home's smoking policy may be discharged from the home. A record review of the facility's in-service dated 8/21/2025 titled Smoking Supplies revealed the entire staff had received the in-service which included, all smoking supplies must be kept in smoking box no resident should be smoking in Rome all residents found with supplies for smoking must be taken away and notify the administrator. A record review of the facility's AdHoc QAPI files dated 8/21/2025 revealed a statement authored by the DON which included, on 8/21/25 myself and a DON rounded and searched all residents who smoke for any smoking paraphernalia smoking paraphernalia was found on any residence all smoking residents were able to verbalize they can only smoke during scheduled smoke breaks. Further review revealed the DON and the ADON signed the statement. A record review of the facility's AdHoc QAPI files dated 8/21/2025 revealed a monitoring worksheet for Resident #63 dated from 8/21/2025 until 8/27/2025. Further review revealed Resident #63 was monitored every 2 hours for safety and behavior without incident. During an observation and interview on 8/28/2025 at 1:40 PM revealed Resident #63 was in his room and was assisted to pack and gather his belongings to discharge to another facility. Resident #63 stated he was discharged related to his episodes of smoking in his rooms' bathroom. Resident #63 stated he did not participate in the supervised assigned smoke breaks due to his inability to participate in the smoke break without his oxygen therapy. Resident #63 stated he could not endure very long without his oxygen because of his COPD. During an interview on 8/28/2025 at 1:50 PM LVN A stated she had received training for safe smoking practices which included monitoring residents for smoking paraphernalia and had monitored Resident #63 every 2 hours when she was on shift to do so. During an observation and interview on 8/27/2025 at 11:39 AM revealed the facility's designated smoking area, the courtyard, where 6 residents assembled for a smoke break. Further review revealed the Activities Director supplied the residents with cigarettes and lite the cigarettes for the residents. The Activities Director was observed to supply clothing protectors for residents who had a need for clothing protectors. The Activities Director stated the facility had developed and implemented a smoking program for residents which included 4 smoke breaks on Monday through Friday, four times a day, at 9:30 AM, 11:30 AM, 1:30 PM, and again at 4:00 PM. The Activities Director stated she organized and supervised the residents smoke breaks which included the storage of residents' cigarettes and lighters in a locked room at the nurse's station. During an observation and interview on 8/29/2025 at 4:33 PM revealed Resident #20, Resident #1, Resident #63, and Resident #36 assembled in the courtyard for a supervised smoke break. Residents #20, #1, #63, and #36 stated they smoked while supervised at the smoke breaks and the staff kept their cigarettes and lighters. During an interview on 8/28/2025 at 11:00 AM LVN X and LVN Z stated the activities Director would coordinate and supervise the smoke breaks for residents Monday through Friday and the nurses would take turns supervising the smoke breaks on the weekends. LVN X and LVN Z stated the cigarettes and lighters were stored locked in the medication room and the nurses would provide the cigarettes. LVN X stated no one should smoke in the facility and any violations would be reported to the leadership to include the Administrator and the DON. During an interview on 8/28/2025 at 4:10 PM the ADON stated she had reviewed the facility smokers several times during June 16/2025 through 8/21/2025 to include monitoring for smoking paraphernalia and safe smoking times with supervision. The ADON stated she and the entire staff had been in serviced several times for safe smoking policies and reporting unsafe smoking practices. During an interview on 8/28/2025 at 5:00 PM the Administrator stated she became aware of Resident #9's and Resident #63's unsafe smoking behaviors in June 15/2025 and in August 12th and august 21st 2025 and began an investigation on 8/13/2025 which concluded with an Ad Hoc QAPI meeting, a plan of correction which included systemic changes, increased monitoring for safe smoking practices and a safe discharge for residents #9 and Resident #63 to facilities which could meet their needs for safe smoking to include smoking cessation efforts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure provided food was prepared in the proper form to meet residents needs for 1 of 6 residents reviewed, (Resident #1), reviewed for food form. On 7/21/24 the facility failed to ensure Resident #1 was given the correct physician-ordered diet texture of a meal which led to choking. An IJ was identified on 07/22/24. The IJ template was provided to the facility on [DATE] at 7:07 pm. While the IJ was removed on 07/26/24 the facility remained out of compliance at a scope of isolated with a 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. This failure could place residents at risk of choking, decline in health and death. Findings include: Record review of Resident #1's admission Record documented a [AGE] year-old female first admitted to facility on 09/26/06 with latest admission on [DATE]. Resident #1's diagnoses included Alzheimer's Disease, aphasia following cerebral infarction, dysphagia following cerebral infarction, contracture of muscle, right lower leg, and Type 2 diabetes mellitus without complications. Record review of Resident #1's Physician's Orders dated 06/25/24 - 07/25/24 revealed she had an order for a regular diet with puree texture and nectar thickened liquids with meals. The orders also included snacks BID (pudding, yogurt, applesauce, or other pureed snack). Record review of Progress Note dated 07/21/24 revealed that Resident #1 was served a regular mech soft diet instead of pureed/nectar liquids, spoon fed by CNA 100%. Resident started vomiting, face flushed. Nurse on unit performed Heimlich maneuver, called ADON, DON, on call PA, and family member. PA ordered stat chest x-ray, monitor O2 frequently during night. X-ray ordered. Vital signs indicated that oxygen was 93% during the event and 98% about an hour later. Record review of Progress Note dated 07/22/24 at 4:48 pm revealed Resident awake and alert. Spoon fed pureed diet as ordered. No s/s of SOB, cough or congestion. X-ray results were negative for aspiration, no Cardio Pulmonary abnormalities. MD made aware. During an interview on 07/22/4 at 1:02 pm with CNA A, it was revealed that CNA B, an agency aide, was assigned to work Hall 300 after having been originally oriented to Halls 100 and 200 earlier in the day. CNA A went to the dining room to assist with the supper meal. When it was discovered that Resident #1 was not in the dining room, CNA A brought Resident #1's tray to the resident's room to give to CNA B. CNA B told CNA A that she had already fed Resident #1. CNA A then realized that CNA B had given Resident #1's roommate's tray to her which was mechanical soft. CNA A then noticed that Resident #1 had bubbles coming out of her mouth. CNA A told charge nurse LVN C who was in the dining room that Resident #1 was having trouble and LVN C told CNA A to get LVN D who was also on the hall as a Med Nurse. LVN D then went to the room and found Resident #1 to be red and choking and did the Heimlich maneuver. CNA A stated she went to get the crash cart and brought it to the room but it was not needed. CNA A stated that Resident #1's tray should have been on the hall tray cart since she normally eats in the dining room for breakfast and lunch and then goes back to bed. Resident #1's roommate, Resident #48, ate either in the dining room or in her room depending on whether or not her family was visiting. On this date, the family was in the dining room with Resident #48. Since her tray had gone to the hall, the dietary department just made her another plate. CNA A stated they try to tell the kitchen whether the residents will eat in the dining room or in their rooms so the trays can be placed on the correct cart. During an interview with LVN D on 07/22/24 at 1:40 pm, it was revealed that she was serving as a Medication Aide on 300 and 400 Halls. LVN D stated that CNA A came and told her that she was needed in Resident #1's room since it appeared she may be choking. LVN D stated, I saw that she was red so I did the Heimlich maneuver and did a finger sweep in her mouth and got some broccoli out. LVN D stated she then relieved LVN C so LVN C could call the doctor, get an order for an x-ray and call the family. LVN D stated that her color came back to normal and her vital signs were good. LVN D stated she was coughing a little. LVN D stated that Resident #1 sometimes eats in the dining room but if she has been up all day she will be put back to bed and eat in her room. LVN D stated that Resident #48 usually sleeps until 1:00 pm and then she usually eats in the dining room or may eat in her room if her family comes and wants to feed her there. LVN D stated that Resident #1 needed total assistance to eat since she was contracted on her right side. LVN D stated she had never seen the agency CNA B in the facility before. LVN D stated that CNAs usually do a walk around to orient agency aides. She said that CNA B left right after this incident since it was at the end of the shift. During a telephone interview with CNA B on 07/22/24 at 2:00 pm, she stated that the nurse checked the trays and told her that they were all correct and to hand them out. She said she did not get any orientation on the residents on that hall since she had originally been placed on the other side of the facility. CNA B also stated she had never worked in the facility before so did not know any of the residents. CNA B stated she just looked at the room number and did not know which was the A bed or B bed. Since Resident #1 was in the room, she fed her the tray with that room number on it. CNA B also said she fed most of the tray which consisted of noodles and some other things but no vegetables. During the interview with LVN C on 07/24/24 at 3:20 pm, she explained the sequence of events for the incident with Resident #1. LVN C stated the hall trays came to the unit and I checked all the trays. The agency CNA B came out of a room and I told her I was going to the dining room. In the dining room, I saw that Resident #48's tray didn't come out on the dining room cart so I asked CNA A to go get her tray from the cart on the hall. Resident #48's family brought her to the dining room. LVN C then stated that she didn't know if Resident #48's family was going to feed her in the dining room or in her room prior to her going to the dining room. Resident #1's tray was on the dining room cart. LVN C stated that when CNA A returned to the dining room CNA A told her about the mixed-up trays so they ordered another tray for Resident #48. LVN C stated that is also when CNA A told her about Resident #1 getting the wrong tray and having issues. LVN C told CNA A to go get LVN D to either assist Resident #1 or come to the dining room so she could go and assist Resident #1. LVN C stated that LVN D took care of the situation with Resident #1 and when she was finished in the dining room she called the doctor and the family. LVN C stated she took Resident #1's vital signs and the oxygen came back up to 95% and by the time she left around 7:00 pm the oxygen level was at 98% and resident was back to normal. A review of the menu on 7/21/24 revealed turkey tetrazzini, broccoli florets, breadstick and mandarin oranges. Interview on 7/22/24 at 4:17 pm with the DON revealed an agency CNA passed the trays. CNA B got the A bed and B bed mixed up. Resident #1 did not get the correct diet and started choking. LVN D performed the Heimlich maneuver. The DON stated, When possible, the agency aides will not pass hall trays; they should be assigned to the dining room since facility nurses are always in the dining room. The DON stated, We are inservicing staff on this now. The DON further stated that after the incident with Resident #1, her oxygen level was 93% and that should have been fine. The DON also stated that Resident #1's x-ray was clear. Facility's policy titled Meal Service-Nursing Responsibilities, dated 12/2017, stated .Nursing Services associates will follow these guidelines regarding meal service: 1. Distribute food trays to residents in resident rooms, dining rooms, and ancillary dining rooms. 2. Trays will be passed in a timely manner. Food must remain covered while being distributed through the hallways and tray cards should remain with trays throughout meal service .14. A licensed member of the nursing staff must check meals trays for accuracy, and be present in the dining room during the entire meal service. The Administrator was notified of the IJ situation on 07/22/24 at 7:07 pm due to the above failures and a template was given. On 07/23/24 at 1:43 pm the POR was accepted. It was documented as follows: 7/22/2024 [Facility] Plan of Removal - F 805 Immediate Action Taken Resident Specific Resident # 1 will receive the appropriate physician ordered diet for all meals going forward. Resident # 1 has had a chest x ray. The results reveal no negative outcome to her lungs. Resident # 1's physician who is also the medical director has been notified both of the incident and the IJ status at the facility. System Changes Starting on 7/22/2024 at 11:20 am a facility audit took place to ensure that all residents requiring modified texture diets for meals will receive their meals in the appropriate texture. Starting on 7/22/2024 at 1:00 pm DON and the dietary consultant audited all residents who require their diet to be served in an altered texture for meals to ensure that their meal tickets reflect the residents individual needs regarding texture with food in accordance with physician's diet orders. * Starting on 7/22/2024 and ongoing there will be a 3 part system to ensure that all diets are served with the correct texture to include the following: * The dietary department designee will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate. * The nurse in the dining room will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate. * The nurse on the hall will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate. Starting on 7/22/2024 and ongoing the DON will monitor two meals daily x 5 days a week to ensure staff compliance with ensuring that all meals/trays have the appropriate texture that matches the meal ticket and the physician ordered diet. Starting on 7/22/2024 and ongoing residents meal texture statuses will be audited upon admission, change of condition, appropriate mds cycles and or anytime necessary. Starting on 7/22/2024 at 11:00 am the facility's mechanism for ensuring correct diet texture for the residents is that all trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The printed meal ticket will be compared to the tray/plate for accuracy. Education Starting on 7/22/2024 at 12:30 pm the Assistant Director of Nursing provided education to all staff regarding residents requiring specially textured meals to ensure those residents will receive the appropriately textured meal at all times. Staff on future shifts will be educated prior to taking the floor. This will be accomplished by having a designated staff member in the building for that purpose and with that specific assignment. Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents. This assigned licensed staff member will ensure specifically that the texture of all resident meals matches the physician ordered diet. Starting on 7/22/2024 at 12:00 pm the Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents requiring specially textured diets for meals. Starting on 7/22/2024 at 12:00 pm the regional clinical consultant will be responsible for ensuring that staff receive the inservice/training regarding residents requiring specially textured food for meals. Starting on 7/22/2024 the residents dietary food texture status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photo copy and or written communication. Starting on 7/22/2024 the DON or their designee will be responsible for ensuring that the residents who require specially textured diets receive their food with the appropriate texture according to the physician's ordered diet. Starting on 7/23/2024 at 9:00 am during the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the dietary supervisor to ensure compliance and follow up for all residents with orders and recommendations. The clinical consultant will review orders and recommendations daily x 4 weeks as a tool for oversight to ensure compliance. Starting on 7/22/24 at 11:00 am staff have bee re educated to identify the resident's diet by room number and bed designation of A or B. 100% Staff education compliance for those who may serve food to a resident will be completed by 3:00 pm 7/23/24. On 7/26/24 the surveyor confirmed the facility implemented their plan of removal (POR) sufficiently to remove the IJ by: During the interview on 07/24/24 at 3:20 pm, LVN C stated she was called for the inservice following the IJ. LVN C stated they are going to put A and B on the doors beside the residents' names and we are not going to let agency CNAs pass trays on the halls. Agency CNAs will only pass trays in the dining room. LVN C stated when she was in the dining room she would check each tray and give it to the aide to pass to the resident. LVN C also stated she helped feed residents in the dining room. Record review of the facility staff list indicated there were a total of 71 staff members and 5 contracted therapists who work full time in the facility. Record review in-service documentation dated 7/22/24 indicated 71 staff members and 5 contracted therapists had been inserviced either in person or by phone on the new procedures which included adding the letters A and B beside each resident name on the doors to indicate bed position in the room whereby the A bed was closest to the door and the B bed was closest to the window. The procedure also includes having only full time staff pass trays in the halls. Agency staff will pass trays in the dining room along with a full time nurse. No agency staff will pass trays without assistance from full time staff members. The charge nurse will check all trays to ensure the meal ticket matches the meal texture, specialized utensils, and liquid texture on the plate prior to its distribution to the resident. Record review of documentation dated 7/23/24 showing the DON had contacted the staffing agencies used by facility and had them place a copy of the inservice on their paperwork for agency staff who may come to work in the facility. Interviews beginning at 4:13 pm on 07/24/24 through 6:00 pm on 07/25/24 with 20 staff members and 1 contract therapist revealed their understanding of the new procedures which included adding the letters A and B beside each resident name on the doors to indicate bed position in the room whereby the A bed was closest to the door and the B bed was closest to the window. The procedure also included having only full time staff pass trays in the halls. Agency staff will only pass trays in the dining room along with a full time nurse. No agency staff will pass trays without assistance from full time staff members. The charge nurse will check all trays to ensure the meal ticket matches the meal texture, specialized utensils, and liquid texture on the plate prior to its distribution to the resident. Interviews with 3 dietary staff and 1 DM on 07/25/24 at 11:30 am, revealed their understanding of the above procedure. Additionally, the dietary staff had highlighted residents who had pureed diets on the meal ticket and had written the word Pureed in yellow highlighter. Observation of Resident #1 on 07/25/24 at 11:45 am revealed the resident was being fed a pureed diet with nectar thickened liquids according to meal ticket and physician orders. Record review of Resident #1's chest x-ray indicated no abnormalities. Record review review of documentation that medical director who was the attending physician for Resident #1 had been notified of the incident and IJ status. Record review and interview with DON and ADON on 07/25/24 at 2:00 pm, provided meal audit forms and identified room/bed changes. Interview with DON revealed she and the Dietary Consultant had audited residents who required altered texture for meals by comparing the facility EHR system with the dietary electronic system to ensure that all diet textures matched on 07/22/24 at 1:00 pm. Record review of dietary audits provided. Observation of meal tickets and interview with dietary staff on 07/25/24 at 11:30 am revealed that room numbers with A or B and pureed textures had been highlighted for all residents requiring specialized texture with the highlighted word Pureed on the ticket. Meal tickets also contained the resident's room number with bed designation of A or B. The Dietary Manager (DM) revealed they are doing this on all meal tickets going forward. Observed nurse in dining room on 07/25/24 at 12:10 pm checking meals coming from dietary to compare ticket with what is being served on plate. Observed nurse on hall checking trays and tickets on hall carts on 07/25/24 at 11:45 pm. Interview with DON on 07/25/24 at 10:00 am revealed she was monitoring the nurses for breakfast and lunch to ensure they are checking trays and ADON is monitoring nurses for supper meal. On weekends the charge nurse will monitor. Record review of audit sheets completed. Interview with DON on 07/25/24 at 10:00 am revealed the DON will monitor meals 2 meals per day 5 times per week. The DON reported that she will continue to monitor meals and once compliance was achieved over a 30 day period, they will do random checks twice a week. Observed the DON in dining room during lunch beginning at 12:15 pm on 07/22/24, 07/24/24, and 07/25/ 24. Interview with the DON on 07/25/24 at 10:00 am stated during their facility Clinical Meeting, dietary textures will be audited and monitored. Interview with the ADON on 07/25/24 at 10:00 am stated during the Care Plan meetings diet changes will be discussed and monitored. Interview with DON on 07/25/24 at 10:00 am, the DON stated mechanism to ensure correct diet texture was included in staff education. Observation of resident room doors on 07/25/24 at 9:00 am revealed A and B had been added to the end of each resident name to indicate their designated bed assignment. While the IJ was removed on 07/26/24 the facility remained out of compliance at a scope of isolated with a 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.