**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, resident record review, and review of a facility policy titled Comprehensive Care Plans, the facility failed to develop and implement a care plan with person-centered safety interventions addressing Resident Identifier (RI) #27's noncompliance with the facility's non-smoking policy, including smoking and vaping inside the facility unsupervised in his/her room from 11/15/2022 through 02/13/2023. Facility staff did not know what to do or how to respond on occasions when RI #27 was found using a vape or smoking in his/her room. This failure affected RI #27, one of 23 sampled residents for whom care plans were reviewed. In addition, this failure placed all 109 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/24/2023 at 5:05 PM, the facility's Administrator, Employee Identifier (EI) #1 and the [NAME] President (VP) of Clinical Operations, EI #36, were provided a copy of the immediate jeopardy template and notified of the immediate jeopardy findings in the area of Comprehensive Resident Centered Care Plan, F656-Develop/Implement Comprehensive Care Plans. Findings include: A review of the policy titled Comprehensive Care Plans, reviewed 04/14/2021, revealed: . POLICY STATEMENT A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. .GUIDELINE: . 4. Each resident's Comprehensive Care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems . RI #27 was admitted to the facility on [DATE] with diagnoses to include Depression, Bipolar Disorder, Anxiety Disorder, Muscle Weakness, Lack of Coordination, Seizures, and Hemiplegia (paralysis of one side of the body) affecting Dominant Side. During the survey, document review and interviews with staff revealed RI #27 had multiple documented episodes of non-compliance with the facility's non-smoking policy, including vaping and smoking in his/her room and hiding vaping and smoking materials from facility staff. This noncompliance was documented to have occurred from 11/15/2022 through 02/13/2023, despite repeated education to RI #27 on the facility's non-smoking policy. Cross reference F689 and F867. Review of RI #27's comprehensive care plans revealed the first care plan related to RI #27's noncompliance was created on 01/26/2023 by EI #15, the MDS/Care Plan Coordinator. This care plan documented: .Problem Start Date: 01/26/2023 Category: Behavioral Resident demonstrates non-compliance with physician orders and/or plan of care as evidenced by: continuing to vape in (his/her) room despite being asked not to . On 01/26/2023 at 3:57 PM, EI #15, the MDS/Care Plan Coordinator, was interviewed. When asked at what point RI #27 first demonstrated noncompliant behavior, EI #15 said since 11/15/2023, according to the progress notes. When asked what had been done to address the concern of noncompliance with the facility's non-smoking policy, EI #15 said they offered a nicotine patch, but RI #27 continued to vape, so the patch was discontinued. EI #15 confirmed RI #27's care plan addressing non-compliance with the facility's non-smoking policy was not initiated until 01/26/2023. When asked why a care plan had not been developed prior, EI #15 said she thought progress notes were effective enough. When asked when a care plan should have been initiated, EI #15 said on 11/15/2023, when RI #27's noncompliance was first noted. EI #15 said the risk of not developing a care plan would be harm to the resident. EI #15 further stated the facility policy for person-centered care plans had not been followed. On 01/26/2023 at 4:46 PM an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked, what was the smoking/vaping policy for the facility. EI #2 said the facility was non-smoking, meaning no smoking or vapes were allowed. EI #2 was asked when she first became aware of RI #27 vaping in his/her room. EI #2 replied, she could not remember the exact date, but indicated they notified the doctor and got RI #27 a nicotine patch. However, EI #2 said RI #27 continued to use a vape, so they had to discontinue the nicotine patch. When asked what interventions were put in place to address RI #27's noncompliance after the nicotine patch was discontinued, EI #2 said she did not think they did anything different. EI #2 was asked when a care plan should have been put in place. EI #2 said immediately after finding the vape. When asked why that was not done, EI #2 said EI #15, the MDS/Care Plan Coordinator, did not do it. EI #2 further stated the facility policy for person-centered care plans had not been followed. On 02/18/2023 at 11:00 AM, the surveyor conducted another interview with EI #2, the DON. When asked what interventions were currently in place to address RI #27's noncompliance with the facility's non-smoking policy, EI #2 said they were offering snacks of choice, a smoke detector in RI #27's room (initiated 02/13/2023), and an in-room sitter for RI #27 (initiated on 02/15/2023). EI #2 said prior interventions had not prevented RI #27 from continuing to be noncompliant, but indicated they had had no further instances since 02/13/2023. An interview was conducted with EI #6, the Medical Director, on 02/19/2023 at 2:30 PM. EI #6 indicated he participated in a discussion in December 2022 regarding interventions that may help address RI #27's noncompliance with the facility's non-smoking policy. EI #6 said he did not recall making any suggestions, but they were trying to come up with options. EI #6 said the nicotine patch was discontinued due to RI #27 continuing to vape, and indicated medications for smoking cessation were not an option for RI #27. When asked what the facility could have done about RI #27 continuing to violate the facility's non-smoking policy, EI #6 said there were really only two options: one being to change the policy, which was not a good idea, or to find alternate placement that would be a better fit. EI #6 indicated that after multiple violations of the facility's non-smoking policy, they should have discussed transferring RI #27 out of the facility for his/her own well-being, as well as for the safety of others in the facility. When asked what approaches could have been attempted to prevent the continued noncompliance, EI #6 said they could have initiated the one on one (in-room sitter) sooner. An interview was conducted with EI #1, the Administrator, on 02/17/2022 at 1:39 PM. EI #1 stated the facility had a meeting in December 2022 to discuss the concern of RI #27's noncompliance with the facility's non-smoking policy. However, when asked if they had discussed a need for a care plan addressing these continued behaviors, EI #1 said she did not recall discussing a care plan. EI #1 further stated she did not remember anyone saying RI #27 would need a care plan in place for his/her behavior of noncompliance related to smoking and vaping. EI #1 acknowledged the facility had a breakdown in the care plan process, and said the facility was not aware there no care plan addressing RI #27's noncompliance until it was brought to the facility's attention during the survey. This deficiency was cited as a result of complaint/report numbers AL00043096 and AL00043372. ****************** The facility submitted an acceptable Removal Plan on 02/26/2023 for F656 that outlined the following: 1. Comprehensive Care Plan education was provided by SCC (Signature Care Consultant) on 01/25/2023 to DON, the MDS coordinator & each department manager responsible for MDS assessments/evaluations upon admission, quarterly, annually & with significant change. Care Planning residents with behaviors education was completed on 01/25/2023 by the Special Projects MDS RN and on 02/25/2023 by the VPCO (Vice President of Clinical Operations) to the DON, MDS coordinator & each department manager responsible for MDS assessments/evaluations upon admission, quarterly, annually & with significant change. The facility developed a care plan on 01/26/2023 for behaviors non-compliant with physician orders and facility policies as evidenced by vaping in her room. The facility updated the plan of care continually with appropriate interventions to address noncompliance with the facility's nonsmoking policy with person-centered safety interventions for RI #27 for noncompliance with the facility's nonsmoking policy. The following are the revisions and interventions to R#27's plan of care: -Vape materials were confiscated, and a nicotine patch was ordered on 11/24/2022. - The Administrator discussed non-compliant behavior in violation of facility policy with R#27 on 02/22/2023 and is documented in the progress note. - A room search was completed on 02/18/2023 and documented in the progress notes with R#27's consent and she was present. - Social Services Director (SSD) educated R#27 on the non-smoking policy 02/22/2023, RI#27 signed the Smoke Free/Non-Smoking policy and was given a copy and a copy was uploaded into the Matrix medical record. - Laundry staff continue to monitor resident clothing and personal items for any burn holes. All Laundry staff was educated by the housekeeping supervisor on 02/21/2023. All housekeeping staff and the HCSG (Healthcare Services Group) housekeeping supervisor were educated by the HCSG (Healthcare Services group) District manager for Housekeeping and Laundry on 02/25/2023. The education included how to audit resident personal laundry for burn holes, soot, or tears and report their findings to the laundry supervisor. - Education to a friend on 12/7/2022 by a staff nurse on not bringing vape or smoke materials into the facility. - Psych referral for non-compliant behavior and evaluation on 1/11/2023, and 12/28/2022. - Collaboration with DHR and Gateway for discharge planning on 12/30/2022, 01/17/2023, 2/6/2023, 2/7/2023, 2/13/2023, 2/15/2023, and 2/16/2023. - Provide snacks as a diversion to smoking on 01/27/2023. - Education to family (Father) by SSD on 02/13/2023 on the non-smoking facility policy and not bringing vape or smoke materials into the facility. - Maintenance placed a smoke detector in the room on 02/13/2023. - 1:1 supervision implemented 02/15/2023 and continues. - 30-day Discharge planning initiated 02/15/2023. 2. All residents residing in the facility were at a safety risk and fire hazard due to a lack of appropriate safety measures developed for residents with noncompliance on the plan of care. All staff in all departments were interviewed by the Staff Development Coordinator (SDC) on 02/17/2023, 02/18/2023, and 02/19/2023 to identify any other residents with behaviors that are non-compliant with the Facility Smoking/Non-Smoking Policy facility. Any resident identified with non-compliant behavior to the Facility Smoking/Non-Smoking policy has a behavior monitoring plan and care planned and implemented. - All residents were interviewed by a member of the interdisciplinary team (IDT) the interdisciplinary team consisted of the SSD, DON, Admissions Liaison, Admissions Coordinator, Life Enrichment Director, SDC, ADON, Unit Manager, Medical Records, and MDS coordinator. These were completed on 02/21/2023 on smoking choices. - Five residents were identified as a smoker or requesting to smoke met with the SSD and signed the Non-Smoking policy. This was completed on 02/21/2023. - Any resident identified as a smoker or requesting to smoke have behavior monitoring implemented observing for any non-compliant behaviors related to not smoking/vaping in the facility and the plan of care revised with approaches and interventions to monitor and manage those residents' behaviors. This was completed on 02/21/2023. - The Interdisciplinary team consisting of the DON, SSD, Administrator, Life Enrichment Director, Signature Care Consultant (SCC), and [NAME] President of Clinical Operations (VPCO) completed an Interdisciplinary Psychotropic review/Behavior meeting on 02/17/2023 and 02/18/2023 to identify and discuss residents displaying challenging behaviors, as well as those residents receiving psychoactive medications. Residents with behavior issues have Target Behaviors identified on the EMAR for documentation. Behavior management care plans were reviewed to evaluate goals and the effectiveness of the interventions and revised as necessary. 3. Comprehensive Care Plan education was provided by SCC (Signature Care Consultant) on 01/25/2023 to DON, the MDS coordinator & each department manager responsible for MDS assessments/evaluations upon admission, quarterly, annually & with significant change. This education focused on care plans are ongoing and revised as information about the resident and the resident's condition or behavior change. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition. b. Changing goals. c. When the desired outcome is not met. d. When the resident has been readmitted to the facility from a hospital stay; and e. At least quarterly - Care Planning residents with behaviors was completed on 01/25/2023 by the Special Projects MDS RN and on 02/25/2023 by the VPCO (Vice President of Clinical Operations) to the DON, MDS coordinator & each department manager responsible for MDS assessments/evaluations upon admission, quarterly, annually & with significant change. This education focused on care plans are ongoing and revised as information about the resident and the resident's condition or behavior change. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition. b. Changing goals. c. When the desired outcome is not met. d. When the resident has been readmitted to the facility from a hospital stay; and e. At least quarterly The Governing Body consisting of the Chief Nursing Officer (CNO), Senior [NAME] President of Operations (SVPO), Senior [NAME] President (SVPC), [NAME] President Operations (VPO), and [NAME] President of Clinical Operations (VPCO) reviewed and granted the approval of the Comprehensive Care Plans policy on 01/25/2023 created on 04/06/2015, revised last on 07/19/2018, and reviewed 04/14/2021 by the Senior Clinical Leadership team consisting of the Chief Nursing Officer (CNO), Senior [NAME] President of Clinical Operations (SVPCO), [NAME] President of Regulatory (VPR), and the [NAME] President of Operations (VPO). - The Comprehensive care Plan policy was in-serviced at the Signature Whitesburg Gardens on 01/25/2023 by the Signature Care Consultant (SCC) to the to DON, the MDS coordinator & each department manager responsible for MDS assessments/evaluations. The VPCO trained the Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) on 02/20/2023 on the Comprehensive Care Plan policy. The VPCO educated the Comprehensive Care Plan policy to the following disciplines on 02/25/2023: Staff Development Coordinator (SDC), ADON, DON, Department Managers for Housekeeping, Maintenance, Dietary, Admissions, Social Services, Business Office, Life Enrichment and/ or Administrator. - The VPCO reviewed the Comprehensive Care Plan policy and prepared and reviewed the training for staff on Comprehensive Care Plans policy on 02/24/2023. - In-servicing will be completed on 02/26/2023 with all LPNs, RNs, MACs, and C.N.A.s, therapy, and all department managers by the SDC, VPCO, and/or department manager. This education focused on care plans are ongoing and revised as information about the resident and the resident's condition or behavior change. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition. b. Changing goals. c. When the desired outcome is not met. d. When the resident has been readmitted to the facility from a hospital stay; and e. At least quarterly - The Director of Nursing (DON) provides oversight five days a week to the nurse/Interdisciplinary Team to ensure care plans are reviewed and updated with changes. - The DON was educated on of DON responsibilities in providing oversight to the nurse/Interdisciplinary Team (IDT) to ensure care plans are reviewed and updated with changes and re-educated on 02/24/2023 by the VPCO. ****************** On 02/26/2023 at 11:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 02/26/2023 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ***************************************************************** The facility submitted an acceptable Removal Plan on 02/26/2023 for F689 that outlined the following: 1. The facility developed a person-centered care plan for non-compliant behaviors with vaping on 01/26/2023, implemented interventions to manage non-compliant vaping behaviors on 11/15/2022, and revised the plan of care to address smoking cigarettes in her room on 02/13/2023 by placing a smoke detector in her room and placing her on 1:1 monitoring on 02/15/2023. RI#27's plan of care has non-compliance with smoking cigarettes in her room added to the care plan problem and approaches and interventions added to the care plan to guide the staff on how to respond if RI #27 was found smoking or vaping. Approaches and interventions that guide staff on how to respond are as follows: 1 on 1 monitoring, Facility staff may confiscate items or substances identified to post a risk to resident's health and safety and are in plain view, observe for triggers of inappropriate behaviors and alter environment as needed, Observe for unmet needs such as for toileting, rest, food, fluids, companionship, etc., Offer smoking succession such as nicotine patch or other alternative, Resident room and belonging searches with resident or family consent PRN, and Social Services met with resident and residents signed and verbalizes understanding of facility NO SMOKING POLICY. 2. All residents residing in the facility were at a safety risk and fire hazard due to a lack of appropriate safety measures developed for residents with noncompliance on the plan of care. The following Immediate actions were taken to address nonsmoking policies and procedures, including developing care plans, and staff training on how to address the noncompliance of residents. The following immediate actions were taken for all residents in the facility so they will no longer be at risk of ongoing safety concerns and/or fire hazards. - All staff in all departments were interviewed by the Staff Development Coordinator (SDC) on 02/17/2023, 02/18/2023, and 02/19/2023 to identify any other residents with behaviors that are non-compliant with the non-smoking facility policy. Any resident identified with non-compliant behavior to the Facility Smoking/ Non-Smoking facility policy has a behavior monitoring plan and care planned and implemented. - All residents were interviewed by a member of the interdisciplinary team (IDT) the interdisciplinary team consisted of the SSD, DON, Admissions Liaison, Admissions Coordinator, Life Enrichment Director, SDC, ADON, Unit Manager, Medical Records, and MDS coordinator. These were completed on 02/21/2023 on smoking choices. - Five residents have signed the Smoke Free/Non-Smoking policy and have behavior monitoring and care plans for smoking. Any resident identified as a smoker or requesting to smoke met with the SSD and signed the Non-Smoking policy. This was completed on 02/21/2023. - Any resident identified as a smoker or requesting to smoke has behavior monitoring implemented to monitor for any non-compliant behaviors related to not smoking/vaping in the facility and the plan of care revised with approaches and interventions to monitor and manage those residents' behaviors. This was completed on 02/21/2023. - The Interdisciplinary team consisting of the DON, SSD, Administrator, Life Enrichment Director, Signature Care Consultant (SCC), and [NAME] President of Clinical Operations (VPCO) completed an Interdisciplinary Psychotropic review/Behavior meeting on 02/17/2023 and 02/18/2023 to identify and discuss residents displaying challenging behaviors, as well as those residents receiving psychoactive medications. Residents with behavior issues have Target Behaviors identified on the EMAR for documentation. Behavior management care plans were reviewed to evaluate goals and the effectiveness of the interventions and revised as necessary. 3. The following actions were taken to address non-compliance with the Facility's Smoking/Non-Smoking Policy and procedures, including implementing individualized interventions in the care plan for noncompliance with smoking policies. All Staff in all departments had training on how to address noncompliance of residents with the Facility Smoking/Non-Smoking Policy and Contraband Discovery Policy. The following disciplines have been educated by the Staff Development Coordinator (SDC), ADON, DON, Department Manager, and/ or Administrator on the following: - On 11/11/2022 nine licensed nurses were in-serviced on the Facility's Smoking/Non- Smoking facility policy and non-compliant behaviors by the ADON. - On 12/07/2022 the Signature Care Consultant (SCC) educated the interdisciplinary team consisting of the MDS coordinator, DON, Administrator, RSM, facility liaison, Plant Ops Director, BOM, HCSG Housekeeping Manager, SDC, ABOM, and 19 nursing staff on the Abuse policy, and residents with non-compliant smoking behaviors. - On 12/29/2022 the Administrator educated 42 staff from different departments in a Town Hall Meeting on reporting behaviors of residents and staff, the Code of Conduct/Ethics, and the Facility Smoking/ Non-Smoking policy. - On 01/25/2023 the Special Projects MDS Coordinator in-serviced the ADON, DON, SSD, MDSC, and Life Enrichment Director on care planning residents with behaviors. - On 01/25/2023 13 licensed nurses were in-serviced on notifying the DON of residents with behavioral issues by the ADON and/or SDC. - On 02/15/2023 all staff in all departments were in-serviced on the Facility Smoking/ Non-Smoking policy by the SDC and/or ADON. - On 02/15/2023 all staff in all departments were in-serviced on the 1:1 Sitter/Care process by the ADON. This in-servicing educated the procedure for staff if they find a resident smoking, drinking alcohol, or engaging in behavior that could lead to harm, ensure safety, remove the contraband, do not leave the resident alone, and notify administration immediately. - On 02/20/2023 all staff in all departments were in-serviced on the Behavioral Health Policy. This included documentation of behaviors in Matrix POC by C.N.A.s, target behavior documentation by licensed nurses in the MAR/TAR, reporting behaviors to the Administration, SSD, and the DON, and the monthly interdisciplinary behavior meeting. The education included but was not limited to identifying and managing non-compliant behaviors, documentation of behaviors in EMR, and documentation from CNA/QMA in POC on daily tasks. In-servicing about identifying and managing noncompliant behaviors was specific to the Contraband Discovery policy and included the following: 1. If facility staff identify items or substances that pose risks to residents' health and safety and are in plain view, they may confiscate them. 2. Facility staff should not conduct searches of a resident or their personal belongings, unless the resident, or resident representative agrees to a voluntary search and understands the reason for the search. 3. Obtain consent from resident and/or resident representative to search resident's body or personal possessions. Only after facility obtains consent from resident and/or resident representative. 4. Inform the resident and/or resident representative that he/she and/or his/her room will be searched and the reason for the search. Give the resident the opportunity to surrender the suspected contraband and to the extent possible, give the resident the opportunity to be present during the search. 5. Remove any items that could pose a potential threat or cause harm to other residents or staff. 6. Searches will be carried out by the Administrator, Director of Nursing Services, Social Services Director or Charge nurse and at least one (1) other staff member. 7. If the resident has a roommate, only the resident's side of the room shall be searched. 8. The Administrator and/or Director of Nursing Services will hold the contraband in a locked and secure place until arrangements can be made for appropriate disposal with either corporate or regulatory agencies. Any illegal substances will be turned over to law enforcement authorities by the Administrator or designee, as soon as possible. - The SDC, DON ADM ,SSD, SDC, ADON were trained on the Behavior Health Management Procedure and Contraband Discovery policy by the VPCO on 02/20/2023. - Residents identified with behaviors will be referred to SSD, MD, and IDT to determine if a need for additional psychotherapy, outpatient services, 1:1, or discharge planning is required. This was completed by the SDC. - On 02/20/2023 all nurses were educated on the 24-Hour Report policy to review how communication is provided from nursing and direct care staff to administration by the SDC. - The 24-Hour Report policy training is specific to communicating the following: The 24-hour report is used to provide communication to nursing, administration, and direct care departments regarding pertinent changes in residents' status. Licensed nurses will place residents on the 24-hour nursing report form if they meet the criteria noted below: Admissions, re-admissions, discharges or transfers , Injuries, Incidents (elopement, falls without injury, medication errors and reactions), Acute changes of behavior, mental status or physical condition, Skin changes (rashes, pressure ulcers, bruises, skin tears), Abnormal laboratory or x-ray findings, Episodic illnesses, flu, infection, UTI, URI. 1. A 24-Hour Nursing Report will be used at each unit. 2. A new form will be initiated daily. 3. The Director of Nursing (DON)/designee will collect the original form each morning and leave the copy on the unit for follow-up. 4. The DON/designee will review the 24-Hour Nursing Report at the daily clinical meeting. 5. The DON/designee will use the 24-Hour Nursing Report on daily rounds for additional assessment of the resident's clinical condition. 6. The licensed nurse will complete the 24-Hour Nursing Report with the resident's name, room number and brief description of the condition change. Complete documentation is to be placed in the clinical record. The data entered for a specific resident continues for each shift, one resident per row. Multiple forms may be needed for a unit for a 24-hour period. 7. Steps to be taken by the Licensed Nurse: a. Identify a change in condition. b. Notify the M.D. c. Initiate any new orders. d. Notify the family. e. Document in the Nursing Progress Notes. f. Update the Plan of Care as needed. g. Add resident to the 24-Hour Nursing Report - On 2/24/2023, 02/25/2023, and 02/26/2023 all staff in all departments will be educated on the Contraband Discovery policy by the SDC and/or department manager to include how staff will provide any contraband confiscated to the Administrator and/or DON to hold the contraband once confiscated in a locked and secure place until arrangements are made for disposal with corporate or regulatory agencies. - All staff in all departments will be in-serviced on the Behavior Health Policy, Comprehensive Care Plans, Care Plans and Care Plan Meetings Accidents and Incident Investigating Reporting, Contraband Discovery policy, Safety and Supervision of Resident policy, Facility Smoking/Non-Smoking policy, and QAPI by the SDC/ADON/DON/VPCO/Administrator/Department manager/SCC/Charge Nurse by 02/26/2023. - Any staff that has not received in-servicing will be contacted by phone and complete the in-servicing and sign the in-servicing sheet on their next scheduled day. - Any staff member not completing in-servicing by 02/26/2023 in person or via the phone will be removed from the schedule until in-servicing is complete. - All contracted staff will complete in-servicing at the beginning of their first shift with the facility. All in-servicing will be included in the Agency Orientation packet. This in-servicing will be completed by the Charge nurse, ADON, SDC, or DON. - All new Signature staff will be in-serviced and educated during general employee orientation by the SDC or department manager. - The DON is responsible for the oversight of the Behavior Management program to include ensuring behaviors are identified, reported, communicated, monitored, and noncompliance is discussed in meetings, and effective interventions put in place. - The DON was educated on the DON responsibilities ************************************************************** On 02/26/2023 at 11:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 02/26/2023 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance. Review of RI #27's comprehensive care plans revealed the first care plan related to RI #27's noncompliance was created on 01/26/2023 by EI #15, the MDS/Care Plan Coordinator. This care plan documented: .Problem Start Date: 01/26/2023 Category: Behavioral Resident demonstrates non-compliance with physician orders and/or plan of care as evidenced by: continuing to vape in (his/her) room despite being asked not to . On 01/26/2023 at 3:57 PM, EI #15, the MDS/Care Plan Coordinator, was interviewed. When asked at what point RI #27 first demonstrated noncompliant behavior, EI #15 said since 11/15/2023, according to the progress notes. When asked what had been done to address the concern of noncompliance with the facility's non-smoking policy, EI #15 said they offered a nicotine patch, but RI #27 continued to vape, so the patch was discontinued. EI #15 confirmed RI #27's care plan addressing non-compliance with the facility's non-smoking policy was not initiated until 01/26/2023. When asked why a care plan had not been developed prior, EI #15 said she thought progress notes were effective enough. When asked when a care plan should have been initiated, EI #15 said on 11/15/2023, when RI #27's noncompliance was first noted. EI #15 said the risk of not developing a care plan would be harm to the resident. On 02/18/2023 at 11:00 AM, the surveyor conducted an interview with EI #2, the DON. When asked the safety risks associated with RI #27 smoking and vaping in the facility, EI #2 said fire and second hand smoke. When asked what interventions were currently in place to address RI #27's noncompliance with the facility's non-smoking policy, EI #2 said they were offering snacks of choice, a smoke detector in RI #27's room (initiated 02/13/2023), and an in-room sitter for RI #27 (initiated on 02/15/2023). EI #2 said prior interventions had not prevented RI #27 from continuing to be noncompliant, but indicated they had had no further instances since 02/13/2023. On 02/16/2023 at 3:52 PM, a telephone interview was conducted with EI #6, the Medical Director. EI #6 said he was notified in late December 2022 that RI #27 was vaping in the facility and in January 2023 was told it was still occurring. EI #6 was asked, in his medical opinion, what would be the dangers of vaping. EI #6 said there was a danger to people around the vape, just like second hand smoke. EI #6 said there could be chemicals in the vape like a cigarette. EI #6 said neither vapes or cigarettes should be smoked in a building or around other people. A follow-up interview was conducted with EI #6 on 02/19/2023 at 2:30 PM. EI #6 indicated he participated in a discussion in December 2022 regarding interventions that may help address RI #27's noncompliance with the facility's non-smoking policy. EI #6 said he did not recall making any suggestions, but they were trying to come up with options. EI #6 said the nicotine patch was discontinued due to RI #27 continuing to vape, and indicated medications for smoking cessation were not an option for RI #27. When asked what the facility could have done about RI #27 continuing to violate the facility's non-smoking policy, EI #6 said there were really only two options: one being to change the policy, which was not a good idea, or to find alternate placement that would be a better fit. EI #6 indicated that after multiple violations of the facility's non-smoking policy, they should have discussed transferring RI #27 out of the facility for his/her own well-being, as well as for the safety of others in the facility. When asked what approaches could have been attempted to prevent the continued noncompliance, EI #6 said they could have initiated the one on one (in-room sitter) sooner. This deficiency was cited as a result of complaint/report numbers AL00043096 and AL00043372. Based on interviews, record review, review of the facility's RESIDENT HANDBOOK & (and) admission DOCUMENTS, review of an article published by the United States Food and Drug Administration titled E-Cigarettes, Vapes, and Other Electronic Nicotine Delivery Systems (ENDS), and review of two reports to the State Survey Agency via the Alabama Department of Public Health Online Incident Reporting System, the facility failed to develop, implement, and revise effective person-centered safety interventions for Resident Identifier (RI) #27, a resident found to have multiple documented episodes of noncompliance with the facility's non-smoking policy dating back to 11/15/2022, including smoking inside the facility unsupervised and falling asleep with ENDS, also known as vapes, in his/her hand. On 02/06/2023, RI #27 was observed lighting a cigarette in the presence of Employee Identifier (EI) #22, a Certified Nursing Assistant (CNA), who then left the room and the resident unattended to notify EI #23, the Charge Nurse. When the Charge Nurse arrived to RI #27's room, she found a lighter, vape and a pack of cigarettes in RI #27's neck pillow. EI #23 also observed around three to four burned cigarettes in a cup on a table beside RI #27's bed. Seven days later, on 02/13/2023, while providing care, another CNA, EI #24, found a previously lit cigarette in RI #27's bed. EI #24 also found a cup on RI #27's over-the-bed table containing ashes and approximately three to five cigarette butts RI #27's behavioral care plan was not created until 01/26/2023, and did not address smoking cigarettes or provide guidance to staff on how to respond if RI #27 was found smoking or vaping. This deficient practice placed all 109 residents residing in the facility in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/24/2023 at 5:05 PM, the facility's Administrator, Employee Identifier (EI) #1 and the [NAME] President (VP) of Clinical Operations, EI #36, were provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F689-Free of Accident Hazards/Supervision/Devices. The immediate jeopardy began on 11/15/2022 and continued until 02/26/2023. Findings include: Cross Reference F656 and F867. On 01/18/2023, the State Survey Agency received an anonymous complaint via the Alabama Department of Public Health Online Incident Reporting System. This report indicated the facility was non-smoking, but RI #27 had fallen asleep while vaping and had 30 plus vapes and cigarettes confiscated. The complainant indicated these thing had been reported to the Administrator, EI #1, and the Director of Nursing (DON), EI #2, but nothing had been done. On 02/15/2023, the State Survey Agency received a second anonymous complaint via the Alabama Department of Public Health Online Incident Reporting System. This report indicated RI #27 was smoking in his/her room. The report further indicated RI #27 had cigarettes and a lighter, which was recently found in his/her pillow case and taken away. The complainant alleged these concerns were reported to EI #1, the Administrator, and EI #2, the DON, but RI #27 continued to smoke in his/her room. Review of an undated article published by the United States Food and Drug Administration (FDA) titled E-Cigarettes, Vapes, and Other Electronic Nicotine Delivery Systems (ENDS), revealed the following: .E-cigarette Problems and Potential Violations There are no safe tobacco products, including ENDS. In addition to exposing people to risks of tobacco-related disease and death, FDA has received reports from the public about safety problems associated with vaping products including: Overheating, fires, and explosions Lung injuries Seizures and other neurological symptoms . These problems can seriously hurt the person using the ENDS product and others around them. The facility's RESIDENT HANDBOOK & admission DOCUMENTS, revised 08/01/2021, documented the following: . Certain Items Are Not Allowed In Your Room, Ever. Any type of smoking or vaping materials or items, including lighters. Smoking Our Facility is (a) smoke-free facility . RI #27 was admitted to the facility on [DATE] with diagnoses to include Depression, Bipolar Disorder, Anxiety Disorder, Muscle Weakness, Lack of Coordination, Seizures, and Hemiplegia (paralysis of one side of the body) affecting Dominant Side. RI #27's most recent quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/22/2022, revealed RI #27 scored a 14 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #17, a Licensed Practical Nurse (LPN) providing care for RI #27 on the 6 AM - 6 PM shift: . 11/15/2022 8:40 (8:40 AM) . While returning to resident's room to update (him/her) on (his/her) labs staff discovered (him/her) with a vape in (his/her) hand. (He/She) quickly attempted to tuck it into the folds of (his/her) arms but handed it over, without any issues, when staff requested the vape. Staff notified DON of issue at 8:39 AM. Currently awaiting any instruction for further action . 11/15/2022 13:33 (1:33 PM) .Upon entering room staff noticed an orange object in resident's left hand. When asked to show staff (his/her) hands resident attempted to hide the object underneath (him/her). (He/She) eventually grabbed the object after staff asked three times and staff noticed it was another vape. Staff confiscated another vape for the second time today, notifying DON and administrator. After confiscating first vape staff was instructed to notify (Medical Director, EI #6) of resident smoking in (his/her) room and to request order for Nicorette patches or gum. MD notified but no response has been received . 11/15/2022 16:44 (4:44 PM) Resident was under the impression that (he/she) would be able to go outside to smoke. Staff informed resident that, per administrator, the facility is 100% smoke free and (he/she is) unable to go outside to smoke. (He/She) informed staff that (he/she) had cigarettes in (his/her) room in addition to the two vapes that were confiscated earlier during the shift. (He/She) surrendered (his/her) cigarettes without and (any) issues but told staff that (he/she) wants to be able to have them back when (he/she) goes out for doctor's appointments or with family. Staff informed (him/her) that (his/her) request would be discussed with management . 11/19/2022 11:49 (11:49 AM) .Resident was asleep in bed and unable to (be) awakened. Staff noticed vape cartridge in resident's hand as (he/she) slept. Attempted to awaken resident to request the vape and re-enforce no smoking policy. Due to failed attempts to awaken resident staff managed to remove vape form (from) resident's hand as (he/she) slept. After confiscating vape staff notified DON and administrator of the issue at hand . 11/24/2022 12:07 (12:07 PM) Offgoing nurse informed staff of resident vaping in room prior to shift change . Staff informed MD (medical doctor) of resident's continued vaping . 11/29/2022 14:30 (2:30 PM) Staff went to respond to resident's call light. Upon entering resident's room staff found (RI #27) sitting on the edge of (his/her) bed vaping. Resident did not notice staff until (he/she) was asked to hand over the vape. Resident asked staff to let (him/her) keep the vape. (He/She) was informed, once again, that Signature Healthcare is a smoke free facility. (He/She) then asked if staff could pretend she didn't catch vaping and just allow (him/her) to put it away. Staff informed (RI #27) that we could not do that and the vape must be taken and reported. (He/She) handed staff the vape without any issues . After leaving resident's room staff reported to DON . 12/07/2022 13:50 (1:50 PM) Resident had a visitor earlier during the shift. Staff noticed (RI #27) completing a list of things that (he/she) wanted (his/her) guest to purchase for (him/her). After the guest exited (RI #27's) room nursing staff introduced herself and asked for the guests name. (RI #27's guest) was educated on the no smoking policy being enforced at the facility and explained that guests are not allowed to bring cigarettes or vapes into the facility on resident's behalf. She stated that she does not ''buy those kinds of things. I only buy (him/her) snacks, drinks and other junk food. Several hours later staff found a vape in (RI #27's) top bedside drawer tucked inside a sock. Vape was handed to the administrator who informed staff to take another peek while (he/she is) not in (his/her) room to see if (he/she) had any other vaping devices. After inspecting resident's room further staff found a brown paper bag containing four more vaping devices. The brown bag was turned into DON before resident returned to (his/her) room . 12/21/2022 9:06 (9:06 AM) During morning med pass staff entered resident's room to find (him/her) asleep with a vaping device in (his/her) hand. Staff attempted to awaken resident to administer medications and remove vape from resident's room. However, after several attempts, resident continued sleeping. Staff removed vaping device from resident's hand and allowed (him/her) to continue resting undisturbed . 12/27/2022 10:55 (10:55 AM) . Upon entering resident's room (he/she) quickly tucked something inside (his/her) gown. When asked if (he/she) was vaping (he/she) immediately said no. But, when asked to remove the object (he/she) had just hidden, (he/she) removed a vaping device from the roll of (his/her) gown. Staff removed vape and reported the event to DON and administrator . 12/27/22 16:28 (4:28 PM) Upon entering resident's room staff found (him/her) with a vape in (his/her) hand. Staff held out hand for (him/her) to hand it over. (He/She) complied but became belligerent . Staff took the second vape today to the DON and reported what had transpired . 12/28/2022 15:00 (3:00 PM) (EI #31), CNA, went into resident's room and discovered (him/her) in bed with a vaping device. She confiscated the vape and turned it in to the administrator . 12/31/2022 16:12 (4:12 PM) Staff found resident sleeping with vape on (his/her) stomach during morning med pass. Vape removed from (his/her) possession and DON notified of findings . 01/05/2023 11:48 (11:48 AM) Resident found sleeping with vape in (his/her) hand this morning when staff went into (his/her) room during med pass . 01/14/2023 9:48 (9:48 AM) During morning med pass resident was found asleep with a vape in (his/her) hand. (He/She) handed it to staff without any issues. Within an hour staff went into the room . While passing (RI #27's) bed staff noticed (him/her) asleep with another vape in (his/her) hand. Staff called out to (him/her) to ask (him/her) to hand over the vape. (He/She) then stated Why did you come back in here to bother me again? Staff explained that while providing care to (his/her) roommate another vape was spotted in (his/her) hand when glancing at (him/her). (He/She) then stated Well don't look at me then. I can't afford to keep buying these things. (He/She) handed staff the second vape without any issues. Findings were reported to DON and administrator . 01/19/2023 9:06 (9:06 AM) During morning med pass staff saw a vaping device inside of (RI #27's) neck pillow. (He/She) handed staff the device without any issues. Vape turned in to DON . 01/19/2023 17:41 (5:41 PM) Second vaping device removed from resident's room prior to shift change . On 02/19/2023 at 9:05 AM, an interview was conducted with EI #17. EI #17 said 11/15/2022 was the first time she recalled seeing RI #27 with a vape. EI #17 confirmed multiple occurrences of finding vapes and a pack of cigarettes in RI #27's possession. When asked if she also found a lighter at the time she found cigarettes, EI #17 said she did not see one at that time, but had not looked. EI #17 said she thought a lighter was found in RI #27's room at a later time. EI #17 indicated she reported all findings of vapes and cigarettes and turned the items in to the DON or the Administrator and documented them in RI #27's progress notes. When asked if EI #1 and EI #2 gave her further instructions on how to address RI #27's noncompliance each time they were notified, EI #17 said she was told to continue providing education on Signature Healthcare of Whitesburg Gardens being a smoke-free facility, which she was already doing, and to confiscate the vapes and document what had been done. EI #17 also indicated she was instructed to search RI #27's room on only one occasion in December 2022, but was not provided any instructions or training on how to conduct the search. On 02/19/2023 at 1:34 PM, a telephone interview was conducted with EI #31, the CNA that found a vape in RI #27's possession on 12/28/2022. EI #31 said on that day she was walking down the hall and smelled a fruity smell. EI #31 said she walked in RI #27's room and saw RI #27 laying there with eyes closed with a vape on his/her chest. EI #31 said when she touched RI #27, RI #27 immediately opened his/her eyes. EI #31 said she informed RI #27 this was a non-smoking facility and he/she was not supposed to have the vape. EI #31 said she went and informed EI #17 and also notified EI #1 and EI #2. EI #31 said she had personally confiscated three vapes off of RI #27. EI #31 recalled one day when RI #27 was in his/her room vaping and blowing the smoke out of his/her nose and mouth, blowing it everywhere. The surveyor asked EI #31 if she thought RI #27 understood the risk of vaping and smoking in the facility. EI #31 said she thought RI #27 did know the risks, but RI #27 was just going to do what he/she wanted to do. When asked if she had ever been in-serviced on what to do if she saw any vapes, cigarettes or lighters in RI #27's room, EI #31 said staff had been told to take them from RI #27 and turn them in to EI #1 and EI #2. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #26, an LPN providing care for RI #27 on the 6 PM - 6 AM shift: . 11/24/2022 4:56 (4:56 AM) At approx. (approximately) 0430 (4:30 AM), CNA notified the nurse of a resident having a vape in (his/her) hand holding it, the nurse went to the resident's room and turned on the light and the resident had (his/her) back turned away from the door towards #B bed with a vape in (his/her) hand up to (his/her) face, the nurse asked (him/her) what does (he/she) have in (his/her) hand? and asked for the vape which was warm to touch, nurse once again educated the resident on smoking in the facility and smoking while having a nicotine patch on (him/her) person, resident . just shrugged (his/her) shoulders, nurse notified DON and attempted to notify MD of the above and no answer of the phone will have on coming nurse to notify MD . 01/07/2023 18:34 (6:34 PM) CNA informed this nurse of the resident lying in bed with (his/her) hand on (his/her) chest, holding a va[TRUNCATED]

Based on interviews, review of a policy titled Quality Assurance/Performance Improvement (QAPI) Program Policy, and review of the facility's 12/23/2022 and 01/25/2023 QUALITY PERFORMANCE/PEER REVIEW FACILITY PLAN OF ACTION/CONTINUOUS QUALITY IMPROVEMENT, the facility's QAPI committee failed to thoroughly implement the 12/23/2021 and 01/25/2023 action plans, which included an action item for laundry staff to monitor residents clothing to evaluate for burn holes, soot, and evidence of smoking. This failure placed all 109 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death, due to the ongoing resident safety risk and fire hazard. On 02/24/2023 at 5:05 PM, the facility's Administrator, Employee Identifier (EI) #1 and the [NAME] President (VP) of Clinical Operations, EI #36, were provided a copy of the immediate jeopardy template and notified of the immediate jeopardy findings in the area of Quality Assurance and Performance Improvement (QAPI), F867-QAPI/Quality Assessment and Assurance (QAA). Findings include: During the survey, document review and interviews with staff revealed Resident Identifier (RI) #27 had multiple documented episodes of non-compliance with the facility's non-smoking policy, including vaping and smoking in his/her room and hiding vaping and smoking materials from facility staff. This noncompliance was documented to have occurred from 11/15/2022 through 02/13/2023, despite repeated education to RI #27 on the facility's non-smoking policy. Cross reference F656 and F689. The facility policy titled Quality Assurance/Performance Improvement (QAPI) Program Policy, reviewed and revised 10/19/2022, documented: PURPOSE STATEMENT: To provide a process that will enhance the care and experience for all residents . POLICY STATEMENT: It is the intent of the facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate and improve the quality and appropriateness of resident care. QAPI supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improving the organization's overall performance with addressing care and management systems. DEFINITIONS . Quality Assurance and Performance Improvement (QAPI) is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and date-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical and creative problem solving. Quality Assurance (QA) is the specification of standards for quality of service and outcomes, and systems throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is ongoing, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards. Performance Improvements (PI) (also called Quality Improvement- QI) is the continuous study and improvement of processes with the intent to improve services or outcomes and prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systematic problems or barriers to improvement . GUIDELINES . 6. The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes. 7. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. 12. Based on audit findings, plans will be developed, and tasks assigned to appropriate Stakeholders to include required completion dates. The facility's 12/23/2022, QUALITY PERFORMANCE/PEER REVIEW FACILITY PLAN OF ACTION/CONTINUOUS QUALITY IMPROVEMENT, documented: PROBLEM AREA IDENTIFIED: Problem/Opportunity: Resident not compliant with No Smoking policy . 4-Step Action Plan: . 2. Measures put in place and systemic changes you will make to ensure the deficient practice does not reoccur: .Laundry to monitor residents clothing to evaluate for burn holes, soot, evidence of smoking . There was no DATE COMPLETED listed on this action plan. The facility's 01/25/2023, QUALITY PERFORMANCE/PEER REVIEW FACILITY PLAN OF ACTION/CONTINUOUS QUALITY IMPROVEMENT, documented: PROBLEM AREA IDENTIFIED: Problem/Opportunity: Resident not compliant with No Smoking policy . 4-Step Action Plan: . 2. Measures put in place and systemic changes you will make to ensure the deficient practice does not reoccur: .Laundry to monitor residents clothing to evaluate for burn holes, soot, evidence of smoking . There was still no DATE COMPLETED listed on this action plan. An interview was conducted with EI #32, Laundry Attendant, on 02/21/2023 at 4:55 PM. EI #32 stated she had not been told anything about observing RI #27's clothing when they come to the laundry. An interview was conducted with EI # 33, Laundry Aide, on 02/22/2023 at 9:51 AM. EI #33 stated she was not informed to observe RI #27's clothes for burn holes and soot until the day before, 02/21/2023. An interview was conducted with EI #34, Laundry Aide, on 02/22/2023 at 10:42 AM. EI #34 stated she was not told anything about monitoring RI #27's clothes. An interview was conducted with EI #21, Laundry Supervisor, on 02/22/2023 at 12:28 PM. When asked what she was told regarding RI #27's clothing, EI #21 stated she was instructed to check for holes and burn marks for all residents, not just RI #27. EI #21 said the Administrator, EI #1, and EI #2, Director of Nursing (DON), told her to do this during a safety meeting, she believed was about a month prior. EI #21 also stated she was told to instruct her workers to make sure they check for holes in clothes. When asked to provide the documentation of where she informed or educated her staff on the need to do this, EI #21 provided documentation of education dated the day prior, 02/21/2023. An interview was conducted with EI #1, the Administrator, on 02/16/2023 at 11:39 AM. EI #1 stated QAPI first discussed RI #27's noncompliance with the facility's non-smoking policy during the 12/23/2022 QAPI meeting. She stated the team discussed interventions they were working on to try to get RI #27 to comply with the policy and they were trying to identify the source of RI #27's vaping and smoking materials. EI #1 said QAPI next discussed RI #27 during the 01/25/2023 QAPI meeting. A follow-up interview was conducted with EI #1 on 02/17/2022 at 1:39 PM. During the interview, EI #1 acknowledged the QAPI committee failed to identify RI #27 did not have a care plan addressing the continued noncompliance with the facility's non-smoking policy. Another interview was conducted with EI #1 on 02/23/2023 at 4:31 PM. EI #1 stated EI #21, the Laundry Supervisor, was responsible for informing her laundry staff they were to look for burn holes, soot and evidence of smoking. When asked when laundry staff had been informed, EI #1 said she did not recall EI #21 saying staff had been inserviced, but she was of the impression EI #21 had told them. When asked why laundry staff were reporting they had not been told, EI #1 said she did not know. EI #1 said EI #21 should have educated her staff after the 12/23/2023 QAPI meeting. EI #1 indicated inservice records related to monitoring RI #27's clothing for burn holes, soot and evidence of smoking would be evidence staff were informed. When asked the importance of monitoring clothing for burn holes, soot or evidence of smoking, EI #1 said it would help determine if the resident had been smoking in his/her room and could indicate a risk of causing harm. EI #1 stated she was the one responsible for ensuring the facility's QAPI action plan was fully implemented, and indicated they should have gone through each item on the action plan to ensure everything was being done. This deficiency was cited as a result of complaint/report numbers AL00043096 and AL00043372. ***************************************************** The facility submitted an acceptable Removal Plan on 02/26/2023 for F867 that outlined the following: 1. Four laundry staff were educated by the HCSG housekeeping supervisor on 02/23/2023 to look for burn holes, soot, and evidence of smoking. The HCSG Housekeeping/Laundry District Manager re-educated six laundry staff and the HCSG housekeeping supervisor on 02/25/2023 to look for burn holes, soot, and evidence of smoking. The HCSG Housekeeping/Laundry District Manager educated the HCSG Housekeeping supervisor on her responsibilities for training laundry staff and monitoring residents' clothing for damage and other reasons such as cigarette burns. This was completed on 02/25/2023. 2. All residents have the potential to be affected. The QAPI committee meet on 02/22/2023 to assess and revise action plans to promote resident safety due to RI #27's noncompliance with the facility's nonsmoking policy. 3. The [NAME] President of Clinical Operations (VPCO) educated members of the QAPI Committee (Administrator, Medical Director, DON, MDS coordinator, Maintenance Director, Registered Dietician, Business Office Manager (BOM), Admissions Coordinator, HCSG Housekeeping and Laundry Supervisor, SDC, Life Enrichment Director, and Assistant Business Office manager) on 02/24/2023 and 02/25/2023, regarding the QAPI process. - The education was to ensure the facility's QAPI committee understands the importance of developing and implementing effective plans to ensure problems are corrected, reducing residents' risk for safety and hazards. This was completed on 02/24/203 and 02/25/2023. The QAPI team analyzed data from the citations, audits, and interviews to ensure effective plans and interventions are in place. - The Quality Assessment and Assurance Committee (QAPI) meeting was held on 02/24/2023 and 02/25/2023, to complete a systematic, interdisciplinary, comprehensive, root cause analysis of the performance improvement action plans related to the Non-Smoking policy, Care Planning behaviors, Behavior Health policy, Accidents, and Supervision, Contraband Policy, QAPI, and non-compliant smokers process to reduce the risk of a hazard related to a fire. This included education provided by the VPCO. - On 02/24/2023 and 02/25/2023 the QAPI committee consisting of the Administrator, Medical Director, DON, MDS coordinator, Maintenance Director, Registered Dietician, Business Office Manager (BOM), Admissions Coordinator, HCSG Housekeeping and Laundry Supervisor, SDC, Life Enrichment Director, and Assistant Business Office manager led by the VPCO evaluated the effectiveness of the action plans for non-compliant smokers and developed a plan of correction addressing if necessary additional education and additional audits required. - The Plan of correction for QAPI (F867) is to review all action plans related to F656, F689, F740, F835, F837, and F867 and use root cause analysis to determine the effectiveness of the action plans and revise the plans with different interventions and approaches when compliance is not achieved for the established thresholds. Based on audit findings, plans will be developed, and tasks assigned to appropriate Stakeholders to include required completion dates. The Administrator provides oversight to the QAPI committee and program. The Administrator was trained on 02/24/2023 by the VPCO on the QAPI Program Policy. ********************** On 02/26/2023 at 11:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 2/26/2023 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.