Based on observation, interview, and record review, the facility failed to ensure eight out of eight sampled residents were safe from fire when one resident (Resident 9) was permitted to smoke in an area that had no immediate access to fire extinguishing equipment, cigarettes were being disposed of in a trashcan that contained paper, the resident had not been assessed to be safe to smoke unsupervised and the resident kept his smoking materials in his room. This failure had the potential for smoking materials to ignite a fire that could cause serious harm or death due to burns or smoke inhalation. On 8/19/19 at 6:15 p.m., due to the facility's failure to maintain a safe smoking area for residents and ensure residents were assessed to be safe to smoke unsupervised, Chief Nursing Officer was notified verbally and in writing of Immediate Jeopardy. The Health Facilities Evaluator Nurses informed Chief Nursing Officer (CNO) of the survey team's findings that the resident smoking area had no equipment for extinguishing fire, no safe receptacle for cigarette disposal, the smoking resident had no documentation he had been assessed to be safe to smoke unsupervised or an order to smoke, and the resident was keeping his cigarettes and his lighter in his room. Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident (Standard Operation Manual, Appendix Q). On 8/19/19 at 1:52 p.m., the facility presented an acceptable corrective plan of action, including but not limited to: 1) placing a suitable cigarette receptacle in the smoking area, 2) mounting a fire extinguisher on the wall adjacent to the smoking area and ordering a fire blanket, 3) keeping residents' cigarettes and lighters locked in the medication room, 4) obtaining a physician order for the resident to smoke and having the physician complete a social assessment that he has been deemed safe to smoke unattended. On 8/21/19 at 10:35 a.m., the abatement (lifting) of Immediate Jeopardy occurred in the presence of Chief Executive Officer after interviews, observations, and record review confirmed the facility implemented the corrective plan of action. On 8/21/1 at 2:35 p.m., Director of Nursing was notified of substandard quality of care identified and that the facility was on extended survey. Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 483.25 Quality of Care that constitute to immediate jeopardy to resident health or safety (level J, K, or L) (Standard Operation Manual, Appendix PP). Findings: During an interview on 8/19/19 at 2:12 p.m., Resident 9 stated he smoked every once in a while. Resident 9 stated he could go out whenever he wanted to, no staff go out with him, he just has to sign out in the book at the nurses' station. When asked where he kept his cigarettes and lighter, Resident 9 stated he kept his own cigarettes and lighter in his room. During an observation on 8/19/19 at 2:51 p.m., Resident 9 was outside smoking on the backside of the building between the cinderblock wall of the facility and the cement retaining wall of the parking lot. Cement walkways led to and from the smoking area, which was under the overhang of the building. No fire extinguisher or fire blanket were in the vacinity, and Resident 9 was not wearing a smoking apron. No ashtray was present in the smoking area. Around the corner, approximately 20 feet from where Resident 9 was sitting, was a trashcan with a clear plastic liner that was half hanging down into trashcan obstructing view of what was inside. Muliple cigarette butts were on the ground surrounding the trashcan. During an observation and concurrent interview on 8/19/19 at 3:15 p.m., Licensed Nurse A confirmed the area where Resident 9 was smoking was the designated smoking area. Licensed Nurse A confirmed there was no fire extinguisher or fire blanket, and no ashtray for cigarette disposal. Licensed Nurse A looked in the trashcan around the corner from the smoking area and stated there were cigarette butts in there. Licensed Nurse A stated he was not aware that there was no equipment in the smoking area to put out a fire if the trashcan or the residents' clothes caught on fire. When asked the location of the nearest fire extinguisher readily available, Licensed Nurse A walked down the path, inside the front lobby, down the hall to the left past the nurses' station before he found one in an alcove. Licensed Nurse A confirmed it was not close to the smoking area. A fire extinguisher was noted down the hall next to the emergency exit near the smoking area, but Licensed Nurse A stated the emergency exit door was locked from the outside. Licensed Nurse A pointed out there was a fire extinguisher across from the nurses' station, which he had not noticed and walked past initially. The fire extinguisher across from the nurses' station was behind a plate of glass that indicated, In Case of Fire, Break Glass. When asked if Resident 9 had signed any kind of consent or waiver related to smoking, Licensed Nurse A searched in Resident 9's medical record, but stated he was unable to find one. Review of facility policy titled Smoking Policy for In-Patients and Residents, dated 4/5/18, revealed, 2. It is necessary that a written order to smoke be placed into the resident/patient chart by the physician. 5. Any smoking products; matches, lighters, pipes, cigars, cigarettes must be kept locked in the medication room in a defined place with resident/patient name. During a record review and concurrent interview on 8/19/19 at 4 p.m., when asked if Resident 9's lighter and cigarettes were in the medication room, Licensed Nurse A stated no, they are in Resident 9's room. Licensed Nurse A reviewed the smoking policy and confirmed it indicated they are to be kept in the medication room. Licensed Nurse A stated he had not known that. When asked if Resident 9 had an order to be allowed to smoke, Licensed Nurse A searched in Resident 9's medical record, and stated no, he does not have one. During an observation on 8/19/19 at 4:57 p.m., the trash can in the smoking area contained wadded up napkins, papers, paper drink cups and approximately 30 to 40 cigarette butts. During an interview on 8/19/19 at 5:10 p.m., Chief Nursing Officer (CNO) stated she did not know if Resident 9 had an assessment done to determine if he was safe to smoke unsupervised. She stated she saw that Resident 9 did not have a physician's order to smoke. CNO stated if the facility policy says he should have a physician's order, then she expectated him to have one. When asked about resident supervision during smoking, CNO stated, There's no direct supervision, [the residents] just let staff know they're going out to smoke, and they go out with no direct supervision. When asked about a cigarette receptacle, CNO stated there used to be a receptacle with sand in it. She stated, It's supposed to be out there. When asked how a fire in the smoking area would be extinguished, CNO stated, We would use an extinguisher from the hallway here or a blanket from the linen closet. When asked where Resident 9's cigarettes and lighter are kept, CNO stated, I was told today that they are in his room. They are supposed to be kept in the narcotic room in his specific bin. During an interview on 8/22/19 at 10:58 a.m., Chief Executive Officer (CEO) stated he did not know if there was a safety plan in place for the smoking area at the facility. When asked if it was anyone's responsibility to monitor the smoking area for a cigarette receptacle, CEO stated not that he was aware of. He stated prior to 8/19/19, he was not aware of what the situation was out there (the smoking area). In response to a request for the facility policy on resident safety, facility policy titled Patient and Staff Safety Plan, dated 4/26/18, was provided. The policy statement indicated, It is the policy of [facility named] to provide a safe environment for patients, visitors, and staff.