Based on observation, interview, record review, and facility policy review, the facility failed to ensure the safety and well-being for 1 (Resident #37) of 1 sampled resident reviewed for smoking. Specifically, the facility failed to failed to implement further interventions to ensure the safety of the resident and others when the resident continued to smoke after there was indication that the resident agreed to smoking cessation and failed to implement interventions when the resident refused to turn in their lighter. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.25 (d) Accidents, at a scope and severity of J. On 03/12/2025 at 4:38 P.M. the Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy situation. Findings included: A facility policy titled, Smoking Policy- Residents, revised 08/2022, revealed, This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. The policy specified, 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc. [et cetera, and other similar things]); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. 13. Residents are not permitted to give smoking items to other residents. 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. An admission Record revealed the facility admitted Resident #37 on 12/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia, delirium due to known physiological condition, and nicotine dependence. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. An admission Nursing Assessment, dated 12/12/2024, revealed Resident #37 was a current smoker and the assessment directed staff to complete a smoking assessment. Resident #37's Care Plan Report included a focus area initiated 12/13/2024, that indicated the resident had a heightened safety risk related to confusion and a personal desire to smoke. Interventions directed staff to apply protective non-flammable apron or cover/barrier during smoking activity (initiated 12/13/2024), keep the resident's cigarettes (initiated 12/13/2024), and keep the resident's lighter(s) (initiated 12/13/2024). Further review of the Care Plan Report included a focus area initiated 01/31/2025, that indicated the resident was noted to smoke used cigarettes found on the ground. Interventions directed staff to post cigarette times in the resident's room (initiated 01/31/2025); explain the risks and benefits to the resident, including the risk of infection (initiated 01/31/2025); and indicated that the resident refused to give staff their lighter (initiated 02/10/2025). Resident #37's Medical Professional Note, dated 12/13/2024, indicated for the resident's diagnosis of tobacco abuse, the resident was counseled and advised to quit and the impact of smoking cessation was discussed in detail. Per the Medical Professional Note, several options, to include patches and gums, medication management, relaxation techniques, and to avoid the company of other smokers were discussed with resident. Resident #37's Smoking - Initial Assessment, dated 01/31/2025, indicated the resident was a smoker with cognitive loss, who smoked two to five times per day. Per the Smoking - Initial Assessment, the resident required a smoking apron and supervision. The Smoking - Initial Assessment indicated the facility stored the resident's smoking materials and a plan of care was used to ensure the resident was safe while smoking. During an interview on 03/14/2025 at 1:09 PM, the MDS Coordinator stated she completed the initial smoking assessment for Resident #37 on 01/31/2025 and verbally communicated with the staff about the care plan interventions on that day, but the communication was not documented anywhere. During an interview on 03/11/2025 at 8:52 AM, the DON stated residents had an initial assessment completed, a smoking safety assessment, an evaluation of whether the resident smoked or not, and a care plan would be completed if the resident smoked. She stated the assessments were completed by the charge nurse The DON stated from what she remembered, Resident #37 was not a smoker initially. She stated that around January 2025, staff observed the resident gathering cigarette butts and trying to smoke them and that was when staff realized the resident smoked, so staff assessed the resident as a smoker at that time. Resident #37's Activities-Progress Notes, dated 03/03/2025 at 10:30 AM, revealed activities staff witnessed Resident #37 smoking on the back patio during a non-smoking time. The note indicated the resident had a lighter, and the activities staff member notified the resident of the designated smoking times and asked the resident to turn in their lighter. The note indicated the resident refused to turn their lighter in to the activities staff member. Resident #37's Activities-Progress Notes, dated 03/04/2025 at 11:30 AM, revealed an activities staff member spoke with Resident #37 and notified them of the facility's smoking policy. According to the note, the resident refused to sign a copy of the smoking policy that was discussed with them. Resident #37's Administrator Notes, dated 03/04/2025 at 4:11 PM, revealed the Administrator contacted the Ombudsman regarding Resident #37's noncompliance with care and smoking. The note indicated the facility received verbal consent to the facility's admission agreement, which included the smoking policy, from Resident #37's family. According to the note, the Administrator informed the resident if they wanted to smoke, they must follow the facility's smoking policy. The note indicated the Administrator informed the resident that if they desired unlimited smoking freedom, then a discharge to another location may be best for the resident. According to the note, the Administrator informed the Ombudsman that Resident #37 was a potential risk to themself or other residents if their noncompliance continued. Per the note, at the recommendation of the Ombudsman, the Administrator agreed to seek discharge for the resident. Resident #37's Activities-Progress Notes, dated 03/05/2025 at 10:36 AM, revealed an activities staff member witnessed Resident #37 smoking outside of the door which led to the back patio. The note indicated the staff member advised the resident they could not smoke outside of the designated times and asked the resident to extinguish their cigarette, but the resident refused and continued smoking until the resident was finished. Resident #37's Activities Progress Note, dated 03/10/2025 at 6:33 PM, indicated the Activity Supervisor was outside sweeping the designated smoking area when Resident #37 came outside looking for cigarette butts. According to the note, the Activity Supervisor explained the facility's smoking policy to the resident and informed the resident they could not pick up cigarette butts from the ground. The note indicated Resident #37 became agitated and attempted to swing at the staff member, then cursed and walked back into the building. Per the note, the Administrator and DON were notified. During a concurrent observation and interview on 03/10/2025 at 3:27 PM, Resident #37 removed a butane cigarette lighter out of their jacket. Resident #37 stated they went outside to smoke by their self whenever they wanted to. During a concurrent observation and interview on 03/10/2025 at 3:43 PM, the surveyor noted Resident #37 wore a gray hospital gown that had multiple brown holes visible through the fabric. There were two small holes near the mid chest area on the left side, one small hole on the left upper chest area, and one dime size hole near the resident's right leg. Resident #37 stated the holes in their gown was from cigarette ashes but was unable to remember when the holes occurred. The resident stated they did not use a smoking apron. During an interview on 03/10/2025 at 3:53 PM, Certified Nursing Assistant (CNA) #5 stated Resident #37 was independent and refused care. CNA #5 stated the resident went outside with activities staff when they wanted to smoke. She stated that she believed staff knew that the resident smoked, but the resident wandered around and went by their self. During an interview on 03/10/2025 at 4:17 PM, Licensed Vocational Nurse (LVN) #6 stated she had no idea how the resident got the burn holes on their gown. LVN #6 stated she was unsure if the resident smoked. During an interview on 03/11/2025 at 2:24 PM, Activity Staff (AS) #1 stated she witnessed Resident #37 go smoke a couple of times and she tried to get them to sign a smoking policy, but the resident refused. She stated she told the resident that smoking could not be done outside of designated smoking times. AS #1 stated the resident had their own lighter, and the cigarettes were obtained from the ash tray or off the ground on the back patio, where everyone smoked. She stated the resident refused to give her their lighter and then she reported it to the Administrator. She stated that the incident occurred at the end of February 2025 or the beginning of March 2025 and that she had not seen the resident smoke prior to that incident. During an interview on 03/11/2025 at 8:52 AM, the DON stated that once a resident was identified as a smoker, the resident was not to have their cigarettes or lighter because it was a safety issue. She stated if they were found with a cigarette or a lighter, then it would be removed, and education provided. The DON stated if a resident refused to follow the policy, then a discharge notice would be provided to the resident. During an interview on 03/15/2025 at 1:36 PM, the DON stated there should have been additional interventions implemented at the time Resident #6 had a lighter on 02/10/2025, to include removal of the lighter, education to the resident, and supervision of the resident. During an interview on 03/11/2025 at 9:13 AM, the Administrator stated residents were assessed by nursing staff at admission to determine their desire to smoke. He stated there was a smoking area with designated times, and the activities staff took the residents who smoked to the designated area. The Administrator stated he was not aware that Resident #37 had burn areas on their gown. The Administrator stated the Ombudsman was contacted regarding the resident's smoking. During an interview on 03/13/2025 at 4:06 PM, the Administrator stated a discharge notice had not been issued to Resident #37 yet, as a safe placement had to be identified before the resident could be discharged . During an interview on 03/14/2025 at 8:58 AM, the Administrator stated that prior to Monday, 03/10/2025, the interventions staff implemented was that a smoking assessment was completed for Resident #6, monitoring was completed by nursing staff each shift, the facility attempted to get the resident to sign the smoking agreement a few times, and discharge had been discussed with the Ombudsman in February 2025 and on 03/04/2025. On 03/14/2025 at 10:08 AM, a Removal Plan was submitted by the facility and accepted by the State Agency. It read as follows: 1. Immediate Smoking Assessments: a. As of 03/12/2025, all five identified residents who smoke were immediately assessed for safety risks, including cognitive impairment and ability to handle smoking materials safely. Residents were identified based on their current desire to smoke. The resident smoking assessment titled, Resident Smoking Initial Assessment, was completed by the Director of Nursing on 03/12/2025 for the five residents identified. The assessments were completed, and the residents' care plans were updated accordingly on 03/12/2025 by the Director of Nursing. b. The active smoker list was updated on 03/12/2025 to included Resident #37. c. All residents were previously assessed on admission for a desire to smoke. All new residents will be assessed on admission if they have a desire to smoke. This will be completed by admitting nurse. d. All five identified residents were re-educated by the Director of Nursing on the risk vs benefit of following the smoking policy on 3/12/25. e. All other necessary interventions including supervised smoking, appropriate storage of smoking materials, smoking in designated areas, and offering of aprons were implemented immediately on 3/12/25. 2. Immediate Supervision Implementation: a. The smoking program was reviewed on 03/12/2025 for resident safety by the interdisciplinary team including the Administrator, Activities Director, Director of Nursing, Medical Records Director, Director of Staff Development, Social Services, and the Medical Director. b. Staff were educated on 03/12/2025 by the Director of Staff Development. Staff education included nurses, nurse assistants, activity assistants, department heads, dietary, administration, and housekeeping. Education included how to ensure smoking activities occur in designated, supervised areas to prevent unsupervised smoking and reduce fire hazards. Additionally, staff were trained on the importance of supervision and monitoring of smoking residents, including the prevention of unsafe practices. Education will be ongoing with an expected completion of all staff by 03/14/2025. Education will be conducted by the Director of Staff Development or designee. Any additional staff or new staff will be given a one on one education prior to start of shift. c. Training on the importance of supervision and monitoring of smoking residents, including the prevention of unsafe practices will be provided for all new hires by Director of Staff Development as part of the orientation process. 3. Restriction of Smoking Materials: a. Any potentially dangerous items, including lighters or cigarettes, have been removed from residents' rooms. This was completed on 03/12/25 by Activity Director b. A lighter was removed from Resident #37's room on 03/10/2025 at 5 :00 PM by CNA. c. On 03/12/2025, all rooms were visually inspected, and residents were asked for any smoking paraphernalia. There was no additional smoking paraphernalia. This was completed on 3/12/25 by Activity Director d. The Activities Director will conduct a monthly sweep visually inspecting all resident rooms and asking for smoking paraphernalia. The Activity Director was educated to this responsibility on 03/13/2025 by the Administrator and Director of Nursing e. All Staff including nurses, nurse assistants, activity assistants, department heads, dietary, administration, and housekeeping educated by the Director of Staff Development on 03/13/2025 that staff who identify smoking paraphernalia should report it to Administrator or designee. All staff off site were educated via phone by department heads, administrator or designee on 3/13/25 and 3/14/25. 4. Revised Smoking Policy and Agreement Enforcement: a. A smoking agreement has been reintroduced and enforced for all residents who smoke, with clear guidelines about safe smoking practices, supervision, and the need to follow all facility policies. The smoking agreement was revised to better match the facility's smoking policy and procedure. A revision was made indicating that aprons are offered and strongly encouraged based on assessment, instead of requiring an apron to be eligible for the smoking program. b. Residents have the right to refuse smoking apron. Staff will continue to offer and encourage the apron. In the event of a refusal, the resident will be educated on the risk vs. benefit of the apron use. The resident will be provided supervision during smoking by Activity aide or designee during smoke break. Fire blanket and fire extinguisher are available in smoking area. c. Staff assisting residents who refuse to wear apron will notify the Activity Director or designee. Activity aides were trained on 3/13/25 by Activity Director. The Activity Director or designee will bring this to the attention to the interdisciplinary team during the interdisciplinary team meeting. This will then be care planned by nursing during the interdisciplinary team meeting. d. Residents who refuse to sign the agreement will have their smoking materials stored securely and will only be allowed to smoke under direct supervision. Residents who refuse to sign will be asked to turn in any smoking paraphernalia. If resident refuses to voluntarily give up paraphernalia the interdisciplinary team including the administrator, director of nursing, activity director, medical record director, director of staff development, infection preventionist, social services or other designee, will confiscate smoking materials as per our policy or discharge the resident. e. Residents who refuse to sign will be placed on every shift visual monitoring for smoking paraphernalia. Monitoring will be done by licensed nurses. Licensed nurses were trained by Director of Staff Development and Director of Nursing on 3/13/25. 5. Staff Education and Training: a. On 03/12/2025, facility staff, including nurses, nurse assistants, activity assistants, department heads, dietary, administration and housekeeping, have been immediately educated on the updated smoking policy, the importance of smoking assessments, and how to ensure that all smoking activities are managed safely. The education was conducted by the Director of Staff Development. 6. Environmental Safety Measures: a. Fire safety training was given on 12/11/2024 and 02/20/2025 by fire training vendor. b. Additionally, fire safety training was done by the Director of Staff Development on 03/14/2025. Staff educated included nurses, nurse assistants, activity assistants, department heads, dietary, administration and housekeeping. Training was completed, and additional fire safety measures, such as fire extinguishers and fire blankets near designated smoking areas, have been implemented. Staff not currently in facility were called and educated by the Director of Staff Development via phone on 3/13/25 and 3/14/25. c. Safe smoking area training was done for the Activities Director and activity assistants on 03/11/2025. Training was done by the Director of Staff Development and Administrator. d. Activities and or designee will do a check after each smoke break to ensure that smoking areas are safe and free from hazards such as loose smoke buds. Aides will verify receptacle is in working order, fire extinguisher is in place and fire blanket is in present. Activity aides were trained on 3/11/25 by activity director and administrator on 3/11/25. e. Activity aides will supervise that all cigarettes will be extinguished and disposed in proper receptacle of after each smoking break. Activity aides were trained by activity director and administrator on 3/11/25. f. A weekly scheduled audit conducted by the Medical Records Director or designee to review and monitor compliance with safety procedures. g. Compliance of audits conducted by the Medical Records Director will be monitored for three months and will be added to the Medical Record Director's portion (or designee) for our [quality assurance performance improvement] QAPI meeting, quarterly thereafter. Corrective Action Completion Date: The Immediate Jeopardy removal actions have been completed as of 03/14/2025, and the facility will continue to monitor compliance on an ongoing basis. X. All corrections were completed on 3/14/25. X. The immediacy of the IJ was removed on 3/14/25. Onsite Verification: The IJ was removed on 03/14/2025 at 3:40 PM after the survey team verified the implementation of the facility's Removal Plan as follows: 1. The survey team reviewed and verified the facility completed smoking assessments for the five residents who smoked in the facility, their care plans were updated, and verified the Active Smokers list had been updated to include Resident #37. The survey team also reviewed and verified the facility reviewed the smoking policy with the five residents. Interviews on 03/14/2025 with the five residents verified facility staff discussed the smoking policy and procedures with the residents. 2. The survey team conducted interviews with the Administrator, the Activity Supervisor, the DON, the Medical Records Staff, the Director of Staff Development, Social Services Supervisor, and the Medical Director to discuss their understanding of the facility's smoking program. The survey team reviewed and verified the facility provided staff training on 03/13/2025 at 4:00 PM through a review of a facility document titled, [the facility's name] Lesson Plan. Per the document, the training was related to smoke breaks, observing smoke breaks, ensuring smoking occurred in designated areas, smoking assessments, fire safety, providing a smoking apron, reporting finding smoking paraphernalia to the Administrator or designated supervisor, and understanding how to extinguish residents in case of an emergency. The team conducted interviews with staff, including CNAs, LVNs, registered nurses (RNs), housekeeping staff, and activities staff to verify training was provided. 3. The survey team reviewed a facility document titled, Secure Smoking Paraphernalia, that indicated that each of the five smoker's rooms were inspected on 03/10/2025. The document indicated that a lighter was confiscated from Resident #37's room on 03/10/2025. The documented indicated that the remainder of the rooms were inspected on 03/12/2025. The survey team confirmed with the Activity Supervisor that room inspections would be continued on a monthly basis and confirmed that a lighter was removed from Resident #37's room. During an interview on 03/11/2025 at 1:34 PM, Resident #37 stated that someone took their lighter on 03/10/2025. 4. The survey team reviewed an undated facility policy titled, Smoking Policy that indicated that the smoking policy would be reviewed with the residents or their legal representative and a signed copy of acknowledgement would be maintained in the resident's health record. The policy indicated that residents would not be able to keep smoking items in their possession, and indicated the smoking aprons would be offered and encouraged to all residents based on assessment. The policy included lines where the resident or their representative as well as a witness could sign. The survey team confirmed through interviews with staff what to do if residents refused to sign the smoking agreement, if they refused to wear a smoking apron, or if they refused to turn in their smoking paraphernalia. An observation of a smoke break on 03/14/2025 at 1:56 PM revealed multiple smoking aprons hung in the area. Two residents were offered a smoking apron and both residents refused. The Activity Supervisor witnessed the refusals. 5. The survey team reviewed and verified the facility provided staff training on 03/13/2025 at 4:00 PM through a review of a facility document titled, [the facility's name] Lesson Plan. Per the document, the training was related to smoke breaks, observing smoke breaks, ensuring smoking occurred in designated areas, smoking assessments, fire safety, providing a smoking apron, reporting finding smoking paraphernalia to the Administrator or designated supervisor, and understanding how to extinguish residents in case of an emergency. The team conducted interviews with staff, including CNAs, LVNs, RNs, housekeeping staff, and activities staff to verify training was provided. 6. The survey team reviewed facility documents titled, Fire Drill Report dated 12/11/2024 and 02/20/2025 that indicated fire drills were conducted on those days. An observation of a smoke break on 03/14/2025 at 1:56 PM revealed a fire blanket and fire extinguisher on the exterior wall of the facility in the area. A facility document titled, Safe smoking Activity Assistant Training log indicated that AS #1, AS #9, and AS #10 were trained related to a safe smoking area. The survey team reviewed a facility document titled, Smoking Area Safety Check, that indicated staff checked the smoke areas five times per day. The survey team reviewed a facility document titled, Performance Improvement Project (PIP) Guide, dated 03/12/2025, that indicated the facility initiated a PIP related to smoking practices at the facility. The survey team conducted interviews with activities staff, the Medical Records Staff, and the Administrator to confirm training was provided and a system to monitor for compliance was established.