**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment was free from potential serious accident hazards for residents and staff in the facility when: 1. The facility failed to assess and identify one of 10 residents (Resident 104) for smoking upon admission and failed to complete quarterly smoking assessments (an evaluation used to determine a resident's ability to smoke safely) for four of 10 residents (Residents 4, 13, 31, and 71). 2. The facility failed to ensure safety when eight of 10 residents (Residents 4, 13, 26, 32, 71, 79, 82, and 104) were observed smoking unsupervised in a non-oxygen free facility. 3. The facility failed to provide safe storage of a lighter for five of 10 residents (Residents 13, 31, 71, 82, 96), who had a physician's order for supplemental oxygen (a medical treatment delivering additional oxygen to a patient that significantly increases both the risk and intensity of fires). 4. The facility failed to ensure safety measures were followed by allowing four of 10 residents (Residents 4, 13, 96, and 104) possess lighters and were in proximity of other residents who used supplemental oxygen. 5. The facility failed to ensure the safety of all residents due to fire risk when 10 of 10 residents (Residents 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104) were in possession of lighters. 6. The facility failed to update the smoking care plans (the plans showing specific interventions to provide effective and person-centered care to meet the resident's needs) for 5 of 10 sampled residents (Residents 4, 13, 26, 79, and 96) and failed to develop an individualized care plan related to smoking for one of 10 sampled residents (Resident 104), addressing safe storage, supervision, and the use of smoking materials. These failures placed residents at risk of serious harm, including fire hazards, burns, and other preventable injuries. Without proper supervision and safe storage of smoking materials, there was an increased likelihood of accidental fires, which could result in property damage, smoke inhalation, or even fatalities. Additionally, inadequate oversight could lead to residents with cognitive impairments or physical limitations mishandling smoking materials, further heightening the risk of injury to themselves and others. Findings: A. During the Entrance Conference on 3/3/25 at 8:58 a.m. with Administrator and Director of Nursing (DON), a list of residents who smoke was requested. Review of the Smoker Worksheet indicated there were eight residents who were smokers in the facility (Residents 4, 13, 26, 31, 32, 71, 79, and 82). The Administrator stated the list needed to be updated to reflect the current number of residents who smoked. The Administrator then provided the Smoker Worksheet showing nine residents who smoked (Residents 4, 13, 26, 31, 32, 71, 79, and 96). During an observation and concurrent record review on 3/4/25 at 9:58 a.m., two residents were observed smoking on the patio unsupervised (Residents 79 and 104). Resident 104 stated he had cigarettes and a lighter in possession. During an interview with Resident 104 on 3/4/25 at 10:15 a.m., Resident 104 stated he was able to smoke whenever I feel like it. During a concurrent observation on 3/4/25 at 10:25 a.m., in Resident 104's room, a sign outside of the room indicated, No smoking oxygen in use. The sign was also noted to have two circles with a slash over a cigarette. Inside the room where Resident 104 resided was also Resident 36 who shared the room. Resident 104's roommate, Resident 36, was observed with 2 liter (L- a unit of measurement) per minute (min) of oxygen in use via nasal cannula (NC - a small, flexible tube with two prongs, used to deliver supplemental oxygen or increased airflow to a patient through their nostrils). During a review of Resident 104's admission Record (a document showing a summary of the resident's information) dated 3/5/25, indicated Resident 104 was admitted to the facility on [DATE]. A review of Resident 104's History and Physical (Amended) dated 3/3/25 indicated Resident 104's diagnoses included but not limited to Chronic Obstructive Pulmonary Disorder (COPD - a group of lung diseases that makes it hard to breathe leading to damaged and inflamed airways), polysubstance abuse, schizoaffective disorder (a mental health condition where a person experiences both schizophrenia [a condition that affects how people think, feel, and behave] and a mood disorder [a condition that impacts a person's emotional state]). A review of Resident 104's Care Plan Report undated, indicated a comprehensive care plan was developed for the resident. However, further review of the Care Plan Report indicated there was no documented evidence a care plan problem was developed to address Resident 104's smoking. During a concurrent interview and record review with the DON on 3/4/25 at 11:28 a.m., the DON reviewed the clinical record for Resident 104 and verified Resident 104 did not have a care plan for smoking. During a concurrent interview and record review on 3/4/25 at 12:07 p.m. with the Activities Director (AD), Resident 104's Activities - Initial Review dated 2/24/25, indicated one of Resident 104's hobbies included smoking. The AD stated she completed an assessment on 3/2/25 when she saw Resident 104 smoking. During an interview and concurrent record review on 3/4/25 at 2:45 p.m. with the Minimum Data Set Nurse Assistant (MDSNA), the MDSNA verified Resident 104 was not on the current Smoker Worksheet provided by the facility. The MDSNA stated, she was unsure if Resident 104 was a smoker when he was admitted to the facility. A review of Resident 104's Clinical Admission (an evaluation conducted upon a patient's arrival or admission to a facility, focusing on gathering data to determine their health status, identify potential problems, and develop a plan of care) dated 2/24/25, indicated under Safety section number 72 for smoking, Resident 104 was marked as being not assessed. An initial screening for smoking was not completed for Resident 104. In addition, Resident 104 was not on the list of smokers on the Smoker Worksheet provided by the facility. During an interview and concurrent record review with the Administrator and DON, on 3/6/25 at 11:43 a.m., the DON reviewed Resident 104's Clinical Admission dated 2/24/25, and verified Resident 104's smoking use was not assessed upon admission. The DON further stated that she was responsible for failing to ensure the baseline screening was completed for the smokers. B. A review of Resident 4's admission Record, dated 3/5/25 indicated Resident 4 was readmitted to the facility on [DATE]. Resident 4's diagnoses included but not limited to CHF (Congestive Heart Failure - a condition that develops when the heart does not pump enough blood for the body's needs), COPD, history of CVA (Cerebral Vascular Accident - an interruption in the flow of blood to the cells in the brain) with right upper weakness, and PVD (Peripheral Vascular Disease - a condition where blood vessels outside of the heart and brain become narrowed or blocked). During a concurrent observation and interview with Resident 4 on 3/3/25 at 10:15 a.m., in his room., Resident 4 stated he smoked about 10 packs of cigarettes daily. Resident 4 displayed that he currently had two packs of cigarettes and two disposable lighters in his possession. Resident 4 further stated that he was able to smoke on the patio whenever he wanted. During an observation on 3/4/25 at 9:14 a.m., Resident 4's room was observed to be located next to a room with a sign outside that indicated, No smoking oxygen in use. The sign was also noted to have two circles with a slash over a cigarette. During a concurrent observation and interview with Resident 4 on 3/4/25 at 9:38 a.m., Resident 4 was smoking unsupervised by staff. Resident 4 was observed in possession of and displayed two packs of cigarettes and two lighters in a bag. Resident 4 stated he kept the lighters and cigarettes with him. Review of the Smoker Worksheet provided by the Administrator showed Resident 4 was a smoker. Review of the Smoking and Safety, assessment dated [DATE], showed Resident 4 follows the facility's policy on location and time of smoking. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with the MDSNA, the MDSNA stated Resident 4's smoking assessment was completed on 11/11/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly. The MDSNA stated the assessments should be up to date because there could be a change in condition where residents were no longer a safe smoker (a resident who was assessed to have appropriate cognitive, vision, communication, and physical functions and was able to verbalize understanding of the facility's smoking policies as per the facility's Safe Smoking Assessment form). A review of Resident 4's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN [as needed] . If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. C. A review of Resident 13's admission Record, dated 3/5/25, indicated Resident 13 was readmitted to the facility on [DATE]. Resident 13's diagnoses included but not limited to COPD, schizoaffective disorder, bipolar type (a chronic mental health condition characterized by extreme mood swings, alternating between periods of mania [elevated mood] and depression [a persistent state of sadness and loss of interest that can significantly impact daily life]), and cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die). Review of the Smoker Worksheet provided by the Administrator showed Resident 13 was a smoker. During an interview with Resident 13 on 3/4/25 at 9:08 a.m., Resident 13 stated that she used a motorized wheelchair to go outside of the facility to buy cigarettes and lighters. Resident 13 further stated she stored and secured her own cigarettes and lighters. Resident 13 stated she smoked in the patio without supervision. During an observation on 3/4/25 at 9:13 a.m. Resident 13's room was observed to be located next to a room with a sign outside of the room that indicated, No smoking oxygen in use. The sign was also noted to have two circles with a slash over a cigarette. During a concurrent observation and interview on 3/4/25 at 9:43 a.m., Resident 13 was smoking in the patio unsupervised. Resident 13 stated she was enjoying her cigarettes and kept her own cigarettes and lighters. During a review of the Oxygen Order Listing Report, dated 3/4/25, an active physician's order for Resident 13 with a revised date of 7/1/24 indicated the use for oxygen 3 liters per min via NC PRN for shortness of breath (SOB) to maintain oxygen at greater than 90% every shift. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with the MDSNA, The MDSNA stated Resident 13's smoking assessment was completed on 11/8/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly. The MDSNA stated the assessments should be up to date because there could be a change in condition where residents are no longer a safe smoker. A review of Resident 13's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN .If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. D. A review of Resident 26's admission Record dated 3/5/25, indicated Resident 26 was readmitted to the facility on [DATE]. Resident 26's diagnoses included but not limited to metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance) and COPD. During a concurrent observation and interview with Resident 26 on 3/3/25 at 10:30 a.m., Resident 26 was smoking in the patio area unsupervised. Resident 26 stated residents were allowed to smoke in the patio at any time without staff permission or notice. Resident 26 further stated his friends would provide cigarettes and lighters for use while he was in the facility. A review of Resident 26's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN .Educate Resident/Responsible Party on the facility's tobacco/smoking policy(s) .If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. E. A review of Resident 31's admission Record, dated 3/5/25, indicated Resident 31 was readmitted to the facility on [DATE]. Resident 31's diagnoses included but not limited to muscle weakness (generalized), acute respiratory failure with hypoxia, and COPD with (acute) exacerbation (a worsening or intensification of a pre-existing disease or condition). During a concurrent observation and interview on 3/4/25 at 9:32 a.m., Resident 31 was observed sitting in his motorized wheelchair. Resident 31 stated the cigarettes and lighters in his possession were provided by his caregiver and were kept in a drawer in his room. Resident 31 further stated smoking in the patio unsupervised was permitted at any time. A review of the Oxygen Order Listing Report, dated 3/4/25, indicated an active physician's order for Resident 31 was revised on 11/6/24 for O2 2L per min via NC PRN for SOB and wheezing related to COPD with acute exacerbation (a sudden and serious worsening of a condition or its symptoms). F. A review of Resident 32's admission Record, dated 3/5/25, indicated Resident 32 was readmitted to the facility on [DATE]. Resident 32's diagnoses included but not limited to encephalopathy, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system (brain and spinal cord) that can lead to numbness and tingling, weakness, vision problems, balance and coordination difficulties, fatigue and cognitive (relating to thought processes) problems. During a concurrent observation and interview with Resident 32 on 3/3/25 at 10:30 a.m., Resident 32 was observed smoking unsupervised. Resident 32 stated she smoked daily and can smoke any time during the day. Resident 32 further stated she kept her lighter in her pocket. During an interview on 3/3/25 at 10:30 a.m., Certified Nursing Assistant (CNA) 2 stated Resident 32 was not supervised during Resident 32's smoking activities. Review of the Smoker Worksheet provided by the Administrator showed Resident 31 was a smoker. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with the MDSNA, The MDSNA stated Resident 32's smoking assessment was completed on 11/29/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly. When asked if the assessment should be up to date, the MDSNA replied yes, because there could be a change in condition where they are no longer a safe smoker. G. A review of Resident 71's admission Record dated 3/5/25, indicated Resident 71 was admitted to the facility on [DATE]. A review of Resident 71's History and Physical dated 11/1/24 indicated Resident 71's diagnoses included but not limited to depression, anxiety (feelings of worry, nervousness, or dread), and insomnia (difficulty sleeping). During a concurrent observation and interview with Resident 71 on 3/4/25 at 9:14 a.m., Resident 71 was observed smoking in the patio unsupervised. Resident 71 was observed to be in possession of a lighter. Resident 71 stated there were instances when no staff were available to supervise the residents while the residents smoked. Resident 71 further stated residents who smoked were all allowed to carry their own lighters. During a follow-up observation on 3/4/25 at 9:25 a.m. Resident 71 was still smoking in the patio unsupervised. A review of the Oxygen Order Listing Report, dated 3/4/25, indicated an active physician's order for Resident 71 was revised on 10/31/24 for O2 2L per min via NC PRN for SOB every 24 hours. Review of the Smoker Worksheet provided by the Administrator showed Resident 71 was a smoker. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with MDSNA, the MDSNA stated Resident 71's smoking assessment was completed on 10/31/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly and should have been done 2/25. When asked if the assessment should be up to date, the MDSNA replied yes, because there could be a change in condition where they are no longer a safe smoker. H. A review of Resident 79's admission Record dated 3/5/25, indicated Resident 79 was admitted to the facility on [DATE]. A review of Resident 79's History and Physical dated 7/26/24 indicated Resident 79's diagnoses included but not limited to asthma (a chronic lung condition that causes the airways to become inflamed and narrow) and hypertension (high blood pressure). During an observation on 3/4/25 at 09:58 a.m., Resident 79 was smoking in the patio unsupervised and accompanied by Resident 104. During an interview on 3/5/25 at 10:00 a.m. with Resident 79, Resident 79 stated he bought and kept his own cigarettes and lighter. A review of Resident 79's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN .Educate Resident/Responsible Party on the facility's tobacco/smoking policy(s) .If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. I. During a review of Resident 82's admission Record dated 3/5/25, indicated Resident 82 was admitted to the facility on [DATE]. Resident 82's diagnosis included but not limited to COPD, acute respiratory failure with hypoxia (a condition where there is not enough supply of oxygen to the body's tissues), schizoaffective disorder, major depressive disorder, and anxiety. During a concurrent observation and interview with Resident 82 on 3/4/25 at 9:20 a.m., Resident 82 was observed in his room while using supplemental oxygen. Resident 82 stated he had his own lighter then proceeded to show a disposable lighter in his hand. Resident 82 also stated he would borrow other residents' lighters if necessary, and residents borrowed lighters from one another. Resident 82 further stated the facility staff did not supervise the residents while smoking. During a follow-up observation and interview with Resident 82 on 3/4/25 at 3:00 p.m., Resident 82 was smoking in the patio. Resident 82 stated he could smoke at any time and did not need to notify staff. A review of the Oxygen Order Listing Report, dated 3/4/25, indicated an active physician's order for Resident 82 was revised on 7/3/24 for O2 2L per minute via NC PRN for SOB or pain which may be increased up to 5L per min every 24 hours. J. A review of Resident 96's admission Record dated 3/5/25, indicated Resident 96 was admitted to the facility on [DATE]. A review of Resident 96's History and Physical dated 1/12/25 indicated Resident 96's diagnoses included but not limited to lung adenocarcinoma (A type of cancer that starts in the cells that line the insides of organs and produces substances like mucus), PTSD (Post-Traumatic Stress Disorder - a mental health condition that can develop after experiencing or witnessing a traumatic event causing persistent distress and difficulty functioning), and depression. During a concurrent observation and interview on 3/4/25 at 9:09 a.m., Resident 96 stated he received his cigarettes from other residents who smoke. Resident 96 stated residents who smoked would light their own cigarettes with a lighter that residents had in their possession. Resident 96 further stated that if he did not have his lighter, he would borrow other residents' lighter to smoke a cigarette. A review of the Oxygen Order Listing Report, dated 3/4/25, indicated an active physician's order for Resident 96 was revised on 1/10/25 for O2 3L per minute via NC PRN. A review of the facility's Daily Census, dated 3/2/25, indicated Resident 96's room was located next to non sampled resident (Resident 81). During a concurrent observation and interview on 3/5/25 at 10:07 a.m. with Resident 2, who was not a smoker, was observed with a nasal cannula and oxygen concentrator (medical device that delivers oxygen and increases the amount of oxygen in the air you breathe) machine at the bedside. Resident 2 stated he felt uneasy and unsafe knowing residents can carry lighters and did not know residents were in possession of lighters. Resident 2 stated lighters posed a concern for safety because he used oxygen. A review of Resident 96's Care Plan Report undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the resident will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to Conduct Smoking Safety Evaluation on admission and PRN .Educate Resident/Responsible Party on the facility's tobacco/smoking policy(s) .If a smoking facility, orient Resident to smoking times and procedures .The resident does not require supervision while smoking. However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. During a concurrent interview and record review with the DON on 3/3/25 at 03:44 p.m., the DON was asked to review the care plans for Residents 4, 13, 26, 79, and 96. The DON verified the care plans were not updated. The DON stated the facility was behind on updating the care plans The DON stated the purpose of developing a care plan was to ensure the staff knew how to care for the residents. The DON stated Resident 4's smoking care plan was last revised on 6/2024. During an interview on 3/5/25 at 8:52 a.m., CNA 3 stated residents who smoked did not need supervision from facility staff to perform smoking activities. During an interview on 3/5/25 at 8:52 a.m., Licensed Vocational Nurse (LVN) 4 stated residents who smoked were not supervised or monitored for smoking. During an interview on 3/5/25 at 9:02 a.m. the Social Services Designee (SSD) stated residents are able to smoke in the patio without supervision. The SSD stated residents who smoke can receive their cigarettes and lighters from family and friends or purchase their own cigarettes and lighters. The SSD stated residents were able to keep their own cigarettes and lighters. During an interview on 3/5/25 at 10:12 a.m. RNA stated residents who smoked were not allowed to carry personal lighters because it could be dangerous and stated accidents such as a fire could occur. During an interview on 3/5/25 at 10:24 a.m. CNA 5 stated residents should not be allowed to carry lighters because it can be unsafe, especially around other residents who are using oxygen. CNA 5 stated lighters around residents using oxygen could cause a fire. During a concurrent interview and record review on 3/7/25 at 2:31 p.m. with Quality Assurance Nurse (QA), Residents 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104's Resident's Clothing and Possessions, was reviewed. The list did not include a lighter for Residents 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104. The QA verified that there was no lighter present upon admission for Residents 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104. The QA stated the Resident's Clothing and Possessions, should be completed upon admission for each resident. During a review of the facility's policy and procedure titled, Smoking Policy - Residents dated 7/2017, showed the . Resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation . A review of the facility's policy and procedure Personal Property, dated 9/2012 showed . A representative of the admitting office will advise the resident, prior to or upon admission, as to the types and amount personal clothing and possessions that the resident may keep in his or her room .The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished . During a review of the facility's policy and procedure titled Oxygen Administration dated 10/2010, indicated under .Steps in the Procedure .step four, remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where the oxygen is to be administered . A review of the facility's policy and procedures titled Goals and Objectives, Care Plans, revised 4/2009, indicated Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . An Immediate Jeopardy (IJ-a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 §483.25(d)(1) (The resident environment remains as free of accident hazards as is possible;) and was identified on 3/4/25 at 6:53 p.m., regarding the following deficient practices: *The facility failed to ensure safe smoking practices were followed when smoking residents were in possession of smoking materials (cigarettes and lighters) and smoking unsupervised. *The facility failed to conduct smoking assessments on admission and on a quarterly basis to ensure smokers were identified in the facility and monitored for smoking activities. *The facility failed to develop individualized care plans addressing smoking activities. The IJ was called in the presence of the Administrator and DON Corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was received on 3/6/25, at 12:35 p.m. and included the following: *Conducted a thorough and complete smoking assessments for all residents who smoke in the facility. *Implementation of a new smoking screening assessment which screens the resident for safety and capability to participate in smoking activities. *Secured all lighters from smoking residents and ensured lighters were kept in a locked box located in the medication room. *Monitored and supervised the residents during smoking activities, with staff responsible for securing and distributing lighters. *Updated the admission process to include admitting nurse to interview and assess the resident for smoking and complete the smoking assessment. *Updated the Medication Administration Record for resident who are an identified smoker so Licensed nurses can monitor and observe residents who smoke. *Updated the care plans for all smoking residents. *In-serviced all staff on the facility's smoking policy and procedures and safety measures related to smoking. * The QA nurse and DSD met with all 10 residents who were identified as a smoker to inform the residents regarding the new protocol with disposable lighters. The disposable lighters will now be in possession of the facility instead of residents who smoke. *Continuous monitoring of the designated smoking area will take place every half hour by staff to ensure that any residents who are smoking, are smoking in a safe manner and no changes of condition are taking place. A monitoring log will be filled out by the staff member and kept on file for further evaluation and review. The acceptable corrective action was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on 3/6/25, at 4:15 p.m., in the presence of the Administrator and DON.