**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy and document review, the facility failed to implement systems and processes to ensure that 1 (Resident #29) of 8 residents who smoked were supervised while smoking and did not have access to cigarettes and lighters. Specifically, on 01/29/2024 at 1:33 PM, Resident #29 was observed with smoking materials in their possession unsupervised It was determined the facility'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 (IJ) was related to State Operations Manual, Appendix PP, 483.25d Accidents, at a scope and severity of K. The IJ began on 01/29/2024 at 1:33 PM, when Resident #29 was observed with smoking materials in their possession unsupervised. The Administrator and the Regional Quality Management Consultant were notified of the IJ and provided with the IJ template on 01/31/2024 at 9:15 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 02/01/2024 at 3:20 PM. The IJ was removed on 02/02/2024 at 11:15 AM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F689. Findings included: A review of a facility policy titled Smoking Residents, effective 08/18/2023, revealed 2. Smoking by residents is allowed outside of the facility in designated, marked smoking areas with the following safety measures readily available: a. Ashtrays made of noncombustible material and safe design; b. Metal containers with self-closing covers into which ashtrays can be emptied, c. Portable fire extinguisher; and d. Fire-retardant blanket (smoking blanket). The policy revealed, 6. Using the Resident Smoking Assessment, the Licensed Nurse will assess residents who express a desire to smoke, upon admission, quarterly, annually and upon significant change of condition, and present it to the Interdisciplinary Team (IDT) for review. Further review of the policy revealed, 8. The IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke. A review of an undated [Facility name] Smoking Schedule revealed residents were permitted to smoke every day at the following times with staff supervision: 8:30 AM, 11:00 AM, 1:30 PM, 4:30 PM, and 6:30 PM. Further review revealed that the designated smoking area was located on the East side of the building perimeter. A review of a facility, Smokers List, updated on 01/22/2024, revealed eight residents were listed, including Resident #29. A review of Resident #29's admission Record revealed the facility admitted the resident on 11/01/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia and tobacco use. A review of Resident #29's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2023, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident used tobacco. A review of Resident #29's Smoking and Safety assessment dated [DATE] revealed Resident #29 was documented as following the facility's policy on location and time of smoking. Continued review revealed a section titled Care Planning with documented goals for the resident to adhere to the tobacco and smoking policies of the facility and to orient Resident #29 to the facility's smoking times and procedures. An observation on 01/29/2024 at 1:33 PM revealed Resident #29 was in their room with a carton of cigarettes. During the observation, Resident #29 stated that until earlier, they also had a lighter. An observation on 01/30/2024 at 7:50 AM revealed Resident #29 was in their room with a cigarette in their left hand. During an observation and interview on 01/30/2024 at 9:00 AM, Resident #29 opened the sliding door in their room, stepped outside, and smoked a cigarette. Resident #29 was observed to have a red lighter and one cigarette in a carton. Resident #29 stated they stepped out of the sliding door and smoked outside. An additional unlit half-burned cigarette was observed lying next to books on the resident's bed. The resident was observed smoking in an area that was not designated for smoking. An observation on 01/30/2024 at 11:19 AM revealed Resident #29 was in the hallway walking with a lighter and a cigarette in their hand. During an observation and interview on 01/30/2024 at 11:23 AM, Certified Nursing Assistant (CNA) #21 stated he was unaware of residents being allowed to keep their smoking materials. During the interview, Resident #29 approached CNA #21 with a cigarette in their hand. CNA #21 then stated he had seen Resident #29 with a cigarette and lighter in their hands. CNA #21 stated Resident #29 had gone to the front of the facility and smoked and did not smoke in non-designated areas. An observation on 01/30/2024 at 1:05 PM revealed Resident #29 was smoking in a non-designated smoking area outside of the front entrance of the facility. During an observation on 01/30/2024 at 3:12 PM, Resident #29 was observed smoking on the front walkway of the facility without staff supervision. After Resident #29 completed smoking, the resident put out the cigarette and placed the cigarette butt in their front shirt pocket. An interview with Receptionist #20 on 01/30/2024 at 10:56 AM revealed the receptionist was responsible for keeping residents' cigarettes but did not keep any of the residents' lighters. Receptionist #20 stated Resident #29's smoking materials were kept at the front desk, and all other residents were allowed to keep their smoking materials. An interview with CNA #22 on 01/30/2024 at 11:28 AM revealed CNA #22 had worked at the facility for forty-three years. CNA #22 stated that residents who smoked were taken outside after breakfast and lunch. CNA #22 stated Resident #29 was allowed to have a lighter and confirmed she had seen the resident with a cigarette. CNA #22 stated she had not seen Resident #29 go outside the sliding glass door in their room to smoke, but the resident did come in smelling like smoke. CNA #22 stated when she asked the resident if they smoked outside their room, the resident stated they did. During an interview on 01/30/2024 at 12:41 PM, Licensed Vocational Nurse (LVN) #23 stated residents were not allowed to keep their smoking materials. During an interview with Registered Nurse (RN) #1 on 01/30/2024 at 12:52 PM, RN #1 stated she had worked at the facility for thirty years, knew which residents smoked, and stated all residents who smoked were supervised. During an interview on 01/30/2024 at 1:40 PM, CNA #24 stated she had observed Resident #29 smoking unsupervised at the front entrance of the facility. CNA #24 confirmed she did not redirect Resident #29 from the front of the building and did not report her observation to the nurse. CNA #24 stated all residents were required to smoke in the designated smoking area in the rear of the facility. During an interview with the Social Service Assistant (SSA) on 01/30/2024 at 2:11 PM, the SSA stated nursing completed smoking assessments, and the SSA followed up to ensure the assessments were completed. The SSA stated the results of the assessments showed all residents were required to be supervised while smoking. An interview with LVN #28 on 01/30/2024 at 3:55 PM revealed LVN #28 had worked at the facility for four days. LVN #28 stated if a resident smoked, an employee had to be with the resident, and residents had to smoke in designated areas. LVN #28 stated residents were not allowed to keep smoking materials, and if she saw a resident with them, she would notify the Director of Nursing (DON) and the Administrator. During an interview on 01/30/2024 at 4:01 PM, LVN #6 stated the facility had scheduled smoking times for residents, and residents were not allowed to smoke unsupervised. During an interview on 01/30/2024 at 4:12 PM, CNA #29 stated the front desk kept residents' smoking materials, and none of the residents were allowed to keep their smoking materials. CNA #29 stated residents must be supervised while smoking. During an interview on 01/30/2024 at 4:19 PM, RN Supervisor #8 stated smoking assessments were completed when residents were admitted to the facility. RN Supervisor #8 stated residents were not allowed to keep their cigarettes and lighters, and she was unaware that residents smoked in undesignated areas. During an interview on 01/30/2024 at 4:33 PM, the Administrator stated residents were required to be supervised while smoking. The Administrator stated that because the facility had residents who required supplemental oxygen, residents were not supposed to keep their lighters, but some residents sneak them in. The Administrator stated the designated smoking area was outside and behind the building by the dumpster. The Administrator stated he had seen the resident's smoking in the front of the facility. The Administrator stated staff were educated on enforcing the smoking location. The Administrator stated staff knew that residents could not have lighters at their bedside, residents were to be supervised when smoking, and residents had to smoke in the designated smoking area. The Administrator stated the receptionist should have kept the lighters. During an interview on 01/31/2024 at 11:18 AM, Primary Care Physician (PCP) #5 stated he was aware of Resident #29 smoking without supervision. PCP #5 stated the resident was ambulatory and went out to smoke whenever they wanted. PCP #5 stated Resident #29 would go out and light a cigarette not in the designated smoking area. On 02/01/2024 at 3:20 PM, a Removal Plan was submitted by the facility and accepted by the State Survey Agency. It read as follows: Immediate Corrective Action/s: 1. On 01/31/2024, Resident #29 was immediately placed on one-to-one supervision, smoking materials were removed by the Administrator and stored in a locked box in the medication room of Station 1. The licensed nurse will provide the Smoking Material Lock Box to the assigned supervising staff and collect it when smoking break is complete. The staff assigned to supervise Resident #29 and other smokers during smoking times will immediately report to the Administrator and/or Director of Nursing (DON) any concerns identified regarding non-adherence to Smoking Safety Policies that were observed. 2. The smoking schedule was developed as follows: for 8:30 AM - Janitor, 11 AM - Activities, 1:30 PM - Activities, 4:30 PM - Activities, 6:30 PM - Activities and 8:30 PM - Janitor. Charge nurse will assign certified nursing assistant (CNA) staff or supervise if assigned staff not available. 3. On 01/31/2024, Resident #29 was reassessed by the licensed nurse and an Interdisciplinary Team (IDT) meeting was held to review the smoking policy and procedures, smoking schedule, storage of cigarettes and lighters, supervision needs, risks and benefits and discussed the plan of care of the resident to ensure safety. Education was also provided by the Administrator, Director of Staff Development (DSD) and Social Services to current staff, and smoking residents related to the proper disposal of cigarettes in the ash tray and to not store any extinguished cigarettes inside a shirt pocket for the resident's safety. 4. On 01/31/2024, the Receptionist was in-serviced on the smoking process and to not allow smokers to leave without supervision and to alert nursing staff if concerns identified related to smoking. 5. The smoking residents were educated on 01/31/2024 by the Administrator, Social Services, and DSD on the smoking area, smoking schedule, and smoking policy. A list of smokers and face sheet were placed at reception for surveillance and alerting staff if residents attempt to exit for smoking outside designated time or area. Smoking materials will be stored in the lock box in the Station 1 medication room. The licensed nurse will distribute the lock box and collect them for storage. A Resident Council meeting was held by the Activities Director on 02/01/2024, providing education on the new smoking policy/procedures, the smoking schedule, and location of the cigarettes. 6. On 01/31/2024, the DSD made rounds on smokers to verify no smoking materials were in the residents' rooms or in the residents' possession and that residents were supervised according to their assessments and plan of care. 7. On 01/31/2024, the Administrator, Clinical Supervisor, and DSD provided immediate education to the Licensed Nurses, CNAs, Social Services Director, Housekeeping Supervisor, Staffing/Central Supply Coordinator, MDS Coordinator, Admissions Director, Director of Business Development, Receptionist, Janitor/Housekeeping staff, Business Office Manager, Business Office Assistant, Social Services Assistant, Infection Preventionist Director of Rehab, Medical Records Director, Maintenance Director, Activities Director, IDT, and Registry Staff on the policies and procedures for smoking with emphasis on the following: safe storage and safekeeping of smoking materials, assessment to determine if residents require supervision and/or assistive devices while smoking, use of apron while smoking and without supervision, and development of the individualized care plan. Those on leave, unscheduled, registry staff will be educated by the Administrator and/or Clinical Supervisor and/or DSD before starting their next scheduled workday. Staff not on duty will be educated on the smoking policies/procedures prior to the start of their next shift. 8. On 01/31/2024, the smoking area was inspected by the Administrator and smoking aprons, ash tray, fire blanket, and fire extinguisher are all available. How to identify other residents who have the potential to be affected by the same deficient practice: 9. On 01/31/2024, the Clinical Supervisor and licensed nurses conducted an audit of current residents who smoke to ensure accuracy of Smoking Assessments and Smoking Care Plan which includes risks, supervision, and device need of the resident while smoking and storage smoking materials such as cigarettes and lighter. There are seven current smokers in the facility, one resident was discharged on 1/31/2024. - 5 out of 7 residents have been identified to require supervision while smoking. - Two residents were identified to be independent smokers. - 5 out of 7 residents have been identified to require an apron while smoking. - 7 out of 7 residents that smoke were offered smoking cessation by the Registered Nurse (RN) supervisor, all residents declined and wished to continue smoking. Systemic Changes and Education: 10. On 01/31/2024, the Administrator, Clinical Supervisor and DSD provided immediate education to Licensed Nurses, CNAs, Social Services Director, Housekeeping Supervisor, Staffing/Central Supply Coordinator, MDS Coordinator, Admissions Director, Director of Business Development, Receptionist, Janitor/Housekeeping staff, Business Office Manager, Business Office Assistant, Social Services Assistant, Infection Preventionist Director of Rehab, Medical Records Director, Maintenance Director, Activities Director, and Registry Staff on the policies and procedures for smoking with emphasis on the following: safe storage and safekeeping of smoking materials, assessment to determine if residents require supervision and/or assistive devices while smoking, use of apron while smoking and without supervision, and development of individualized care plan. Those on leave, unscheduled, registry staff will be educated by the Administrator and/or Clinical Supervisor and/or DSD before starting their next scheduled workday. Staff not on duty will be educated on the smoking policies/ procedures before their next shift starts. New Process: 11. The new process will include the following: - Facility reviewed and updated the smoking schedule. - Residents in the smoking area will be supervised by designated staff members during scheduled smoking times. - Residents' cigarettes and smoking paraphernalia will be kept in the Smoking Storage Lock Box and attended and secured by facility staff. - Smoking schedule assigned staff for supervision: 8:30 AM - Janitor, 11 AM - Activities, 1:30 PM - Activities, 4:30 PM - Activities, 6:30 PM - Activities, and 8:30 PM - Janitor. Charge nurse will assign certified nursing assistant (CNA) staff or supervise if assigned staff not available. Monitoring: 12. During the morning clinical meeting on Mondays to Fridays, the IDT will review residents who are newly admitted , residents who are due for their quarterly assessments, and residents with significant change in condition, to ensure that smoking evaluations and person-centered care plans are completed for those residents who currently smoke and those who have expressed the desire to smoke including vaping. Identified concerns will be immediately addressed and reported to the Administrator and/or DON for resolution as warranted. 13. The department managers will conduct rounds of their assigned rooms and observe residents who smoke weekly for four weeks, then bimonthly for two months, to ensure that residents who smoke adhere to the smoking policy and procedures, that lighting and smoking materials are safely stored according to the residents' care plan, residents who require supervision and/or assistance are provided assistance by the staff and no lighting materials are in their possession, and that smoking aprons are worn by residents according to their care plans and assessments. Concerns identified during the observations will be immediately addressed and reported to the Administrator and/or DON for resolution as warranted. QAPI: 14. On 02/01/2024, the Administrator, department heads, and the Medical Director conducted an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting and presented the corrective action plan for safe smoking and the committee and Medical Director had approved the plan. 15. The Administrator and/or DON will present the results of the smoking monitoring audits to the QAPI Committee for monthly review for the next three months and quarterly thereafter until substantial compliance is achieved. The Administrator, DON, and IDT are responsible for monitoring and sustaining compliance by conducting routine audits, spot check observation, Ambassador room rounds, and routine in-services. All corrections were completed on 02/01/2024. The immediacy of the IJ was removed on 02/01/2024. Onsite Verification: The IJ was removed on 02/02/2024 at 11:15 AM after the survey team verified the implementation of the facility's Removal Plan as follows: 1. The survey team conducted observations of Resident #29 on 02/01/2024 and 02/02/2024 and verified staff provided one-to-one supervision for the resident and that Resident #29 did not have any smoking materials in their possession. During an interview with the Administrator on 02/02/2024 at 8:41 AM, an interview with one-to-one assigned staff, and an observation conducted at the Station 1 nursing station verified smoking materials were in a locked box. 2. The survey team reviewed and verified the smoking schedule and conducted interviews on 02/01/2024 and 02/02/2024 with CNAs, activity staff, janitorial staff, nursing staff, and the Administrator. 3. The survey team reviewed the IDT conference notes. The SSD confirmed a meeting was held with Resident #29 and Resident # 29's family member regarding possible discharge because the resident no longer required skilled nursing services. The SSD confirmed the facility would work with the family member to discharge the resident to an Assisted Living facility. The smoking assessment was reviewed by the surveyor. The survey team reviewed staff education. 4. The survey team verified that the Receptionist was in-serviced on the smoking process through a review of the in-service sign-in sheet and an interview with the Receptionist to ensure they received education; the Receptionist confirmed education. 5. Interviews were conducted with four out of the seven residents who smoked, and they verified they were educated on the smoking area, smoking schedule, and smoking policy. Interviews were conducted with residents who attended the resident council meeting and verified they were educated on the new smoking policy and procedures. The survey team verified education was provided through interviews with the DSD and Administrator on 02/02/2024. 6. An interview with the DSD on 02/02/2024 at 9:10 AM verified the DSD conducted rounds on residents who smoked to ensure no residents had smoking materials in their possession or in their rooms. 7. The survey team conducted interviews with five CNAs on the day shift, four nurses on the day shift, one activity staff member, one housekeeping staff, two evening shift nurses, four evening shift CNAs, two nurses from the overnight shift, three CNAs on the overnight shift, two janitorial staff, one dietary staff, Director of Staff Development, Activity Director, Social Service Director, Social Service Assistant, Administrator, and Maintenance Director. The interviews verified that staff were educated on the facility's policies and procedures for smoking. 8. An observation of the smoking area on 02/02/2024 and an interview with the Administrator on 02/02/2024 verified that the Administrator inspected the smoking area and that smoking aprons, an ashtray, a fire blanket, and a fire extinguisher were available. 9. Interviews conducted with licensed nurses on 02/01/2024 and 02/02/2024 verified audits of current residents who smoked were conducted. Review of the care plans and smoking assessments of the seven residents who smoked verified the care plans and smoking assessments were reviewed. Interviews were conducted with four smoking residents. 10. The survey team reviewed the sign-in sheets and verified staff were educated on the facility's policies and procedures for smoking. Interviews conducted with the Administrator and DSD on 02/02/2024 verified staff were educated on the facility's policies and procedures for smoking. An interview with the Clinical Supervisor verified that staff were educated on the facility's policies and procedures for smoking. 11. The survey team verified this through interviews with the Administrator, department heads, Clinical Supervisor, and nursing staff. An observation was made to verify that a locked box contained residents' smoking materials. The survey team reviewed the smoking schedule and verified it with assigned staff members. 12. The Administrator verified the IDT review during an interview on 02/02/2024. The Clinical Supervisor was interviewed and verified the IDT review. 13. An interview with the Administrator on 02/02/2024 verified department managers would conduct rounds and observe residents who smoke. An interview with the Clinical Supervisor verified department managers would conduct rounds and observe residents who smoke. 14. An interview with the Administrator on 02/02/2024 verified the ad hoc QAPI meeting was held on 02/01/2024. 15. An interview on 02/02/2024 with the Administrator verified the results of the smoking monitoring audits would be presented to the QAPI committee monthly for the next three months and quarterly thereafter until substantial compliance was achieved.