**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of seven sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopement. The facility failures created a situation with serious harm and a situation of likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with metabolic encephalopathy (improper brain function due to underlying medical condition), unspecified psychosis (mental condition caused by loss of contact with reality), dementia and anxiety, eloped from the facility on 2/1/25 at an unknown time. Facility staff were unaware Resident #1 was missing until after 6:00 a.m. on 2/2/25 when certified nurse aide (CNA) #2 began answering call lights at the start of her shift. At approximately 6:20 a.m. on 2/2/25, CNA #2 noticed Resident #1's dinner tray, untouched, in the resident's room. Resident #1's roommate reported to CNA #2 she had not heard Resident #1 in the room since approximately 5:30 p.m. on 2/1/25, the previous day. CNA #2 reported this to a nurse on duty and the assistant director of nursing (ADON) was notified at approximately 6:30 a.m. A full facility check was conducted, the staff checked the surrounding neighborhood and the resident was unable to be located. At 8:10 a.m. the admissions coordinator (AC) informed the interdisciplinary team (IDT) that Resident #1 had been located at a local hospital. The facility began investigating the incident immediately after Resident #1 was discovered in care of the local hospital and determined Resident #1 eloped from the facility after CNA #1 and licensed practical nurse (LPN) #1 failed to monitor Resident #1 every two hours per facility protocol and due to Resident #1's refusal to wear a wanderguard. Findings include: Observations, interviews and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/12/25 to 2/13/25, resulting in the deficiency being cited as past noncompliance with a correction date of 2/4/25. I. Situation of serious harm The facility failed to ensure the facility staff performed a check of Resident #1 every two hours throughout the evening on 2/1/25 resulting in the facility being unaware of Resident #1's whereabouts for approximately 12 to 15 hours. Resident #1 eloped from the facility on 2/1/25 and was found by the local police approximately 0.3 miles from the facility. She was taken to a local hospital for evaluation where she was admitted at 8:36 p.m. and treated for a urinary tract infection (UTI). II. Facility plan of correction The corrective action plan the facility implemented in response to Resident #1's elopement incident on 2/2/25 was provided by the clinical resource (CR) on 2/12/25 at 2:30 p.m. A. Immediate action One-on-one education was provided to the staff who worked on the 2/1/25 overnight/evening shift and CNA #1 and LPN #1 were placed on suspension pending the investigation of Resident #1's elopement. A facility wide resident count was conducted and all other residents were accounted for. An assessment was conducted of all exterior doors and doors and door alarms were all functioning properly. The incident investigation began immediately and was conducted by the director of nursing (DON) and the nursing home administrator (NHA). B. Identification of others affected The facility determined the deficient practice had the potential to affect all the residents in the facility. C. Systemic changes The DON educated all of the staff on the importance of staff expectations with rounding, high risk for elopement residents (if a resident had not been seen in a few hours), reviewing the resident sign out book, any resident that required one-to-one staff to resident monitors, frequent or 15-minute checks and the post test for elopement. Residents in the facility were interviewed and educated on the use of the resident sign out log. D. Monitoring The facility would evaluate the effectiveness of the plan in quality assurance and program improvement (QAPI) committee meetings for three months and implement additional interventions as needed to ensure sustained compliance. Audits, along with resident records reviewed and analysed for trends, would be reported monthly to the QAPI committee. III. Facility policy and procedure The Elopement/Unsafe Wandering policy, undated, was provided by the CR on 2/12/25 at 2:30 p.m. The policy read in pertinent part, This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attending or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement. Wandering is defined as random or repetitive locomotion and can either be goal directed or non-goal directed and aimless. Elopement is when a resident leaves the facility premises or a safe area without authorization and/or any necessary supervision to do so. Residents with capabilities of ambulation and/or mobility in a wheelchair will have an unsafe wandering evaluation completed to determine risks for elopement and unsage wandering on admission and with observed behaviors of wandering or attempting to elope. Residents with high risk factors identified on an elopement/wandering evaluation are considered at risk and will have an individualized care plan developed that includes measurable objectives and time frames. The care plan interventions will consider the particular elements of the evaluation that put the resident at risk and the observations of wandering behavior. These interventions will address the individualized level of supervision needed to prevent elopement and unsafe wandering. Staff shall promptly report any resident who is trying to leave the premises, or is suspected of being missing, to the charge nurse or supervisor to evaluate the need for further interventions. If a resident is missing, it is a facility-wide emergency. The missing resident procedures will be initiated. Determine if the resident is out on an authorized leave or pass. If the resident was not authorized to leave, institute a search of the premises. If the resident is unaccounted for after a thorough search of the building and grounds, immediately notify the IDT team, the resident's legal representative or emergency contact, physician and law enforcement. A review of the elopement incident by the IDT will include an investigation to determine safety of the environment and probable cause factors leading to the elopement. A summary of the investigation and recommendations will be documented in the resident's medical record. IV. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 2/1/25. According to the February 2025 computerized physician orders (CPO), diagnoses included metabolic encephalopathy, frostbite, unspecified psychosis, convulsions, dementia and anxiety. The 12/22/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score (BIMS) of eight out of 15. The 2/1/25 discharge MDS assessment documented Resident #1 required set-up assistance for meals, dressing, personal hygiene and dressing. She was independent with all other activities of daily living (ADL). The assessment documented the resident wandered one to three days during the assessment period, experienced delusions and rejected care. B. Record review 1. Care plans Resident #1's comprehensive care plan, initiated 4/19/24 and revised 6/24/24, documented Resident #1 was an elopement risk and exhibited wandering behaviors related to her impaired safety awareness and had two previous elopements. Pertinent interventions, initiated 6/18/24 and resolved 6/24/24, included one-to-one staff supervision and to document wandering behavior and attempted diversional interventions. Resident #1's dementia care plan, initiated 6/24/24 documented the resident was at risk for acute confusional episodes and had a history of elopements related to dementia with exit seeking behaviors. Pertinent interventions, initiated 6/24/24, included to document wandering behavior and attempted diversional interventions, completing one-to-one staff supervision or 15-minute checks as needed, reminding the resident where her room was and that it was divided by the curtain, identifying the resident's pattern of wandering - was it purposeful, aimless or escapist and intervening as appropriate and redirecting the resident as needed. Resident #1's care plan for ADLs, initiated 12/28/22, revealed she had a self-care performance deficit related to impaired mobility and cognition due to dementia. She refused medications, medical testing and labs, vital signs, assessments and showers. Pertinent interventions, initiated 12/30/22, included to converse with the resident while providing care, explaining all procedure and tasks before starting and providing the resident required set-up assistance to eat. 2. Elopement/wandering evaluation Resident #1's 12/20/24 elopement/wandering evaluation documented she had a predisposing condition of mental illness, was disoriented and ambulated independently and/or with supervision. The evaluation further documented Resident #1 did not have a history of elopement and the resident had no history or current behavior of wandering within the look back period of the previous six months. -However, the resident's February 2025 CPO documented Resident #1 had a diagnosis of dementia, which was not indicated on the elopement/wandering evaluation (see interviews below). The resident's electronic medical record (EMR) documented wandering behaviors (in the last six months prior to the elopement/wandering evaluation) on 6/25/24 and 7/21/24, in which Resident #1 attempted to leave the facility and the wanderguard alarm was activated. 3. Treatment records and progress notes A review of Resident #1's February 2025 treatment administration record (TAR) revealed on the 2/1/25 to 2/2/25 overnight shifts from 6:00 p.m. to 6:00 a.m., LPN #1 documented that Resident #1 had zero exit seeking attempts. The TAR further documented Resident #1 was provided with non-pharmacological interventions for pain that included dim light, a quiet environment, relaxation and distraction. A review of Resident #1's EMR revealed the following documentation completed by CNA #1: -Resident #1's fall prevention intervention of a low bed in place was documented at 9:26 p.m. on 2/1/25 and 1:35 a.m. on 2/2/25; -Resident #1's snack was documented as accepted at 9:26 p.m. on 2/1/25; and, -Resident #1 was documented as being turned and repositioned at 9:27 p.m. on 2/1/25 and at 1:35 a.m. on 2/2/25. -However, Resident #1 was admitted to the hospital on [DATE] at 8:36 p.m. after being found downtown by police. -The facility failed to recognize Resident #1 was not in the building until after 6:00 a.m. the following morning (2/2/25). A 2/3/25 IDT note, written at 11:39 a.m. and related to Resident #1's elopement, documented it was noticed by the facility staff on 2/2/25 at approximately 6:10 a.m. that Resident #1 was not in the facility and the facility's elopement protocol was initiated. Resident #1 was located at a local hospital where she was admitted on [DATE] at 8:36 p.m. after being found by police downtown. It was discovered that the assigned LPN (LPN #1) and CNA (CNA #1) did not follow facility policy and procedure during their shift and were placed on suspension pending investigation. The resident had been accepted to a secure unit at another facility after her hospital discharge. C. Review of Resident #1's elopement incident on 2/1/25 On 2/12/25 at 2:30 p.m. the CR provided the investigation of Resident #1's elopement on 2/1/25. The investigation revealed the following: On 2/1/25 staff reported seeing Resident #1 in the hallways from 2:00 p.m. to 3:00 p.m. On 2/1/25 at 5:00 p.m. CNA #1 said Resident #1 was not in her room and to mark her down for the regular meal. On 2/1/25 at 6:00 p.m. Resident #1's dinner tray was delivered to her room. On 2/1/25 at 9:26 p.m. CNA #1 documented Resident #1 ate 100% (percent) of her meal. On 2/1/25 at 11:41 p.m. LPN #1 documented she had completed a pain evaluation for Resident #1 and that the resident had no exit seeking attempts for the 6:00 p.m. to 6:00 a.m. shift. On 2/2/25 at 6:00 a.m. CNA #2 arrived to the facility, took a report from the night shift CNA #1, and immediately went to the hall and answered the call lights. On 2/2/25 at 6:15 a.m. a bath aide told CNA #2 that Resident #1 was not in her room. Resident #1's roommate said she had not heard her roommate in the room since 5:30 p.m. the night before. On 2/2/25 at 6:20 a.m. CNA #2 reported to a nurse and LPN #1 she could not find Resident #1. LPN #1 told CNA #2 she saw Resident #1 walking down the hallway at 3:00 a.m. -However Resident #1 had already been admitted to the hospital on [DATE] at 8:36 p.m. On 2/2/25 at 6:30 a.m. CNA #2 called the ADON to report she was unable to find Resident #1. The staff were instructed to conduct a full facility check for the resident, including bathrooms, back hallways, the garden and surrounding outside areas. On 2/2/25 at 7:36 a.m. the IDT was alerted the resident was unable to be located. The DON arrived at the facility immediately after and conducted a second search of the facility and surrounding outside areas. At 8:10 a.m. the AC informed the IDT that Resident #1 had been located at a local hospital. At 8:20 a.m. the DON arrived back at the facility after looking for the resident in the surrounding area and a house wide resident count was conducted and all other residents were accounted for. An assessment was conducted of all exterior doors and door alarms and all were all functioning properly. An internal investigation was initiated by the DON and the NHA. LPN #1 was interviewed on 2/2/25 by the DON. LPN #1 stated she heard Resident #1 in her room around 3:00 a.m. when she was taking care of the resident's roommate. LPN #1 said she had not laid eyes on Resident #1 during her shift. LPN #1 explained that her documentation on Resident #1 on the overnight shift was just documentation on the resident's' usual' to explain Resident #1's pain evaluation and number of times the resident attempted to exit the facility. CNA #1 was interviewed on 2/2/25 by the DON. CNA #1 said she documented Resident #1's meal was 100% of the meal intake because Resident #1 did not like to be bothered when she was in her room. LPN #1 and CNA #1 were asked by the DON during the investigation to provide written statements for the events involving Resident #1 on 2/1/25 and 2/2/25, but they did not. V. Staff interviews The CR was interviewed on 2/12/25 at 2:35 p.m. The CR said the facility placed a wanderguard bracelet on Resident #1's wrist in June 2024 and she removed it multiple times until August 2024 and she refused multiple times to have the bracelet placed back on her wrist. The CR said Resident #1 was supposed to be on two-hour checks at the time of her elopement and staff were to check on her every two hours because she was refusing to have the wanderguard on. The CR said the facility thought it had to be around suppertime that the resident left the building through the front door because the front door closed at 6:00 p.m. Dietary aide (DA) #1 and DA #2 were interviewed together on 2/13/25 at 9:55 a.m. DA #1 said residents could exit the facility through the front door or through one of the dining rooms' side doors. DA #1 said the side doors of the dining room went to a lobby and were alarmed. DA #1 said if a resident had a wanderguard on and tried to exit through the side doors, the wanderguard alarm on the wall would sound. DA #1 said if the alarm sounded, there was a code that could be entered to turn the alarm off. DA #1 said residents could also use the dining room side door to go visit a friend in assisted living or get a coffee in the other dining room of the building. DA #1 said she was not at the facility when Resident #1 eloped but she knew of Resident #1. DA #1 said it seemed as though Resident #1 had days she wanted to leave the buildings more than others. DA #1 said she knew who the at-risk residents were in the building and monitored them in the dining room even if they were not attempting to leave through the side door. DA #2 said the dietary staff knew which residents should be redirected away from the dining room side door and the staff should check the elopement wanderguard book every day. The AC was interviewed on 2/13/25 at 10:20 a.m. The AC said was educated on the facility elopement policy after Resident #1's elopement from the facility. The AC said she came to the facility on the morning of 2/2/25 and called local hospitals. The AC said she discovered Resident #1 was in a local hospital during the first phone call she made. The AC said when elopements happened, the facility staff all had specific assignments. She said some staff contacted the hospital and other staff might contact the jails or homeless shelters. The AC said when she called the hospital, she provided specific resident information and the hospital was able to tell her Resident #1 was there. The AC said the facility staff might have to visit the homeless shelters in person because the homeless shelters did not typically provide information on who was there. The AC said if a resident had previously eloped, the facility would try to find that resident at their known or favorite place first. The social services assistant (SSA) was interviewed on 2/13/25 at 11:15 a.m. The SSA she was educated about Resident #1's elopement. The SSA said she had worked at the facility for a very long time and worked various positions in the facility that included the front desk of the assisted living (AL) facility connected to the nursing facility. The SSA said she knew which residents were at risk for elopement and those residents lived on the nursing side of the facility. The SSA said residents at risk for elopement were noted upon admission. She said she noted residents with a dementia diagnosis, even if that resident was not a high elopement risk and also looked out for those residents. The SSA said if a resident consented, the facility took a picture of the resident and included the resident's picture with their information in the elopement binder. The SSA said when she took her break she locked the front doors of the building so people could not enter from the outside, but residents were still able to exit. She said she locked the entrance doors with a key and on the inside of the door she hung a stop sign. The SSA said the stop sign was effective in deterring residents from exiting through the double doors. The SSA said if a resident who was an elopement risk started to or did exit the building through the AL side of the building, or if she was notified of a resident elopement, she immediately called to the nursing side of the facility. The SSA said she would try to reach the DON or other nursing supervisor to inform them of a potential elopement. The SSA said she would also inform the facility plant manager and then attempt to redirect the resident back inside the building. The SSA said she took her cell phone with her to update other staff by phone if she was successful or not in redirecting the resident. The SSA said the facility employed overnight staff that did laundry and while waiting for the laundry to finish, the overnight staff did security rounds outside the facility and checked entrances and doorways. LPN #2 was interviewed on 2/13/25 at 12:10 p.m. LPN #2 said if he was informed of a resident elopement, he would immediately lock his medication cart and start looking for the resident. LPN #2 said if he had to report a resident missing, it depended on the resident what he would report. LPN #2 said some residents were more independent and could sign themselves out of the facility. LPN #2 said if that was the case, he would check the sign out log to see where the resident signed out to go, and then inform the DON or the ADON if he thought the resident had been gone too long. LPN #2 said a resident that needed to be checked every two hours meant the resident needed to be checked at the start of his shift and every two hours after that. LPN #2 said he would, at minimum, put eyes on the resident and depending on the time of day, might ask the resident how they were doing and if they needed anything. LPN #2 said if a resident needed assistance with repositioning, he would have to physically assist the resident with the repositioning and needed to be able to see them directly. The CR, the DON and the NHA were interviewed together on 2/13/25 at 1:15 p.m. The DON said Resident #1 had a diagnosis of dementia. The DON said the dementia diagnosis should have been marked on Resident #1's elopement/wandering evaluation but it would not have increased Resident #1's risk category. The CR said Resident #1's elopement/wandering evaluation should have included the resident's wandering behaviors from the last six months. The CR said indicating those behaviors on the elopement/wandering evaluation placed the resident as high risk (instead of low) but her interventions would have still been the same. The CR said the resident was in the elopement binder at the front desk due to the resident's risk of elopement. The CR said the elopement/wandering evaluation reviewed as part of the plan of correction was correct. The DON said in IDT meetings, new resident admissions or readmissions were reviewed and one of the key parts of the resident admission assessment was the resident's elopement risk and what interventions were needed. The DON said if a resident was an elopement risk, the resident was included in the elopement binder, as were residents with a wanderguard. The DON said nursing staff, such as the DON or other designee, maintained the elopement binder. The DON said the primary failure revealed in the investigation of Resident #1's elopement was the staff working failed to check on Resident #1 as required. The DON said both LPN #1 and CNA #1 should have checked on Resident #1 every two hours. The DON said it was a standard of care the staff should know. The DON said she interviewed the staff who worked during Resident #1's elopement. The DON said said both LPN #1 and CNA #1 had just finished their overnight shift and were still present to look for Resident #1. The DON said LPN #1 had assisted looking for Resident #1 in the nearby neighborhood. The DON said when she received notice Resident #1 was admitted to the hospital, she asked LPN #1 to come back to the facility to interview her further. The NHA said the facility could not confirm for certain the resident was in the building at 5:00 p.m. when the dinner meal tickets were completed. The NHA said it was not unusual for Resident #1's tray to be dropped off in her room and Resident #1 was very independent. The DON said Resident #1 liked to keep her door closed often and did not like to be bothered. The DON said if the resident's door was closed, staff needed to just put eyes on the resident. The DON said LPN #1 and CNA #1 did not put eyes on Resident #1 in the time frame they should have. The DON said to conduct a resident search, the staff started first in the resident's room, and then checked the dining room, the second dining room, and started the other facility rooms, such as shower rooms. The DON said when she arrived at the facility the morning of 2/2/25, the staff had already done the facility search and she did a second room and facility search herself.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting three (#1, #2, and #3) out of five residents. Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 9/8/22) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen who smoked. Interviews with leadership revealed staff had not received training on smoking safety when the facility transitioned to a smoking facility. And, on 3/27/24, Resident #1, a supervised smoker due to his increased confusion and change in safe smoking practices, was given a cigarette and a lighter by the registered nurse (RN) while in the building and walked ahead of the certified nurse aide (CNA) supervising him to the designated smoking area. The resident had his oxygen on, and his nasal cannula in place when he stepped outside the door and lit his cigarette. The oxygen from the cannula ignited immediately. The CNA who followed the resident immediately turned off the resident's oxygen and removed the cannula. While the facility revised the smoking policy after the incident on 3/27/24, record review and observations revealed the revisions were inadequate and ineffective. Smoking and oxygen use were not adequately addressed with residents who smoked and on 4/9/24, observations revealed supervised smoker Resident #1 with a cigarette on his bedside table that had been smoked, with three-quarters to one-half left. The facility's failure to implement interventions to ensure resident safety from smoking accidents before and after 3/27/24 created a situation with the likelihood of serious harm. Resident #1, who had severe cognitive impairment, sustained first-degree burns to the neck, head, and face after lighting a cigarette on 3/27/24, while wearing oxygen administered via nasal cannula. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 1/1/23) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility and related to resident oxygen use and smoking. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen that smoked. Interviews with leadership revealed staff had not received training on smoking safety when the facility transitioned to a smoking facility. And, on 3/27/24, Resident #1, a supervised smoker due to his increased confusion and change in safe smoking practices, was given a cigarette and a lighter by the registered nurse (RN) while in the building and walked ahead of the certified nurse aide (CNA) supervising him to the designated smoking area. The resident had his oxygen on, and his nasal cannula in place when he stepped outside the door and lit his cigarette. The oxygen from the cannula ignited immediately. The CNA who followed the resident immediately turned off the resident's oxygen and removed the cannula. Resident #1, sustained first-degree burns to the neck, head, and face after lighting a cigarette on 3/27/24, while wearing oxygen administered via nasal cannula. While the facility smoking policy was amended on 3/27/24 to provide that the smoking products of residents who required supervision to smoke would be kept secured in either the medication room or nurses' cart, on 4/9/24, Resident #1 was found with a cigarette on his bedside table. It had been lit and three-quarters to one-half remained. B. Imposition of Immediate Jeopardy On 4/9/24 at 3:35 p.m., the Colorado Department of Public Health and Environment (CDPHE) informed the nursing home administrator (NHA) that the facility's failure to implement safe smoking interventions for residents who smoked and to implement effective interventions to prevent injury from cigarettes to Resident #1, created a situation of immediate jeopardy with the potential for serious resident harm. C. Facility Response On 4/10/24 at 3:42 p.m., the facility submitted the following plan (draft #4) to remove the immediate jeopardy. The plan read: Removal of Immediacy Plan: Unsafe Smoking Date/Time Presented to Surveyors: 4/10/24 at 3:35 p.m. Identified here are the steps and immediate action(s) (name of facility) will take to address the reported non-compliance, keep residents safe and free from serious harm or death, and prevent serious harm from occurring or recurring. 1. Resident #1 was identified as a supervised smoker on 03/19/2024. On 3/27/24 Resident #1 was given a cigarette and lighter by a RN while in the building. The CNA supervising did not ensure oxygen was removed prior to Resident #1 lighting cigarette which in turn led to oxygen from cannula igniting. CNA immediately following turned oxygen off. The smoking UDA was updated to include questions referring to oxygen use on 4/9/24. Items added: -Can the resident light their own cigarette? -Does the resident utilize oxygen? -Is the resident able to manage oxygen safety, remove and store for safe smoking practices, -Observe the resident smoking in designated smoking area, -Is the resident able to safely light smoking materials, hold smoking materials safely and dispose of smoking materials appropriately, -Has the resident been educated on safe smoking practices? On 4/10/24 an additional smoke detector was placed in residents (Resident #1's) bathroom. 2. Director of nurses (DON)/Designee and Clinical Resource completed a full house audit of all smoking evaluation(s) by 4/9/24 and updated all residents' care plans. Facility placed an updated smoking list out at the units on 4/9/24. DON to complete additional full house audit of all smokers starting on 4/9/24 to identify need for supervision or adaptive equipment, facility will review all residents BIMS score, and update a smoking assessment (completed 4/9/24). Any resident who smokes with a BIMS (brief interview of mental status) of 12 or below will be placed on supervised smoking (Resident #1 identified). Smoking policy updated on 4/9/24 to reflect the change. Administrator or designee to review updated smoking Policy with all residents who smoke on 4/9/24 or their representative. 3. All Staff/All residents who smoke to be educated on updated Smoking Policy to address the following: -Use of oxygen, -Who is Supervised and Unsupervised, - How to properly supervise smokers -Supervised smoking times -Proper adaptive equipment available and locations, -Proper smoking equipment indicated in smoking area such as blankets/extinguisher,g -Cleanliness of smoking area, and -Monitoring for proper disposal of cigarette butts. -Safety education was provided to residents regarding our smoking policy and -Use of oxygen to ensure that they remove oxygen prior to going out to smoke. -Smoking materials need to be safely stored out of sight of other residents. -No cigarettes or lighters [will] be given to other residents. 4. Staff education to be completed by Administrator, Nurse Manager, SDC (staff development coordinator), Social Worker, or Activity Director. This education will be provided to all staff/residents who smoke by 4/10/24, any staff that is not able to come in for education will be educated over the phone and will be reviewed with Administrator prior to start of next scheduled shift. 5. On 4/9/24 Resident #1 was found to have a cigarette butt on his bedside table. All staff will be educated on Proper Supervision of smokers to include disposing of any non smoked tobacco product in proper receptacle before re-entering building. A facility audit was implemented on 4/10/2024 to include observations of any smoking materials in resident rooms or on their person. An order was initiated to monitor the residents' room for smoking items every shift. If any are found, remove and provide education to the resident on facility smoking policy and safety. This education will be completed by 4/10/24 any staff that is not able to come in for training education will be educated over the phone and will be reviewed with Administrator prior to start of next scheduled shift. This education will be provided by DON/NHA/Designee. Monitoring: DON/Designee will audit all new admissions for smoking preference, complete a smoking evaluation (to include oxygen use and if they are to be supervised or unsupervised) and update the care plan with current interventions. Assessment and care plan to be completed within 24 hours. Smoking assessments will be completed by ADON (assistant director of nursing) or designee. DON/Designee to review all those residents who smoke weekly and document if they continue to follow safe smoking rules, or if there are changes needed to their care plan. Specifically, for Resident #1 daily audits of resident's room and on his person to ensure he has not brought in any smoking materials from the smoking area. Maintenance to monitor smoking area daily for cigarette butts, safety blankets, and No Oxygen use signs x 12-weeks or until compliance is achieved, any issues identified will be discussed in monthly QAPI (quality assurance performance improvement). These audits will continue for 12-weeks until compliance is achieved, any issues identified will be discussed in monthly QAPI. 6. NO OXYGEN WITHIN 10 FEET signage ordered for designated smoking area to arrive 4/12/24. D. Removal of immediate jeopardy On 4/10/24 at 4:00 p.m., CDPHE notified the NHA that the immediate jeopardy was removed based on observations that the facility was taking steps to begin implementation of the above correction action plan. However, based on observations, interviews, and record review, the deficient practice remained at a G level, actual harm that is isolated. II. Resident #1 - smoking incident 3/27/24 A. Resident #1 Resident #1, age [AGE], was admitted on [DATE]. According to the 4/10/24 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, emphysema, dementia, and acute respiratory failure with hypoxia (insufficient oxygen to the body tissues). The 2/19/24 minimum data assessment (MDS) showed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. A 3/23/24 MDS documented the resident had moderately impaired decision-making skills, had poor cues, and required supervision. Per the MDS, he used oxygen. Per the resident's care plan, oxygen was to be administered as ordered by the physician. B. Smoking status Review of Resident #1's care plan, initiated on 3/6/24 for smoking, revealed he had a history of smoking in his room. Pertinent interventions included smoking materials to be kept at the nurses' station or other designated areas. The cigarettes/lighter were to be kept with the nurse and the resident was to ask for them. Review of a resident safe smoking evaluation completed on 3/19/24 at 3:31 p.m. revealed the resident, who smoked five times a day, was determined to be unsafe to smoke without supervision due to increased confusion and cognitive loss. Review of a smoking evaluation completed on 3/27/24 at 2:47 p.m. (prior to the smoking incident the same day) revealed the resident, who now smoked six times a day, remained unsafe with smoking independently. He had cognitive loss and fell forward while standing. The clinical resource nurse assisted the resident in removing his oxygen before attempting to stand from his wheelchair and walk to the designated smoking area. There, he was able to light his cigarette and flick the ashes away from his body but was unable to extinguish his cigarette butt into the receptacle. Failure: There was no evidence the resident's care plan was updated on 3/19/24 to document the resident's status as a supervised smoker. Further, there was no evidence the IDT considered additional safety interventions to instruct staff on how to assist the resident in smoking safely. There was no evidence the resident was educated regarding what staff expected of him as a supervised smoker to ensure his and other residents' safety when smoking. C. Smoking incident on 3/27/24 1. Nurses' notes A review of nurses' notes from 3/27/24 at 3:45 p.m. revealed Resident #1 was assisted to smoke outside by the CNA. The resident was walking ahead of the CNA when he lit his cigarette. The CNA turned off the resident's oxygen and removed the nasal cannula from his face. The resident was noted to have seared facial hair and nose pain. The resident was transferred to the emergency department for evaluation and a review of Resident #1's emergency department records revealed a diagnosis of mild first-degree burns to the face. 2. NHA interview The NHA interviewed on 4/8/24 at 5:34 p.m., said she completed an investigation following the resident's smoking incident. The NHA said the investigation revealed Resident #1 was observed walking outside with CNA #1. RN #1 had given the cigarette and lighter to the resident, rather than to the CNA. CNA #1 said she was assisting the resident outside; he was moving swiftly with his front wheel walker and had his oxygen on. Before she could remove the oxygen and turn it off, the resident lit the cigarette. The NHA said the resident had singed his mustache and the hair to the left side of his face along with the oxygen tubing. She said the resident's primary physician was in the building and had him assessed. The primary physician had him sent to the emergency department for further evaluation as the resident complained of burning in his nose. III. Facility failures contributing to the smoking incident on 3/27/24. 1. Facility failure to review and revise the facility smoking policy and resident safe smoking evaluations, and obtain smoking agreements that addressed oversight and safety interventions after the facility transitioned to a smoking facility, allowing smoking on campus and supervised smoking. On 4/8/24 at 5:34 p.m., the social services director (SSD) and NHA were interviewed. The SSD said before March 2024, the facility was a non-smoking facility, which meant residents who chose to smoke had to smoke cigarettes off campus. She said in March 2024 (a definite date was not provided), the facility became a facility that would allow smoking on campus and there could be supervised smoking. On 4/9/24 at 12:38 p.m., the NHA provided the facility smoking policy and smoking evaluation in effect after the transition to a smoking facility and before the incident with Resident #1 on 3/27/24. a. Smoking Policy The policy, last revised 9/8/22 read that its purpose was to address the wishes of both smoking and nonsmoking residents without compromising the safety of either. Procedures read in part: -The facility does not allow smoking of any kind to occur within the facility. Designated smoking areas outside the building are available for this purpose. -Upon admission, residents who desire to smoke will be assessed for their ability to do so safely. Until the completion of the initial smoking safety evaluation residents will be on supervised smoking. Supervised smoking will be offered during designated smoking times and last no more than 20 minutes. -If IDT (interdisciplinary team) determines that the resident is unable to safely store their smoking materials or require supervision to smoke safely, smoking products will be kept secured in either medication room or nurses cart. -Upon quarterly review by the IDT, or any time a significant change of condition occurs, smoking residents will be re-evaluated as to their ability to smoke safely, either independently or under supervision, and their ability to understand and comply with facility smoking policy. Failure: There was no evidence the smoking policy had been reviewed and revised to address the safety risks associated with the facility's transition to a smoking facility and the plan to allow smoking on campus and supervised smoking. The policy failed to include adequate consideration of the risks and the procedures necessary to ensure the safety of residents with an order for oxygen who smoked. The NHA was interviewed on 4/9/24 at 12:38 p.m. She said residents who are supervised smokers should not be handed their cigarettes or their lighter. Rather, the smoking material needed to be handed to the staff member responsible for assisting the resident outdoors, and oxygen needed to be removed before exiting the facility. -However, these safety interventions were not part of the facility's smoking policy. b. Resident safe smoking evaluation The evaluation asked all residents who smoked the following questions. 1. Cognition- Resident has cognitive loss? 2. Vision- Has a visual deficit? 3. Dexterity- Has a dexterity problem (e.g tremors, paresis, etc)? 4. Balance- Falls forward? Falls leans sideways? 5. Smoking frequency- How many times does the resident smoke per day? 6. Safety- Can resident light own cigarette? Resident need for adaptive clothing, device or assistance? Plan of care is used to assure resident is safe while smoking. Failure: The evaluation failed to include any questions regarding oxygen use and, if the resident, whether an independent or supervised smoker, understood the safety considerations of oxygen use and smoking. c. Smoking agreement The facility failed to provide evidence that residents signed smoking agreements after the facility transitioned to a smoking facility in March 2024 and before Resident #1's smoking incident on 3/27/24. 1. Review of Resident #1's record (see above) revealed his care plan read to administer oxygen as ordered and smoking evaluations revealed he was a supervised smoker. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before his smoking incident on 3/27/24. 2. Review of the record for Resident #2, admitted on [DATE], revealed orders on 1/15/23 that included use of oxygen at 3 liters per minute via nasal cannula, to keep her oxygen saturation at or above 90%. Smoking evaluations revealed she was an independent smoker. Smoking evaluations revealed she had no dexterity problems, could light her own cigarette, and had no need for adaptive clothing, devices, or supervision. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before the smoking incident involving Resident #1 on 3/27/24. Further, there was no evidence the resident was educated on the facility's smoking policy. 3. Review of the record for Resident #3, admitted on [DATE], revealed a progress note dated 9/4/23 that read the resident was oxygen at 2 liters per minute continuously. Smoking evaluations revealed she had no dexterity problems, could light her own cigarette, and had no need for adaptive clothing, devices, or supervision. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before the smoking incident involving Resident #1 on 3/27/24. Further, there was no evidence the resident was educated on the facility's smoking policy. 2. Facility failure to educate staff regarding the transition to a smoking facility and the oversight and necessary safety interventions when allowing smoking on campus and supervised smoking. The assistant director of nursing (ADON) was interviewed on 4/11/24 at approximately 11:00 a.m. The ADON said staff were not provided training on the smoking program before the building transitioned to a smoking facility. She said it was just rolled out. She said after the incident on 3/27/24 with Resident #1, the staff were provided education on the facility smoking program. IV. Continued facility failures after 3/27/24 A. NHA interview The NHA was interviewed on 4/8/24 at 5:34 p.m. She said she immediately provided education to CNA #1 and RN #1 after the incident on 3/27/24. A review of the education revealed it read in pertinent part: -Residents who are supervised smoking should not be handed their stored smoking material. Smoking materials should be handed to the staff member responsible for assisting residents outside for a supervised smoke. -When assisting residents outside for supervised smoking, if residents are noted to be on oxygen, staff is to remove the portable concentrator prior to exiting the facility and prior to handing over the residents smoking materials or assisting with lighting cigarettes. The NHA further stated she then provided training to all staff regarding the smoking policy, which she revised after the incident on 3/27/24, and about safety issues with oxygen. All residents were assessed and all the residents signed a smoking agreement that included the rules of the facility. 1. Smoking policy Review of the facility's revised smoking policy revealed the substantive changes from the 9/8/22 revisions (see above) included the removal of the frequency of smoking for residents that required staff supervision. However, as noted above, the policy failed to include adequate consideration of the risks and the procedures necessary to ensure the safety of residents with an order for oxygen who smoked. Safety interventions disclosed in the NHA's 4/9/24 interview regarding when to hand cigarettes to the supervised resident were not part of the smoking policy. 2. Resident safety smoking evaluation However. as noted above, the resident safety evaluation failed to include any questions regarding oxygen use and, if the resident, whether an independent or supervised smoker, understood the safety considerations of oxygen use and smoking. 3. Smoking agreement However, as noted above, the facility failed to provide evidence that residents signed smoking agreements after the facility transitioned to a smoking facility in March 2024 and before Resident #1's smoking incident on 3/27/24. While smoking agreements were signed by Resident #1, #2, and #3 on 3/29/24, two days after the 3/27/24 incident, the agreements were incomplete. Resident #1's agreement read, all smoking supplies will be kept out of sight within rooms. However, as a supervised smoker, per the smoking policy, smoking products were to be kept secured in either the medication room or nurses' cart. Finally, a review of Resident #1, #2's, and #3's smoking agreement revealed they failed to include specific safety interventions, such as the residents agreeing to remove the nasal cannula before leaving the facility or lighting a cigarette. V. Observations confirmed continued noncompliance with oversight and implementation of safety interventions. Record review revealed the facility updated Resident #1's care plan on 3/28/24 to read Resident #1 was to be provided 1:1 observation while smoking. And, on 4/5/24, a new care plan related to smoking read that a smoke detector was in place in the resident's room and staff was to ensure the resident was escorted to the designated smoking area by staff. However, on 4/9/24 at 9:50 a.m., Resident #1 was observed lying in bed with oxygen on and being administered via a nasal cannula. The resident had a bedside table near his bed. On the bedside table was a cigarette that had been previously lit. Three-quarters to one-half of the cigarette remained. The assistant director of nurses (ADON) was notified at 9:52 a.m. and she removed the cigarette. The ADON told the resident that the cigarette was being removed and the resident responded that it was his cigarette. The ADON told the resident that he was not allowed to keep cigarettes. The ADON said the cigarette would be put with the others in his medication cart. VI. Action taken on 4/9/24 after notification of immediate jeopardy The smoking policy was reviewed and updated on 4/9/24. The changes to the policy were in pertinent part: Smoking times for supervised smokers: 6:00, 9:30, 11:30, 1:30, 3:30, 6:00, 8:30. If the IDT determines that the resident is unable to safely store their smoking materials or [to] require supervision to smoke safely, smoking products will be kept secured in either the medication room or nurses cart. If a resident is deemed an independent smoker, they may keep their smoking supplies in their rooms as long as they kept out of site. If a resident is on oxygen, the tank must be left inside the building and not taken outside to the designated smoking area. For independent residents, cigarettes will not be lit until they are within the designated smoking area. For supervised smokers, once within the designated smoking area, the resident may be given their cigarette and the supervisor will light the cigarette. The lighter is not to be given to the resident. Upon completion of the smoking task, the supervisor will ensure that the cigarette has been put out and the remaining cigarette will be placed inside the cigarette butt receptacle. No partially smoked cigarettes are to be kept. No smoking supplies will be allowed to stay with the supervised smoker. Any resident with a brief interview for mental status (BIMS) score of 12 and below and/or demonstrates the inability to perform safe smoking practices will be placed on supervised smoking. No resident is to give cigarettes or lighters to other residents.