**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident #73 1. Resident status Resident #73, age younger than 70, was admitted on [DATE]. According to the April 2021 CPO, diagnoses included monoplegia (paralysis) of upper limb affecting left non-dominant side, muscle weakness, generalized, and epileptic seizures related to external causes, not intractable, without status epilepticus. The 2/14/21 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. He required supervision for bed mobility, transfers, toilet use, and personal hygiene. He required one-person limited assistance for dressing. Review of Resident #73's comprehensive care plan, initiated 12/12/19, and revised 9/28/2020, revealed the resident was a smoker and had a smoking care plan to ensure his success with the facility smoking policy. Pertinent interventions included encouraging the resident to have his smoking materials in the smoking cart, reviewing the resident quarterly for a smoking assessment, ensuring the resident smoked during supervised smoking times, monitoring the resident's behaviors during smoke breaks, and noting times the resident was seen smoking in undesignated areas and times. Registered nurse (RN) #1 was interviewed on 4/8/21 at 12:26 p.m. RN #1 said Resident #73 was a supervised smoker. She said the facility had designated smoking times for the residents. She said there was a staff member with the residents during the smoking times to supervise them 2. Resident interview and observation Resident #73 was interviewed on 4/5/21 at 3:25 p.m. Resident #73 said he smoked a pack of cigarettes every two days. He said he had his own cigarettes and lighter, and the staff did not keep his smoking supplies for him. He said the staff did not supervise him when he smoked, and he did not wear any type of protective apron when he smoked. He said residents were supposed to smoke in the designated smoking gazebo outside the north entrance of the facility. On 4/7/21 at 2:04 p.m., Resident #73 was observed sitting outside in the parking lot on the north side of the facility. He was sitting in his wheelchair smoking a cigarette. He was not in the designated gazebo smoking area. There was no staff member present for supervision while Resident #73 smoked his cigarette. 3. Review of Resident #73's electronic medical record (EMR) revealed the resident had a known history of failing to comply with the facility's smoking policy and procedures. Progress notes read: -2/13/2020: Resident was smoking a cigarette during nonsmoking time. He was unwilling to leave facility property. -2/17/2020: Social services reviewed and obtained signature in regards to resident's violation of smoking agreement. The Notice of Formal Written Warning was signed by the resident. -3/19/2020: NHA witnessed Resident #73 smoking unsupervised and during non-designated smoking times, which is a violation of the smoking agreement. NHA asked the resident to put out his cigarette and the resident refused. NHA reminded him that he has to smoke during designated times and be supervised. Also, that he is not allowed to have smoking paraphernalia on him. Resident replied he doesn't care. -3/23/2020: Resident was noted smoking on property during a non smoking time. Resident asked to put it out and or to go off of property. Resident refused. - 6/26/2020: Writer observed resident smoking during non-designated times and smoking in a non-designated smoking area. NHA asked the resident to go off property to smoke and not to smoke next to the entrance of the building. Resident told this writer in an aggressive tone, go on inside, I hear you and continued to smoke. -9/2/2020: Social services coordinator (SSC) spoke to resident regarding his non-compliance with the facility smoking policy to discuss interventions that can be put into place in order to promote his success with said policy to avoid discharge. -1/8/21: Resident refused to sign smoking agreement for the new year. Review of Resident #73's EMR revealed a facility smoking agreement dated 1/8/21. It confirmed Resident #73 had refused to sign the smoking agreement. Further review of the resident's EMR revealed the resident had received a Notice of Formal Written Warning on 2/17/2020 for violation of the facility's smoking policy. The warning read in pertinent part, The facility's policy is to issue one warning with the first violation of the smoking policy. This document serves as your formal warning. If subsequent violations occur, the next step will be to issue a 30-day discharge notice due to safety concerns. The signature below indicates you have received the written warning and understand the consequences related to your actions. Your signature also indicates your understanding that the next violation of the smoking policy will result in a 30-day discharge notice. Resident #73 signed the warning on 2/17/2020. The Smoking Safety Screen assessment dated [DATE] documented Resident #73 had dexterity problems and had been known to smoke in non-designated places. The assessment further documented the resident had been educated on correct areas and times for smoking. 3. Failure to take sufficient steps to address the resident's noncompliance and unsafe smoking. Record review revealed no revisions to the resident's care plan to address his noncompliance or to promote his safety when smoking. His dexterity problems were not identified and addressed. Any interventions discussed with the SSC on 9/2/2020 were not incorporated into the resident's care plan, even though record review revealed current interventions were ineffective. There was no evidence the facility had considered new interventions such as increasing supervision. C. Resident #67 1. Resident status Resident #67, age younger than 70, was admitted on [DATE], and readmitted on [DATE]. According to the April 2021 CPO, diagnoses included acquired absence of right leg below knee, other chronic osteomyelitis, unspecified site, polyneuropathy, unspecified, unspecified convulsions, and acquired absence of other left toes. The 3/5/21 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. He required supervision for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #67's comprehensive care plan, initiated 5/1/19, and revised 2/9/2020, revealed the resident was a smoker. The care plan further revealed the resident understood the smoking policy, but refused to follow it or sign the smoking agreement. The resident also kept his smoking materials with him. Pertinent interventions included conducting a smoking assessment quarterly, annually, with a significant change, and as needed, continuing to remind the resident of the smoking agreement and policy, encouraging the resident to keep his smoking materials locked up while he was in the building, and remind the resident of smoking times and the policy if he was seen smoking on the facility property. RN #1 was interviewed on 4/8/21 at 12:26 p.m. RN #1 said Resident #67 was a supervised smoker. 2. Resident interview and review of the resident's EMR revealed the resident had a known history of failing to comply with the facility's smoking policy and procedures. Resident #67 was interviewed on 4/6/21 at 11:16 a.m. Resident #67 said he was not supervised when he was smoking. He said he usually took his wheelchair off facility property when he smoked. He said he kept his cigarettes and lighter in his room. Review of Resident #67's EMR revealed the following progress notes: -5/26/2020: Around 4:00 p.m., this nurse was informed that Resident #67 went to the smoking area and started having a seizure. 911 was called and the resident was sent to the emergency room. -6/17/2020: Resident #67 is a smoker who has been noted to not be compliant with the facility smoking policy. Resident is currently seeking placement in the community. -1/8/21: Resident refused to sign smoking agreement for the new year. Further review of Resident #67's EMR revealed a facility smoking agreement dated 1/8/21. It confirmed Resident #67 had refused to sign the smoking agreement. The Smoking Safety Screen assessment dated [DATE] documented Resident #67 had dexterity problems. The assessment further documented the resident had been informed of and encouraged to safely follow the smoking policy. 3. Failure to take sufficient steps to address the resident's non-compliance with facility policy. Record review revealed no revisions to the resident's care plan to address his noncompliance or to promote his safety when smoking, even though record review demonstrated current interventions were ineffective. There was no evidence the facility had considered new interventions to promote compliance with facility policy and procedure. Further, there were no interventions to increase the resident's supervision to address the safety concerns raised by his seizure while in the smoking area 5/26/2020. Finally, his dexterity problems were not identified and addressed. D. Resident #46 1. Resident status Resident #46, age [AGE], was admitted on [DATE], and readmitted on [DATE]. According to the April 2021 CPO, diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, post traumatic seizures, epilepsy, unspecified, not intractable without status epilepticus, vascular dementia without behavioral disturbances, and Parkinson's disease. The 2/11/21 MDS assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. He required supervision with bed mobility, transfers, and toilet use. He required one-person extensive assistance with dressing and personal hygiene. Review of Resident #46's comprehensive care plan, initiated 8/17/2020, and revised 4/8/21 (during survey), revealed the resident was a smoker. Pertinent interventions included encouraging the resident to have his smoking materials in the smoking cart, reviewing the resident quarterly for a smoking assessment, the resident smoking during supervised smoking times, monitoring the resident's behaviors during smoke breaks and noting times he was seen smoking in undesignated areas and at undesignated times, and staff assessing the resident for any holes in his clothes and/or burns on his fingers related to smoking. 2. Observations On 4/5/21 at 12:59 p.m., Resident #46 was observed sitting in his wheelchair outside the north entrance of the facility. He was smoking a cigarette in a non-smoking area. There were no staff members present outside while the resident was smoking. 3. Review of Resident #46's EMR revealed the following progress notes that the resident continued to smoke, although he was not an approved smoker and not allowed to smoke on facility property. -8/17/2020: SSC educated resident on the smoking policy, helping him to understand that the facility is a non-smoking environment and the resident was not grandfathered into the facility to indulge in smoking. Resident expressed his understanding of this. -9/1/2020: SSD observed resident smoking late yesterday while leaving the building. SSD educated resident that he was not an approved smoker and would not be allowed to smoke on the property. Resident #46 stated that he understood and would not smoke anymore. -9/3/2020: Resident was observed smoking in the smoking area. Resident was not grandfathered in to be able to smoke on the facility grounds since we are a smoke free facility. NHA informed him that he is not allowed to smoke on grounds. Resident understood and put out his cigarette. Social Service will follow up. -9/3/2020: SSC met with resident regarding recent sightings of him smoking. SSC drafted a written warning educating resident that he is not allowed to smoke because he is not a grandfathered smoker. SSC offered resident multiple means to help curb his craving including a nicotine patch which he openly expressed desire to have. SSC will collaborate with nursing staff and resident's DR. in order to provide him with materials that will promote his success. -9/13/2020: Social services director (SSD) saw resident in the smoking area again today. SSD educated Resident #46 that he was not an approved smoker. Resident stated that he didn't care, but did put his cigarette out and toss it so that it could not be re-lit. SSD called up to the nurse to inquire about nicotine patch, nurse stated that patch has been ordered and is available, but resident has refused to put it on. -9/22/2020: Resident continues to smoke despite interventions put in place to help curb his craving and continuous education on why he is unable to smoke. Interventions include having the nicotine patch ordered for him, as well as providing him with mints and gum. He continues to deny he ever started smoking but continues to be observed doing so. When the resident was asked what else SSC can do for him to help this, he is unable to express his needs at this time. SSC will continue to follow up and observe as needed. -9/24/2020: Recently, resident has been noted to take up smoking and as he is not a grandfathered smoker he was educated by the interdisciplinary team as to why he is not allowed to smoke and given choices as to what his options are to help him quit. SSC will continue to follow resident as needed and will continue success with anti-smoking program. -10/6/2020: Resident observed smoking in smoking area, outside of designated smoking times. Reminded the resident that he is not included in the smoking agreement and is not allowed to smoke at the facility. Resident voiced understanding and put out cigarette. - 10/7/2020: SSC spoke with Resident #46 regarding creating a plan to help him stop smoking as he is not a grandfathered smoker in the facility. Resident made it abundantly clear to SSC that he did not want any rewards or incentives in order to help him stop smoking as he has no desire to stop. -10/11/2020: Writer observed resident smoking in smoking area. -3/12/21: Administration note: Nicotine Patch 24 hour 14 milligram/24 hours. Apply one patch transdermally one time a day for tobacco abuse. Resident is still smoking. Patch not recommended when smoking. Review of Resident #46's EMR revealed a facility smoking agreement dated 4/8/21 (during the survey). Resident #46 had signed the smoking agreement, however, there were no previously signed smoking agreements found in the resident's EMR. Further review of the resident's EMR revealed the resident had received a written smoking notice on 9/3/2020. The notice read in pertinent part, I, Resident #46, am receiving this written notice to acknowledge that I am not a smoker but have been recently noted to pick up smoking. I am signing this document to acknowledge that I have been educated twice now that I am not a grandfathered smoker and if I continue to do so, I will be given a 30-day notice. Resident #46 had signed the warning on 9/3/2020. The Smoking Safety Screen assessment dated [DATE] (during the survey) documented Resident #46 had been informed of the smoking rules. The assessment further documented the resident stated he does not smoke and denied smoking within this last year. The assessment did not document that Resident #46 was not a grandfathered smoker. C. Facility failures in addressing Resident #46's noncompliance. See care plan above; the resident's care plan failed to identify the resident as not grandfathered in to smoke at any time at the facility. His repeated noncompliance was not noted or specifically addressed. When measures identified in the progress notes were not effective, the facility failed to consider a care conference or interdisciplinary team meeting to discuss additional ways to address his noncompliance. Further, review of the schedule for Smoking Safety Screen assessments revealed Resident #46 had not had a Smoking Safety Screen assessment conducted prior to 4/8/21, despite the facility staff witnessing the resident smoking on several occasions. Based on observations, interviews and record review, the facility failed to ensure the residents' environment remained free from accident hazards as possible, affecting eight out of 15 sample residents (#65, #73, #67, #79, #46, #42, #22 and #10). Specifically: SMOKING FAILURES The facility failed to develop and implement an effective system of oversight and safety interventions to prevent smoking accidents involving Residents #65, #73, #67, #79, #46, #42. Failures included a lack of identification and communication of residents' smoking risks and safe smoking needs, a failure to develop effective smoking interventions, and a failure to take steps to ensure the facility's smoking policy and procedures were implemented. The facility's failures created a situation with the likelihood of serious harm for Residents #65, #73, #67, #79, #46, #42, all of whom smoked, if immediate action was not taken. Resident #65, who was moderately cognitively impaired and diagnosed with left hemiparesis (weakness), sustained multiple cigarette burns in various stages of healing to the left thigh and left upper extremity, as well as cigarette burns to his clothing and his wheelchair. EQUIPMENT FAILURES The facility failed to investigate the root cause and assess Resident #22 for injury when the Hoyer mechanical lift broke and tilted during a transfer, and failed to properly position the [NAME] lift for Resident #10 to prevent an accident. Findings include: SMOKING FAILURES I. Immediate Jeopardy A. Findings of Immediate Jeopardy Observation, record review, and interviews with staff and Resident #65 demonstrated the facility did not have an effective system in place to implement safe smoking practices for residents who smoked. Interventions were not implemented to prevent cigarette burns to Resident #65. Resident #65, according to the electronic medical record, had a known history of burns to his wheelchair and upper extremities from cigarette smoking. On 6/3/20, the resident experienced burns to his left upper extremity. There were no new interventions put in place. On 1/7/21 the resident's wheelchair was documented in the electronic medical record to have burns in the seat. No new interventions were implemented. Resident #65 was observed smoking on 4/7/21 at 4:33 p.m. without being encouraged to wear a smoking apron as his care plan indicated. On 4/8/21 at 11:00 a.m., Resident #65 was observed with three cigarette burns to his left upper extremity and burns to his wheelchair seat. Interviews revealed staff were not knowledgeable about the safe smoking interventions needed for Resident #65. Record review indicated smoking assessments were not accurate or complete for Resident #65, failing to include his need for an apron or supervision while smoking. Review of the facility policy revealed all residents who smoked were to be supervised; yet, staff interviews revealed not all were aware of this expectation in the policy. Further, contrary to facility policy, Residents #73, #67 #42 and #79 reported they kept their cigarettes, Residents #73, #67 and #42 kept both their cigarettes and lighter, and Residents #79 and #42 said they smoked when they chose to. Observations revealed Residents #73, #46, and #79 smoking on facility grounds in non designated areas; Residents #73 and #46 were not being supervised Finally, staff was not aware which residents had safe smoking interventions, such as smoking aprons, and unaware which residents currently smoked. B. Imposition of Immediate Jeopardy On 4/8/21 at 12:51 p.m., the nursing home administrator (NHA) was informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to take steps to implement the facility's smoking policy, implement safe smoking interventions for residents who smoke and implement interventions to prevent multiple cigarette burns to Resident #65, created a situation of immediate jeopardy with the potential for serious resident harm. C. Facility response On 4/9/21 at 2:59 p.m., the facility submitted the following plan (draft #4) to remove the immediate jeopardy. The plan read: Corrective Action: On 4/8/2021 at 2:51 p.m., the community implemented one to one (1:1) with resident #65, 24 hours per day, seven days per week when the resident is on the facility's premises. Around the clock 1:1 will be reevaluated following discussion with MHCD (local mental health center). The nurse practitioner (NP) assessed the resident on 4/8/2021. An NP Acute Progress note stated, Resident #65 has several superficial scattered wounds L (left) lower forearm and L (left) thigh. Patient denies pain or concern about them. Patient declines to have leg examined. Diagnostic Statement: Abrasion of left little finger, Blister (nonthermal) of left forearm, initial encounter, and scar condition and fibrosis of skin. Wound team to assess and follow until resolved. Abrasion to the left little finger is being treated with skin prep. Assistant director of nursing (ADON) completed head to toe assessment of Resident #65 on 4/8/2021. The ADON observed: Left Medial wrist Wound # 1, l x 0.8 scab, Wound # 2, 1x 0.8 scab, Wound # 3, 0.7 x 0.7, Left thumb cluster Wound #4, 2.0 x 2.0, Left Pinky Wound #5, l.3 x 0.7, Left thigh Wound #6, left thigh 2 x l.7, Wound #7, left thigh l.8 x 0.7. All measurements listed in centimeters (cm). All wounds closed and not needing treatment. Social Service Coordinator reviewed the smoking agreement with Resident #65 and provided a copy on 4/8/2021. The community initiated smoking apron and cigarette extender for safety for Resident #65 by 4/8/2021. If resident #65 refused to wear a smoking apron and use cigarette extender resident will be observed 1:1 by Smoking Supervisor. Refusal to wear apron and use extender will be reported to Administrator or designee. Refusals may result in resident losing smoking privileges as designated by the care plan and per community smoking policy up to and including 30 day discharge from community. Director of Rehab ordered Resident #65 a bag for his wheelchair to hold smoking adaptive equipment for when he leaves Saint [NAME]'s premises. Resident #65's 1:1 will ensure resident has his smoking adaptive equipment in the bag prior to resident leaving St. [NAME]'s premises. The community ordered flame-resistant clothing for Resident #65 on 4/8/2021. The flame resistant clothing will arrive by Tuesday, April 13, 2021. Director of Nursing educated resident on how to safely use cigarette extender and smoking apron on 4/8/2021. Smoking supervisor/designee will load and unload Resident #65's cigarette extender during designated smoking times. On 4/8/2021 Resident #65 agreed for Saint [NAME] Health Center to search his room if Saint [NAME] has probable cause. Community will request permission with resident each time a search may be indicated. On 4/9/2021 the community will begin to collaborate with Resident #65's mental health provider to develop a behavior management program to keep Resident #65 safe. On 4/9/2021, the Director of Nursing (DON) offered Resident #65 an e (electronic) cigarette. Resident refused intervention. Social Service Coordinator/designee conducted a full house audit to identify residents that are smoking on 4/9/2021. 11 residents were identified as actively smoking. On 4/5/2021 it was initially reported that 15 residents were smoking however the audit conducted on 4/9/2021 indicated 4 residents have quit smoking. Social Service Director/designee will audit all residents who are identified as a resident who smokes to confirm accurate and current smoking safety screens, smoking agreements, and care plans to be completed by 4/9/2021. On 4/9/2021 Director of Nursing reviewed smoking safety screens, smoking agreement and care plans for accuracy. By 4/9/2021, Nurse/designee completed a skin observation tool for all residents who smoke. Nurse/designee documented results on Skin Observation tool. Results were communicated to IDT (Social Services, Nursing Administration, Administrator and Assistant Administrator) if burn marks were observed on resident's clothing, wheelchair, and cushion a high risk progress note would be completed. IDT will review the dash board during morning meeting for high risk progress notes. Systemic Measures: Director of Nursing/designee will provide education to all staff regarding smoking policy by 4/8/2021. Education includes the facility will provide a safe smoking environment that ensures the health and well-being of all members of the SPHC community. Smoking on campus is only allowed during the scheduled smoking times of: 7:00 a.m. to 7:30 a.m., 9:30 a.m. to 10:00 a.m., 11:30 a.m. to 12:00 p.m.,1:30 p.m. to 2:00 p.m., 4:30 p.m. to 5:00 p.m., 7:30 p.m. to 8:00 p.m., and 9:00 p.m. to 9:30 p.m. A staff member must be present during smoking times for residents. All residents are considered supervised for smoking. If a staff member identifies burns, ashes, or holes in clothing on a resident, they will immediately report to the SS (social services), Nurse, and/or NHA. A skin assessment, a risk report, smoking safety screen and notifications to family will be completed. Tobacco products, e-cigarettes and smoking materials must be stored in smoking cart. If smoking materials are visualized in room, the staff will request to move the materials to the smoking cart. If any resistance from resident a call must be placed to facility management to report concerns. Residents are not to buy, borrow, trade, or give cigarettes/smoking materials to any other resident or visitors. Smoking supervision will be provided by an assigned member of the interdisciplinary or direct care staff as follows: Obtaining smoking materials and smoking products from the smoking cart. -Escort the residents to the designated smoking area. -Assistance with removal of oxygen apparatus, if applicable. -Assistance with application of smoking apron, if applicable. -Providing/lighting the tobacco product for the resident once they have arrived in the designated smoking area and/or loading their e-cigarette. -Monitor the smoking process until the tobacco product is extinguished. -Monitor the use of ashtrays and disposal of used tobacco products and e-cartridges. If a resident does not follow the smoking safety rules, the resident will be reassessed by direct care staff with the interdisciplinary team. If unsafe, residents may lose smoking privileges as designated by the care plan. If a resident is unable or unwilling to follow their safe smoking care plan, social services will coordinate additional education, assessment, and notifications to address smoking safety and residents' rights. This may include verbal or written warnings indicating the consequences of continued unsafe smoking, and family/responsible party, physician, and ombudsmen notification. Smoking Interventions for resident #65: -Must wear a smoking apron. -Must use extender on cigarettes. -Will have a one on one monitoring him. Starting 4/9/2021 Director of Nursing/designee will train all staff on how to properly use smoking adaptive equipment. Starting 4/9/2021 education is to be provided to resident by Social Services/designee about interventions identified on smoking safety screen. Quality Improvement Specialist will complete education with social services on Smoking Safety Screen by 4/8/2021. Director of Nursing/designee will educate all new employees on Saint [NAME]'s Smoking Policy prior to working the floor. Starting on 4/9/2021, Social Service Coordinator/designee will develop and implement a tool, Smoking Cliff Note to have in the smoking cart for staff to reference on residents who have smoking adaptive equipment. Social Service Coordinator/designee will update as needed. Social Service Director/designee will train all staff on Smoking Observation Form. Designated Smoking Supervisor will complete a Smoking Observation Form at every designated smoke time starting 4/9/2021. Starting 4/9/2021, prior to locking the Smoking Safety Screen, Social Services/designee will review quarterly per MDS schedule the screen with IDT for accuracy and interventions, if indicated. Starting 4/9/2021 SSC/designee will review Saint [NAME]'s Smoking Policy and Smoking Agreement with all residents who smoke as well as provide them a copy by 4/9/2021. Starting 4/9/2021 the nurse is to notify nursing management if a resident refuses a weekly skin observation or bath. All refusals will be reassessed by nursing management. Monitoring: Social Services Director/designee will complete audits of all smoking safety screens, smoking agreements, and care plans weekly based off the (minimum data set (MDS) schedule, policy violations, and change of conditions starting 4/8/2021. NHA/designee will review Smoking Observation Form in morning clinical meetings Monday Friday. On Saturday and Sunday the manager on duty will review Smoking Observation Form. Screener/designee will monitor 24 hours/day via camera or in person the smoking area during unsupervised times for four weeks, and if no issue is identified, the IDT can determine how often going forward. D. Removal of immediate jeopardy On 4/9/21 at 3:54 p.m., the NHA was notified the immediate jeopardy had been 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, deficient practice remained at a G (actual harm that is isolated). II. Facility policy and procedure A. The Smoking Policy, reviewed 8/20/15, was received from the director of nursing (DON) on 4/8/21 at 12:49 p.m. The policy documented in pertinent part: This policy includes the use of tobacco in cigarettes, pipes, cigars and vapors from electronic cigarettes (e-cigarettes). An illicit drug free environment will be maintained, including but not limited to medical marijuana. Colavria maintains smoke free facilities, with designated outdoor smoking areas. To sustain a safe environment, a smoking safety screen should be performed on admission, quarterly with a potential change of condition or behavior and as needed. The facility may impose smoking restrictions on residents at any time if the resident cannot smoke safely with the available levels of support and supervision. The facility may also conduct room and body searches in situations of a resident not complying with smoking privileges and creating a safety risk to others. If resident behavior or choices place them or others at risk, it may be necessary to consider a 30-day or emergency discharge notice. However, every effort will be made to partner with residents to safely accommodate their preference to smoke. Smoking times may be scheduled by the Community for all residents, or individualized as designated in a residents' care plan. Smoking paraphernalia will be kept at the nursing station for all residents. Residents may not manage or store their own cigarettes and lighters, and must follow the safety rules, including oxygen management. Safety Rules: All residents that smoke must follow safety rules which include: Tobacco products, e-cigarettes and smoking materials must be stored at the nursing station. Family members and visitors will be educated to leave tobacco products and smoking materials for these residents at the nursing station. Additional resident smoking interventions will be addressed on individual resident care plans. Residents are not to buy, borrow, trade, or give cigarettes/smoking materials to any other resident or visitors. Residents and resident rooms may be searched at any time by facility staff for[TRUNCATED]