**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect and keep residents safe from abuse and neglect for two (#2 and #11) of three residents reviewed for abuse out of 16 sample residents. A review of resident records and interviews with staff revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care-secure unit that protected residents from resident-to-resident abuse. RESIDENTS #6 AND #2 On 4/8/24, Resident #6 was admitted to the facility's memory care-secured unit. It was known to the facility, before the resident's admission, that he was displaying an increase in unsafe wandering and physical and verbal aggression toward other residents at the facility where he had previously resided. Resident #6 was discharged from his previous facility to the hospital due to his aggressive behaviors and remained at the hospital waiting until another long-term care facility placement could be obtained. A pre-admission long-term care (LTC) level of care eligibility assessment completed on 3/27/24 at the hospital documented Resident #6 exhibited inappropriate behaviors that put himself and others at risk and he frequently required more than verbal redirection to interrupt inappropriate behaviors. During the admission process, the facility failed to fully assess Resident #6's care needs and develop and implement a behavioral management care plan with interventions to monitor his behavior through his transition and adjustment to the facility's secured memory care unit and to prevent Resident #6 from being aggressive towards other residents residing in the facility. Additionally, the facility failed to inform the facility staff about the resident's history and increasing aggressions that led to his discharge from the previous facility where he had resided. In the first 48 hours of Resident #6's stay in the memory care unit, staff did not identify the resident's behaviors were becoming more aggressive. There was no reassessment of Resident #6's care needs despite staff observing changes in his demeanor from being extremely polite and asking for permission to do things, to wandering the unit and engaging in aggressive behaviors, which included rude mocking and bullying towards the unit's other residents. On 4/10/24 at approximately 5:00 p.m., Resident #2 was in her bed for the night. Licensed practical nurse (LPN) #1 heard moaning noises and a second person making mocking noises following each of Resident #2's moans. LPN #1 went to check on the resident and discovered Resident #6 on top of Resident #2 punching her in the face several times with a closed fist. LPN #1 called for additional staff assistance to separate the residents. Resident #2 suffered severe injuries to her face and body as a result of the physical assault. Because the staff did not have a full history of Resident #6 behavior or assess the resident's care needs and develop a behavior-focused care plan with interventions to monitor and treat potential aggressive behaviors, they failed to monitor Resident #6's activities closely enough to prevent him from physically assaulting Resident #2 who was incapable of protecting herself. As a result of the facility's failures, Resident #2 suffered significant facial trauma, including a subdural hematoma (pooling of blood between the brain and its outermost covering), left frontal scalp hematoma (pooling of blood outside of a blood vessel and under the skin), frontal process of the maxilla (upper jaw) fractures, nasal septum (cartilage between the right and left nostril) fractures, hemorrhaging of the right parietal gland (gland located on each side of the face just below the ears), left periorbital (area around the eye) soft tissue hematoma and bilateral sacral (the bone located at the base of the spine) fractures. Resident #2's injuries required hospitalization and ongoing monitoring of her injuries. Although Resident #6 was discharged from the facility on 4/10/24 due to the incident involving Resident #2, record review and interview revealed the facility failed to identify and correct gaps in its screening and admission process. Specifically, the facility failed to consider and implement practices to obtain and communicate information that would ensure an admission was safe and appropriate for the newly admitted residents and residents who were already settled in the facility. Further, the facility failed to consider and implement practices to screen prospective residents with behavioral needs to ensure the facility could provide care as identified during the screening assessment. The facility's failures in its screening and admission process and the communication to staff of the information obtained during this process created a situation of immediate jeopardy with the potential for serious harm to other residents residing in the facility's memory care-secured unit. RESIDENTS #5 AND #11 Record review revealed the facility failed to take sufficient steps to prevent Resident #5 from physically abusing Resident #11 who Resident #5 hit when Resident #11 wandered into Resident #5's room. Resident #11 sustained a bloody nose and cuts to his face. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy A review of resident records and interviews with staff revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care-secure unit that protected residents from resident-to-resident abuse. On 4/8/24 Resident #6 was admitted to the facility's memory care-secured unit. It was known to the facility, before the resident's admission, that he was displaying an increase in unsafe wandering and physical and verbal aggression toward other residents at the facility where he had previously resided. Resident #6 was discharged from his previous facility to the hospital due to his aggressive behaviors and remained at the hospital until placement in another facility could be obtained. A pre-admission long-term care (LTC) level of care eligibility assessment completed on 3/27/24 at the hospital documented Resident #6 exhibited inappropriate behaviors that put himself and others at risk and he frequently required more than verbal redirection to interrupt inappropriate behaviors. During the admission process, the facility failed to fully assess Resident #6's care needs and develop and implement a behavioral management care plan with interventions to monitor his behavior through his transition and adjustment to the facility's secured memory care unit, and to prevent Resident #6 from being aggressive towards other residents residing in the facility. Additionally, the facility failed to inform the facility staff about the resident's history and increasing aggression that led to his discharge from the previous facility. In the first 48 hours of Resident #6's stay in the memory care unit, staff did not identify that the resident's behaviors were becoming more aggressive. There was no reassessment of Resident #6's care needs despite staff observing changes in his demeanor from being extremely polite and asking for permission to do things, to wandering the unit and engaging in aggressive behaviors, including rude mocking and bullying towards the unit's other residents. On 4/10/24 at approximately 5:00 p.m., Resident #2 was in her bed for the night. Licensed practical nurse (LPN) #1 heard moaning noises and a second person making mocking noises following each of Resident #2s moans. LPN #1 went to check on the residents and discovered Resident #6 on top of Resident #2 punching her in the face with a closed fist. LPN #1 separated the residents. Resident #2 suffered severe injuries to her face and body as a result of the physical assault she endured. Because the staff did not have a full history of Resident #6 or a care plan with interventions to monitor and treat potential aggressive behaviors, they did not monitor Resident #6's activities closely enough to prevent him from physically assaulting Resident #2 who was incapable of protecting herself. As a result of the facility's failures, Resident #2 suffered significant facial trauma, including a subdural hematoma (pooling of blood between the brain and its outermost covering), left frontal scalp hematoma (pooling of blood outside of a blood vessel and under the skin), frontal process of the maxilla (upper jaw) fractures, nasal septum (cartilage between the right and left nostril) fractures, hemorrhaging of the right parietal gland (gland located on each side of the face just below the ears), left periorbital (area around the eye) soft tissue hematoma and bilateral sacral (the bone located at the base of the spine) fractures. Resident #2's injuries required hospitalization and ongoing monitoring of her injuries. Although Resident #6 was discharged from the facility on 4/10/24 due to the incident with Resident #2, record review and interviews revealed the facility failed to identify and correct gaps in its screening and admission process. Specifically, the facility failed to consider and implement practices to obtain and communicate information that would ensure an admission was safe and appropriate for the newly admitted residents and residents who were already settled in the facility. Further, the facility failed to consider and implement practices to screen prospective residents with behavioral needs to ensure the facility could provide care as identified during the screening assessment. The facility's failures in its screening and admission process and the communication to staff of the information obtained during this process created a situation of immediate jeopardy with the potential for serious harm to other residents residing in the facility's memory care-secured unit. B. Facility notice of immediate jeopardy On 6/13/24 at 4:15 p.m., the director of nursing (DON) and corporate nurse consultant (CNC) #1 were notified the facility's failure to ensure its new resident admission screening process was effective and created an environment in the memory care-secure unit that protected residents from resident-to-resident abuse, created a situation of immediate jeopardy with the potential for serious harm if not immediately corrected. C. Plan to remove immediate jeopardy On 6/14/24 at 2:36 p.m., CNC #1 and the DON presented the following plan to address the immediate jeopardy situation. It read in pertinent part: Plan to remove Immediate Jeopardy Immediate Action Done Resident# 6 was discharged from the facility. On 6/13/24, Resident #5 was placed on one-to-one monitoring. Will continue one-to-one support and will review with the interdisciplinary team (IDT) team on 6/18/24. The facility will hold admissions until it can review the pre-admission screening tool for residents with known behaviors. Once the review is completed, an ad hoc (done for a particular purpose) quality assurance performance improvement (QAPI) meeting will be held. The abuse policy was reviewed on 6/13/24. On 6/14/24, the nurse practice educator (NPE)/designee educated all staff on the facility abuse policy. Staff not educated on this date will be educated prior to their next shift. On 6/14/24, facility management staff reviewed the facility assessment on staffing and skills to care for residents with behaviors. Plan: Beginning 6/14/24, the facility revised its pre-admission screening intake form to include a history of behaviors and supervision needs by the admissions director. This will be an ongoing process. The admission team will review electronic records and utilize the pre-admission screening tool. Pre-admission screening forms will be reviewed with nursing, social services, and administration to determine if the facility can meet the needs of residents based on the screening process or if additional information is needed to decide. On 6/14/24, the director of nursing educated the admissions team on the pre-admission screening tool and process. Beginning 6/14/24, residents in the memory support unit will be reviewed by social services and/or nursing/designee for behaviors, wandering, current interventions, and their care plan related to behaviors. This review will be completed by 6/21/24. Upon completion of the review, staff who are assigned to the memory support unit will be trained in specific resident care needs. The training will be completed prior to their next assigned shift. Any admission to the memory support unit will be reviewed by social services and nursing to enter behavior tracking and a baseline care plan to meet the resident's needs. The facility assessment was reviewed and revised to include staffing levels for all departments in the memory support unit. New hires will receive education on abuse prevention and de-escalating behaviors during onboarding by the NPE (nurse practice educator). The nursing home administrator (NHA) will implement a review with the quality assurance performance improvement (QAPI) committee to review and interpret all abuse findings. All audit findings will be reviewed at the monthly meeting for at least three months or until the compliance pattern is maintained. D. Removal of immediate jeopardy On 6/14/24 at 3:30 p.m., the DON and CNC #1 were notified that the facility's plan to remove the immediate jeopardy was accepted based on the facility's plan to implement the measures above. However, the deficient practice remained at a G level, isolated, actual harm. II. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Prevention Program policy, revised April 2021, was received from the DON on 6/14/24 at 10:30 a.m. The policy read in pertinent part, Residents have the right to be free from abuse. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to, facility staff and other residents. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and responding to abuse, stress management, and handling verbally or physically aggressive resident behavior. Implement measures to address factors that may lead to abusive situations, for example: -Adequately prepare staff for caregivers' responsibilities; -Provide staff with the opportunity to express challenges related to their job and work environment without reprimand or retaliation; -Instruct staff regarding appropriate ways to address interpersonal conflicts; and, -Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. III. Resident-to-resident physical abuse between Resident #6 and Resident #2 A. Resident #2 (victim) 1. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, depression, and disorder of bone density. The 4/25/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to complete the brief interview for mental status (BIMS). The resident had short and long-term memory problems and was unable to recall staff names or faces, the location of her room, and was unaware she was in a nursing home facility. The resident had unclear speech and only sometimes understood conversations and responded only to direct communication. The resident was dependent on staff for bed mobility, toilet use, and transfers and was unable to walk. 2. Record review A hospital service report, dated 4/11/24, documented Resident #2 presented to the emergency room (ER) on 4/10/24 via EMS (emergency medical services) for evaluation after she sustained an assault. The resident was residing at a memory care facility when a staff member found the patient in her bed with another patient on top of her and hitting her in the face with a closed fist. Per EMS, staff denied any loss of consciousness and stated she was nonverbal at baseline. Imaging was obtained by the ER provider with findings of a subdural hematoma, bilateral sacral fractures, frontal processes of maxilla and nasal septum fracture, injury to the right parotid gland, facial and left periorbital soft tissue hematomas. The ER provider consulted neurosurgery who recommended the resident be admitted to the floor. Facial trauma was also consulted by the ER provider. The ER provider consulted trauma surgery services for admission and medical management. Resident #2 discharged from the hospital on 4/12/24 with a referral to see a neurosurgeon within two weeks of discharge. She was to follow up with facial trauma specialist as needed and follow up with her primary care physician in one week for further medical management and refill of medications. A nurse practitioner exam note dated 4/29/24 documented Resident #2 had increased weakness since she was assaulted, per reports from nursing staff. The resident used to feed herself and was now requiring assistance with meals. The resident was previously a two-person assist for transfers and was now requiring the use of a sit-to-stand lift for transfers. A neurosurgical consult follow-up dated 5/7/24 documented the subdural hematoma collections had resolved with no increase in intracranial hemorrhaging and further treatment was not warranted. B. Resident #6 (assailant) 1. Resident status Resident #6, age [AGE], was admitted on [DATE] and discharged to the hospital on 4/10/24. According to the April 2024 CPO, diagnoses included cerebral palsy, dementia, and major depression. The 4/10/24 discharge MDS assessment revealed the resident needed partial to moderate assistance with toileting hygiene; putting on and taking off footwear; and with dressing and grooming. He was independent with chair-to-chair transfers, rolling left to right, sitting, and lying down. The resident was able to walk short distances but was using a manual wheelchair to get around. The assessment documented the resident was prescribed antipsychotic and antidepressant medications. 2. Record review A hospital admission summary dated [DATE] documented Resident #6 had a pertinent history of dementia with behavioral disturbance and presented to the hospital for chief complaints of agitation. The patient was at an assisted living memory care facility (facility name) where, according to EMS, he had attacked people in the past. Per EMS, they were called because he was in the common area and was screaming and inconsolable. A referral for placement dated 3/21/24 documented Resident #6 presented to the emergency ER on [DATE] for agitation. The facility where he lived was unable to handle him anymore. The facility would not take the resident back due to his behavior and he has been in the ER awaiting placement. The resident would be very difficult to place given his history of aggression/agitation. While in the hospital, Resident #6 was prescribed the following psychotropic medications: Escitalopram oxalate (Lexapro) (an antidepressant medication) tablet 20 milligrams (mg) daily for depression and anxiety, ordered 3/17/24. Risperidone (an atypical antipsychotic medication) tablet 0.5 mg two times a day for agitation, ordered 3/16/24. Trazodone (Desyrel) (a medication used for major depressive disorder) tablet 150 mg at bedtime for sleep, ordered 3/16/24. Quetiapine (Seroquel) (an antipsychotic medication) tablet 25 mg two times a day as needed for delirium or agitation, ordered 3/21/24. The medication was given during the resident's stay in the hospital. A LTC (long-term care) level of care eligibility assessment for Resident #6, dated 3/27/24, revealed the resident exhibited inappropriate behaviors that put himself, others, or property at risk and he frequently required more than verbal redirection to interrupt inappropriate behaviors. Resident #6 was assessed to be delusional with mood instability. He needed supervision due to aggressive behavior, agitation, disruption to others, impaired judgment, need for medication management, memory impairment, verbal abusiveness, and wandering behaviors. Per Resident #6's court-appointed guardian, the resident was asked to leave the memory center where he was living due to yelling, screaming outbursts, and hitting other residents and staff with his walker. The guardian reported the behaviors tended to happen in the late afternoon or early evening, and there were no known prompts for behaviors. Resident #6 could not verbalize when he was upset or identify why he was upset. Resident #6's baseline care plan, dated 4/10/24, revealed the resident was alert and oriented to self and needed cueing and prompts to complete activities of daily living. Resident #6's comprehensive care plan, initiated on 4/10/24, documented the resident was able to make his needs and preferences known. He was pleasant and cooperative. He used a wheelchair and could self-propel. His vision and hearing were adequate. He enjoyed watching television, listening to music, playing the harmonica, having conversations with staff, and napping. He passively participated in most scheduled activities. -Neither care plan included a behavior management focus or interventions to manage Resident #6's aggressive behaviors. A social services note dated 4/10/24 at 4:30 p.m. revealed Resident #6 was starting to show aggressive behaviors similar to behaviors he was displaying at his previous facility when he was discharged . The note documented that when Resident #6 was eating, he would wheel himself away from the table and run his wheelchair into other residents who were standing or passing nearby and he had to be redirected to the dining room table. C. Facility investigation of the incident between Resident #2 and Resident #6 A facility physical abuse investigation dated 4/10/24 revealed that on 4/9/24 at approximately 5:38 p.m., licensed practical nurse (LPN) #1 discovered Resident #6 on top of Resident #2 punching her in the face with a closed fist. Resident #6 was using his bodyweight to pin Resident #2's arms down while using his right hand to hit her in the face. LPN #1 called for help and staff separated the residents. Immediately following the incident, Resident #2 presented with labored breathing and hyperventilation, repeated troubled calling out, loud moaning, groaning and crying, facial grimacing, rigidity, clenched fists, knees pulling up, pulling and pushing staff away, and striking out. The resident was inconsolable. Resident #2 showed signs of being in pain and had observable abrasions, lacerations, skin tears, and discoloration on her body. Resident #6 had no observable injuries. Emergency medical services (EMS) were called and Resident #2 was sent to the emergency room to be assessed for trauma and injuries. Resident #6 was sent out to the hospital for assessment and monitoring due to his aggressive behaviors. Staff witness statements Certified nurse aide (CNA) #1 was interviewed on 4/10/24 following the resident-to-resident physical assault. CNA #1 said she heard LPN #1 yelling for help. CNA #1 said she ran to the area of the call for help and encountered LPN #1 in the hall. LPN #1 instructed CNA #1 to respond to Resident #2's room to help. Upon entering Resident #2's room, CNA#1 observed Resident #6 punching Resident #2 in the face. Resident #6 would not stop. CNA #1 said CNA #2 arrived at the room and they pulled Resident #6 off Resident #2 by the back of his shirt and dragged him to the floor and out into the hall because he was hitting them as well. CNA #1 said Resident #6 was physically and verbally aggressive toward the staff intervening to stop the assault. CNA #2 was interviewed on 4/10/24 following the resident-to-resident physical assault. CNA #2 said between 4:30 p.m. and 5:00 p.m., she was in the other hallway assisting a resident to eat dinner when she heard LPN #1 yelling for help. CNA #2 said she responded immediately and witnessed Resident #6 punching Resident #2 nonstop in the face. She and another CNA (CNA #1) who responded to the call for help had to pull Resident #6 off of Resident #2 to get him to stop punching her. LPN #4 was interviewed on 4/10/24 following the resident-to-resident physical assault. LPN #4 said he was called to Resident #2's room to assist with Resident #6. LPN #4 said he arrived at Resident #2's room and saw Resident #6 on the floor in the hall sitting on the floor scooting back towards Resident #2's room. Resident #6 was redirected away from Resident #2's room. LPN #4 said Resident #6 had blood on his hands and Resident #2, still in bed, had blood on her face and her bed linens and her face had visible signs of swelling. LPN #4 said Resident #6 was starting to get physically aggressive with other residents in the common area. LPN #4 said he had to shield the other residents from Resident #6's physical aggression. Resident #6 then directed his aggression toward staff and began kicking LPN #4 in the legs. After approximately 10 minutes, EMS arrived, restrained Resident #6, and transported him to the hospital for assessment. -The facility failed to show they implemented any new process for their admission screening of new residents or assessed other residents for appropriate interventions for behaviors and behavior monitoring following the incident. D. Staff interviews The DON was interviewed on 6/13/24 at 11:05 a.m. The DON said the facility had a marketing intake person who conducted initial screens on potential new admits and provided her with potential candidates for admission. The DON said she reviewed the available documentation that the recruiter or marketer gave to her to decide whether or not the facility could meet the individual's needs as a resident of the facility. The DON said if the documentation indicated the individual had behaviors she would have to look deeper. The DON said Resident #6's intake referral papers documented that he had behaviors that were resolved at the hospital, so the interdisciplinary team (IDT) allowed his admission to the facility. The DON said the IDT based admission decisions on the current information presented. She said that in the case of Resident #6, the facility was given limited information. She said the facility had no documentation from the resident's previous placement to review. -However, the facility knew the name of the previous facility the resident was discharged from and did not ask the resident's guardian for assistance in requesting treatment records from that facility for review before the resident's admission. Further, the facility was aware of the resident's extended hospitalization due to difficulty finding placement. The DON said the intake documentation did not raise red flags and it looked like Resident #6 presented with typical concerns. She said there was no indication that his behaviors would escalate to him becoming abusive towards the other residents. The DON said the referral just provided her with a snippet of information and if she had more information when reviewing the resident's intake, she would not have accepted him. The DON said she did not receive any information that Resident #6 had a history of aggressive behaviors toward other residents. She said she did not recall seeing the long-term care eligibility assessment (see record review above) and was not familiar with the assessment that the resident was verbally and physically aggressive towards others and required more than verbal redirection to interrupt inappropriate behaviors. -However, the long-term care eligibility assessment was uploaded to Resident #6's EMR on 4/8/24. The DON said Resident #6 was fine upon arrival. She said he was acclimating to the environment and was playing his harmonica. The DON said she was not aware that Resident #6 had displayed any behaviors before his assaulting Resident #2. The DON said the number one goal of the facility was to keep the residents safe and be a partner for the non-clinical needs. LPN #1 was interviewed on 6/13/24 at 1:20 p.m. LPN #1 said the day of admission [DATE]), Resident #6 was pleasant and cooperative. Resident #6 was talking to staff and asking permission for everything. He said on the second day, in the evening, Resident #6's behavior started to change. He said Resident #6 was wandering around the unit and was mocking other residents' actions. LPN #1 said staff had to redirect him several times throughout the day. LPN #1 said when Resident #6 was admitted to the unit, he was told some past reports documented Resident #6 had been aggressive in the past but his record was sealed so they did not know exactly what happened at his previous facility. LPN #1 said when he arrived on shift on 4/10/24, he was informed by the previous shift staff that he needed to keep an eye on Resident #6 as he was mocking others in an inappropriate tone. LPN #1 said one example of his aggressive behavior was that one of the female residents was drinking coffee and expressing her pleasure of it uttering an mm-hmm sound. Resident #6 started mocking and mimicking her sound, getting louder and more aggressive in his actions. Resident #6 progressed and moved closer to her face and continued his mocking. LPN #1 said he had to approach Resident #6 to get him to stop. LPN #1 said later in the day, Resident #6 had to be redirected to the dinner table. He said after the resident was done he wandered from the dining room area. LPN #1 said Resident #6 was quick and quiet when wandering around and he did not notice him leaving the dining room. LPN #1 said it was very noisy in the dining room because the television was turned up loud and another resident was listening to his music, which also was loud. LPN #1 said, for some odd reason, the sound stopped and it got quiet in the room. He then heard moaning noises and heard another resident mocking the first resident's moaning sounds. LPN #1 said, thinking something was not right, he went down the hall to see what was going on. He said as soon as he arrived at the source coming from Resident #2's room, he saw Resident #6 on top of Resident #2. LPN #1 said at first, from the doorway, he thought Resident #6 was kissing Resident #2 but then he observed Resident #6 rocking backward and making a fist. He said Resident #6 made a moaning sound and punched Resident #2 in the face. LPN #1 said Resident #2 moaned when he punched her. LPN #1 said he immediately called for help and staff responded to assist in separating the residents. LPN #1 said Resident #2 was not able to move or defend herself. LPN #1 said Resident #2 was very distressed following the incident and was inconsolable. He said she was bleeding and crying and appeared to be in pain. He said EMS was called immediately so her injuries could be assessed and treated at the hospital. LPN #1 said Resident #2 returned to the facility two days later. He said the EMS provider reported that the resident was showing fear of male caregivers at the hospital and with the EMS providers. LPN #1 said resident-to-resident aggression occurred frequently in the unit but it had never been this severe. He said he worked four shifts a week and would estimate that, on average, there were two to three instances of resident-to-resident aggression each shift. He said most of the time the staff were able to intervene and redirect the residents before it rose to a physical altercation or abusive nature. Resident #6's legal guardian was interviewed on 6/13/24 at 9:00 a.m. The guardian said she talked with the facility during Resident #6's admission intake to request that they keep a close eye on him due to his unsafe wandering and past aggr[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the admission Record revealed the facility admitted Resident #110 with diagnoses that included quadriplegia and right-hand contracture. A review of Resident #110's care plan, last revised 08/15/2022 revealed a focus area that stated the resident may smoke with supervision per smoking assessment. Patient refuses to wear a smoking apron at times. Patient often insists on going out to smoking (sic) at 3:30 in the morning. Patient refuses to let staff assist with flipping [his/her] ashes. The goal was that the resident would smoke safely for 90 days, and the interventions included encourage the resident to wear a smoking apron, inform and reinforce smoking restrictions, inform and remind the resident of locations of smoking areas and smoking times, supervise patient with smoking in accordance with assessed needs, and monitor the residents compliance with the smoking policy. A review of Resident #110's Smoking Evaluation (SNF) [skilled nursing facility] form, dated 07/07/2022 revealed supervised smoking was required for the resident. The form indicated the resident was unable to safely hold a cigarette, did not have the ability to light a cigarette, did not properly dispose of ashes or butts, and the resident could not smoke safely without use of a smoking apron. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS further documented that the resident currently used tobacco. During an observation of Resident #110 on 09/12/2022 at 2:38 PM, the resident was observed sitting in a wheelchair in the facility's smoking area. The resident was observed with a cigarette in his/her mouth with no smoking apron present and both hands contracted so he/she could not hold the cigarette. Resident #110 requested the cigarette be removed from his/her mouth. Another resident (Resident #55) was observed to try and remove the cigarette from Resident #110's mouth; however, Resident #55's hand was shaking, and knocked the ash off the resident's cigarette causing the ash to land on Resident #110's shirt. Resident #55 wiped the ash from the resident's shirt and removed the cigarette from Resident #110's mouth. An interview with Resident #110 on 09/12/2022 at 2:38 PM revealed the resident stated the nurse (Licensed Practical Nurse [LPN] #1) had originally lit his/her cigarette, but he/she then stayed outside to smoke with no staff supervision. Resident #110 stated he/she normally spits the cigarette out when he/she was done smoking. An interview with LPN #1 on 09/12/2022 at 3:32 PM revealed Resident #110 was supposed to be a supervised smoker and refused to wear a smoking apron while smoking. LPN #1 stated other residents usually assist the resident, but they are not supposed to. She stated Resident #110 often blows the ashes when the ash gets too long, but sometimes blows the cigarette out of his/her mouth. An observation and interview on 09/13/2022 at 2:41 PM with the Assistant Dietary Manager (ADM) revealed the ADM was observed smoking in the designated smoking area where residents also smoked. ADM stated that all staff smoked in the same designated smoking areas as the residents and said he was usually outside on a smoke break about four to five times during his shift, but he was not familiar with smoking protocol. ADM stated he believed there were some residents that required supervision while smoking, but he did not observe staff supervising residents during smoke times and he had not seen that occur for about two years now. ADM stated there used to be specific smoking times for residents and it was usually after a meal because he remembered staff rounding up all resident smokers. Currently, residents smoked at all times during the day, and there usually was not any staff observing. He did say that staff would be in the designated smoking areas smoking but they were not monitoring residents for safety while they were smoking. ADM stated he did watch Resident #110 because he was familiar with that resident, and he was aware Resident #110 required supervision when smoking. ADM stated he monitored Resident #110 because if he did not, the resident would just have another resident put a cigarette in Resident #110's mouth, and he knew Resident #110 was not safe to smoke unsupervised because Resident #110 could not light or extinguish a cigarette on their own. ADM stated because of that, Resident #110 could burn themself if the resident dropped their cigarette and there was no one around to pick it up, and ADM wanted Resident #110 to be safe. ADM stated he had never lit a cigarette for Resident #110, and Resident #110 always had another resident light the cigarette. During an interview with Certified Nursing Aide (CNA) #4 on 09/13/2022 at 3:54 PM, CNA #4 stated that Resident #110 did not always allow staff to assist him/her with smoking and she was aware when the resident smoked the cigarette ash would fall on the resident at times. She explained she would offer a smoking apron to Resident #110 but that he/she would refuse. CNA #4 stated she was not concerned about the ash from Resident #110's cigarette falling on him/her because it was just a little bit. An interview with the Director of Nursing (DON) on 09/14/2022 at 4:12 PM revealed the process for residents to smoke included a smoking assessment to determine if a resident was an independent smoker or a supervised smoker. The DON stated each unit had their own smoking times and each unit supervised their own supervised smokers. She explained a CNA would escort the supervised smokers outside to the smoking area, light their cigarettes and stay with the residents until they had completed their smoking. The DON stated staff had been educated on the smoking policy either 6 months ago or a year ago and stated she could not remember when the education was completed. She stated she expected supervised residents to wear smoking aprons but said if the resident refused, the resident would still be allowed to smoke while being supervised by a staff member. While discussing Resident #110, the DON stated she did not expect other residents to assist Resident #110 in helping him/her to ash his/her cigarette or remove the cigarette from his/her mouth. She explained if Resident #110 would not allow staff to help with smoking, then further interventions would be necessary such as enhanced monitoring, notification to the Ombudsman and a care plan meeting. An interview with the Administrator on 09/15/2022 at 4:42 PM revealed Resident #110 was supposed to be supervised when smoking and stated the resident should be wearing a smoking apron but often refused to wear the apron. The Administrator discussed the resident also refused to allow staff to assist him/her to ash his/her cigarette allowing the ash to fall on his/her clothes. He stated he expected staff to monitor Resident #110 closely. Based on interviews, record review, and facility policy review, the facility failed to supervise residents that required supervision while smoking, ensure residents assessed to wear a smoking apron were provided one, and failed to ensure independent and supervised residents had a safe place to discard cigarette butts after smoking for 3 of 3 residents reviewed for smoking (R #110, R #74, and R #21). Failed to ensure Resident #74 smoked in designated area, and used the trash can It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The IJ began on 09/12/2022 when Resident #21 was observed unsupervised while smoking, without wearing a smoking apron, and threw a lit cigarette into a trash can. The Administrator and DON were notified of the IJ on 09/12/2022 at 7:02 PM and provided the IJ Template at 7:03 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 09/14/2022 at 5:22 PM. The IJ was removed on 09/16/2022 at 9:50 AM after the survey team performed onsite verification that the Removal Plans 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 include: The facility policy, OPS131/Smoking Policy, revised on 11/20/2018, revealed, For centers that allow smoking, smoking will be permitted in designated areas only. Patients will be assessed upon admission, quarterly, a change in condition, for the ability to smoke safely and if necessary, with supervision. The policy indicated 2.2.1 An area as a smoking area will be environmentally separate from all patient care areas (e.g., outdoors or a smoking lounge), will be well ventilated, and, if outdoors, will protect patients from weather conditions. 2.1.4 Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in all designated smoking areas as well as at all entrances. 2.3 The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. 2.3.1 Patients will be re-evaluated quarterly and with a change in condition. 2.5 A patient's smoking status-independent, supervised, or not permitted to smoke-will be documented in the care plan. 2.6 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. 2.6.1 Patients will not be allowed to maintain their own lighter, lighter fluid, or matches. 2.7 Center leadership will consider special circumstances on an individual basis (e.g., the need for a smoking apron and/or flame retardant clothing. 1. A review of Resident #21's admission Record revealed the resident had diagnoses of atherosclerotic heart disease, vascular dementia with behavioral disturbance, muscle weakness, polyneuropathy, dysphagia, and lack of coordination. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #21 had a Brief Interview for Mental Statis (BIMS) score of 9, indicating moderately impaired cognition. The MDS revealed Resident #21 required limited assistance of one person with bed mobility, transfer, toileting, and personal hygiene; and was independent with eating. According to the MDS, Resident #21 had no behaviors, and did not reject care that was necessary to achieve the resdient's goals for health and well-being. Indicated utilized oxygen while a resident of the facility and within the last 14 days. A review of Resident #21's care plan revised 05/11/2022 revealed the resident was resistive to care related to being noncompliant with supervised smoking times. The care plan indicated Resident #21 would get cigarettes from other residents. The goal was for Resident #21 to ask for staff assistance when going out to smoke. The facility developed interventions that included evaluating the nature and circumstances of the resistive behavior; encouraging participation in identified special treatment programs; providing a consistent, trusted caregiver and structured daily routines, when possible; explaining all care; and providing for opportunities for choice during care/activities to provide a sense of control. Continued review of Resident #21's care plan revised on 05/11/2022 revealed the resident may smoke with supervision per the resident's smoking assessment. Interventions included educating the resident on the facility's smoking policy, informing of and reinforcing smoking restrictions, reassessing the residents ability to smoke with supervision with any change in condition, providing a smoking apron if indicated, supervising the resident with smoking in accordance with the resident's assessed needs, ensuring there was no oxygen in use in the smoking area, ensuring appropriate cigarette disposal receptacles were available in smoking areas, monitoring residents compliance with the smoking policy, and maintain residents' smoking materials at the nurses' station. A review of Resident #21's Smoking Evaluation dated 08/02/0222 revealed had dementia, had a history of unsafe smoking habits, had a history of sharing/selling cigarettes or smoking material. According to the evaluation, Resident #21 could safely hold a cigarette, had the ability to light a cigarette, properly disposed of ashes or butts, and could smoke safely without use of a smoking apron. According to the evaluation, supervised smoking was required for Resident #21. Observation was conducted on 09/12/2022 at 3:45 PM of Resident #21 placing a lit cigarette into the trash can in the smoking area. Resident #21 was not wearing a smoking apron, and there were no staff in the line of sight of the smoking area or the resident. Observation revealed there were several burn holes in the resident's yellow sweatpants. An observation and interview on 09/12/2022 at 4:21 PM with Resident #21 revealed the resident was sitting in a wheelchair in the hallway wearing yellow sweatpants and a dark colored sweatshirt. Observation revealed there were also visible burn holes on the front of the resident's shirt. Resident #21 stated he/she smoked in the morning and afternoon. The resident stated staff did not ask the resident to wear an apron while smoking, and staff did not remain outside while the resident smoked. Resident #21 stated he/she lit his/her own cigarettes. The resident pulled out a blue lighter from his/her pocket and grabbed an object in the other pocket and stated that was his/her pack of cigarettes. Further interview with Resident #21 revealed the resident stated the holes in his/her sweatshirt was burn holes from cigarette ashes falling on the resident's clothing while smoking. An interview on 09/13/2022 at 1:40 PM with Licensed Practical Nurse (LPN) #1 revealed a resident smoking schedule was located on the Garden Unit that listed smoking times and the staff member assigned to supervise the smoke break. LPN #1 stated the schedule listed a hall number and the Certified Nursing Aide (CNA) assigned to that hallway was required to monitor the residents while they smoked. According to LPN #1, Resident #21 let staff know when he/she wanted to go outside to smoke, and there should never be a resident smoking without a staff member aware or present to monitor. LPN #1 stated both independent and supervised smokers followed the same smoking schedule, and all the cigarettes and lighters were kept secured in a cart and labeled with the resident's name at the nurse's station. LPN #1 stated there were no residents that she was aware of that kept their cigarettes or lighter with them. LPN #1 stated she when she was alerted that Resident #21 threw a lit cigarette into the trash can outside, she, Registered Nurse (RN) #4 and another staff member ran outside and retrieved the cigarette from inside the trash can to extinguish it. LPN #1 stated she saw several staff members standing outside in the smoking area wearing black scrubs, but she was unsure who the staff were, and she did not try to speak to any of them about the situation. According to LPN #1, there were no other residents outside. Further interview with LPN #1 revealed she was unsure where the list was located that indicated which residents required supervision with smoking. Subsequently, she did not know which residents required supervision and which did not. An observation and interview on 09/13/2022 at 2:41 PM with the Assistant Dietary Manager (ADM) revealed the ADM was smoking in the designated smoking area where residents also smoked. The ADM confirmed that staff smoked in the same designated smoking areas as the residents. The ADM stated he was usually outside on a smoke break four to five times during his shift, but he was not familiar with smoking protocol. The ADM stated he believed there were some residents that required supervision while smoking, but he did not observe staff supervising residents during smoke times and he had not seen that occur for about two years. However, the ADM stated when he was outside smoking, he had no way of knowing which resident required supervision when smoking or which were independent unless he personally knew the resident. Continued interview with the ADM revealed most residents kept their lighters and cigarettes with them and lit their own cigarettes without staff supervision. According to the ADM, there used to be specific smoking times for residents, usually after a meal because he remembered staff assisting residents to smoke. However, the ADM stated that currently, residents smoked at all times during the day, and there usually was not any a staff member monitoring the resident. He stated staff may be smoking while in the designated smoking areas but were not monitoring residents for safety while they were smoking. The ADM stated he was not sure why the process to supervise smoking residents stopped being enforced, and he stated he had not seen a silver smoking apron on a resident in about two years. The ADM stated he had voiced concerns about the safety of residents who smoked to staff in the past but not recently. An interview on 09/13/2022 at 3:13 PM with RN #4 revealed she was a unit manager on the Garden Unit. RN #4 stated a smoking list was kept at the nurses' station at the front of the staff schedule book. The smoking list had smoking times for the residents on the Garden Unit and listed a hall number that indicated which CNA was responsible for supervising each smoke break. RN #4 stated all residents who smoked were supposed to smoke during the designated times unless a resident who had behaviors had an intervention to offer a cigarette. RN #4 stated she was aware that residents were allowed to smoke on their own in the past and were allowed to keep their own cigarettes and lighters. The RN stated there were still some residents who kept their own cigarettes and lighter, but other residents needed staff to provide them. According to RN #4, when staff observed a resident go outside to smoke, staff had to go with them to monitor the resident. RN #4 also stated staff knew which residents required supervision because they had to request to smoke since staff had to provide their cigarettes and a lighter. RN #4 stated she was not familiar with Resident #21 and did not know if the resident required supervision. RN #4 stated a surveyor alerted her when Resident #21 dropped a lit cigarette in the trash can. She said she went out to the trashcan to retrieve the lit cigarette. RN #4 stated she did not remember if there were any staff present in the smoking area because she never thought to see what staff allowed Resident #21 to leave the smoking area before extinguishing the cigarette. RN #4 also stated smoking aprons were kept in the medication room on the Garden Unit, but those were only for the residents who lived on that unit. She stated residents from other units would need to bring smoking aprons with them from their unit. Further interview with RN #4 stated revealed Non-Certified Nursing Aide (NCNA) #1 assisted residents outside for the smoke break on 09/12/2022 at 3:30 PM. The RN stated she expected staff to remain outside during the entire smoke break. According to RN #4, she did not know which residents were smoking safely since she was not familiar with the residents from other units. She stated staff would intervene if they observed something obviously unsafe, but otherwise staff would not know which residents required supervision from other units in the facility. An observation and interview on 09/13/2022 at 4:52 PM with Registered Nurse (RN) #4 revealed the medication room located on the Garden Unit had two smoking aprons, and another smoking apron was located at the nurse's station. RN #4 stated there were no more smoking aprons that she was aware of. During an interview on 09/14/2022 at 1:16 PM, NCNA #1 revealed there was a smoking schedule with a list of smoking times, and the staff scheduled to monitor each time was on a board located at the nurse's station on the Garden Unit. NCNA #1 stated the facility was provided a handwritten list of residents who smoked who required staff supervision, but she did not have the list anymore. NCNA #1 stated she got rid of the list after she became familiar with the residents on the garden unit. NCNA #1 stated there were residents who smoked who lived on other units, but the provided list of residents did not identify what type of supervision residents from other units required. She states she assumed the list of times located on the board was only for the residents on the Garden Unit, but she had never asked for clarification. NCNA #1 stated that on Monday, 09/12/2022, she was responsible for monitoring the smoke break at 1:30 PM and 3:30 PM. NCNA #1 stated she had observed residents from other units smoking during the Garden Unit smoke times, but she was not sure what level of supervision those residents required, and she had never seen aides from other units supervising residents while smoking. NCNA #1 stated staff got the residents together about five or ten minutes before the scheduled time by asking the residents on the Garden Unit if they wanted to go outside to smoke. NCNA #1 stated there were four residents that smoked who lived on the Garden Unit. NCNA #1 stated she provided the cigarettes and lighter to each resident, lit all the residents' cigarettes for them, and then took the finished cigarette and extinguished it for the resident. Further interview revealed NCNA #1 did not typically provide the residents anything else during their smoke break. NCNA #1 stated she tried to get residents to wear a smoking apron, but not all the residents complied and allowed those residents to smoke without the apron. NCNA #1 stated she was not familiar with Resident #21 and was not in the smoking area when Resident #21 placed a cigarette in a trach can. Further interview with NCNA #1 revealed all residents who smoked independently were allowed to keep their cigarettes and lighters and she had never been instructed otherwise. NCNA #1 stated she had observed some of the independent residents going to the smoking area that day. NCNA #1 stated independent smokers did not adhere to the smoking times, and she had never been instructed to ensure all residents smoked during the scheduled times. NCNA #1 also stated she had never received any training about the smoking protocol, and all her knowledge came from asking questions during her orientation. An interview on 09/14/2022 at 4:10 PM with the Director of Nursing (DON) revealed staff were The DON stated staff received training related to the smoking protocol about six to twelve months ago. all residents were assessed upon admission for smoking status. Each unit had a list of residents at the nurses' station who smoked. The list also indicated which residents required supervision and which were independent. The DON stated that each unit was responsible for supervising their residents during smoke breaks, and those units had their own designated smoke times. The DON stated there were carts with cigarettes, lighters, and smoking aprons stored on a cart on the Garden Unit and assumed they could also be found on the Evergreen Unit also had a cart, and she assumed there were also smoking aprons stored there. The DON stated there were no residents who smoked who lived on the Arbor Unit. Only one resident who smoked, Resident #21 lived on the Aspen Unit, and the DON stated she was not sure where Resident #21's smoking supplies were stored. According to the DON, Resident #21 was considered an independent smoker and the resident did not require a smoking apron. The DON stated CNAs were required to escort residents who needed supervision to the smoking area, provide their cigarettes, and light the cigarette for the resident. The CNA was required to remain with the residents for the entire break. The DON stated CNA staff were also required to either assist the residents with extinguishing the cigarette or observe the resident extinguishing the cigarette in the correct receptacle. Further interview revealed residents who were assessed to smoke independently were allowed to smoke at different times. The resident was supposed to ask staff to provide them with their cigarettes and lighter. The DON stated residents should not have been allowed to keep their lighters and cigarettes on them. The DON did state that residents that required supervision were required to wear a smoking apron when smoking, but if a resident refused they still allowed the resident to smoke with staff supervision. Staff would notify the responsible party about the refusal. The DON also stated there was a chance that staff may not know which residents required supervision or were independent. She was aware of the incident when Resident #21 threw a lit cigarette into the trash can. When provided with documentation that Resident #21 was a supervised smoker, the DON stated she would have expected staff to be outside supervising Resident #21 during smoke breaks. The DON was also provided documentation by corporate nurse there was only one smoker list for all smokers located on the Garden Unit and only staff from that unit supervised smoke breaks. An interview on 09/15/2022 at 4:43 PM with the Administrator revealed there were supervised and independent residents and a list of smoking times. Administrator stated any residents that required supervised smoke breaks should have been offered smoking aprons and assisted by staff, but the independent residents were allowed to be unsupervised when smoking and light their own cigarettes. Administrator stated he was not sure if the independent residents were able to keep their cigarettes and lighter or if staff had them stored somewhere. Administrator stated residents were only supposed to smoke in designated areas. If staff became aware of a resident smoking in a nonsmoking area, they were supposed to intervene. Administrator stated staff should have remained with Resident #21 until after staff properly disposed of the cigarette butt for the resident. Administrator stated there were designated smoke times for all independent and supervised smokers, and staff were only required to supervise if there was a resident smoking who required supervision. Administrator also stated residents should not have been allowed to keep their lighters and he was aware that some residents had them in their possession. However, if staff asked the resident to give them their lighter and the resident refused, staff would only educate the resident but allow them to keep it. Administrator stated he expected all smokers to properly dispose of cigarette butts in proper receptacles. Administrator further stated he was unaware that Resident #21 was assessed to be a supervised smoker and he thought Resident #21 was independent. He did not know that Resident #21 kept their own cigarettes and lighter and the resident should not have been allowed to do so. Administrator stated the facility policy stated residents should not have been allowed to keep their lighter in their possession. F-689-Free of Accident Hazards/Supervision/devices Corrective Action: 1. Nurse Manager and/or designee completed a smoking assessment on RI #110, RI #74, and RI #21 on September 12, 2022 and revised the plan of care to include supervised smoking and q15 min checks for 24 hours. 2. RI #110, RI #74, and RI #21 were placed on supervised smoking on September 12, 2022. Supervised smoking consist of direct staff observation during smoking times. 3. Social Service Director and/or designee re-educated RI #110, RI #74, and RI #21 on the Smoking Policy and Procedure on September 12 202. Education included adherence to the smoking times, smoking allowed only with staff supervision, smoking in designated smoke areas, smoking aprons, discarding of cigarette butts, and turning in cigarette paraphernalia to Nursing. A Behavior Contract was initiated with RI #110, RI #74, and RI #21 to acknowledge and obtain written agreement to smoke only in designated smoke areas, dispose of cigarette butts in fire receptacles, adhering to smoke times, and wearing smoking aprons if needed. 4. Licensed Nurse (s) implemented enhanced monitoring consisting of every 15 minute checks of RI #110, RI #74, and RI #21 on September 12, 2022 until September 13, 2022. One on one supervision will be implemented as needed to maintain resident safety. 5. Administrator and/or designee conducted a room search of RI #110, RI#74, and RI #21 to search for and confiscate cigarette paraphernalia. Cigarette lighters were retrieved and placed in a secure (locked) storage cart on Evergreen unit. Only Nursing and/or Ancillary staff will have access to the storage cart. 6. Effective September 13, 2022, designated smoking times will be implemented for all residents who smoke. 7. Maintenance Director and/or designee placed signage on the trash can in the smoking area on September 13, 2022 for trash only. 8. Administrator hosted an Ad Hoc Quality Assurance Performance Improvement meeting with Medical Director engagement on September 12, 2022 to discuss Smoking Policy and specific emphasis on supervision of residents during smoking times, application of smoking aprons, adherence to smoking areas, discarding cigarette butts in fire receptacles, and reporting observations of non-compliance. Version 4 F 689 Identification: 1. Nurse Managers and/or designee completed a new smoking assessment on all residents identified as smokers on September 13, 2022 and revised the plan of care as needed. 2. Interdisciplinary Team thoroughly checked resident rooms to ensure all smoking materials have been confiscated and securely place in the supervised smoking compartment on September 13, 2022. Any resident who would not relinquish cigarette paraphernalia on September 13, 2022 was placed on one to one supervision until materials were confiscated and secured. 3. Interdisciplinary Team thoroughly checked clothing for all resident identified as smokers to ensure no holes or burns were observed on September 13, 2022. No additional concerns were identified 4. Maintenance Director completed an audit of the smoking area on September 12, 2022 to validate availability of smoking blanket, fire receptacles, and fire extinguishers. Effective September 13 2022, smoking aprons will be located in the designated smoking storage cart. 5. Maintenance Director and/or designee validated no smoking signage is posted in non-smoking areas on September 12, 2022. Systematic Measures: 1. The Nurse Practice Educator or designee re-educated Nursing, Social Services, Housekeeping, Dietary, Therapy, and Maintenance employees on the Smoking Policy and Procedure beginning September 12, 2022 with emphasis on designated smoke times, supervision of residents during smoking times, application of smoking aprons, adherence to smoking areas, discarding cigarette butts in fire receptacles, and reporting observations of non-compliance. Any employee on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. 2. On September 13, 2022, Social Service Director and/or designee re-educated residents identified as smokers on adherence to the Smoking Policy to include: smoking only in designated smoke areas, designated smoke times, smoking aprons, discarding of cigarette butts, and turning in cigarette paraphernalia to Nursing. 3.&n[TRUNCATED]