**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan for smoking with appropriate interventions to minimize risks and ensure the safety of 1 of 2 residents reviewed for accidents, of 51 sampled residents, (#61). This failure contributed to resident #61 smoking inside his room and placed him and others at risk for serious injury/impairment/death. While resident #61 smoked in his room with an oxygen concentrator nearby, there was likelihood he could have suffered and/or caused burn injuries and/or death from unsafe smoking practices or oxygen combustion. On 12/06/21 at 12:35 PM, resident #61 informed a staff member he wanted to smoke. He was instructed to wait until someone was available to supervise him in the smoking area. Although the staff member was aware resident #61 habitually kept a cigar in his pocket and had a history of inappropriate access to smoking materials including matches and lighters, she left the resident to wait unattended. Approximately 40 minutes later, a strong smell of smoke was noted in the hallway outside the resident's room. Resident #61 was inside his room, seated in a wheelchair with a lighter on his lap. He was a few feet away from his wife who had oxygen infusing, and a distinct odor of cigar smoke emanated from the partially open bathroom door. The facility's failure to develop and implement appropriate interventions for known noncompliance with safe smoking practices placed all nearby residents at risk. This failure resulted in Immediate Jeopardy starting on 12/06/21. The Immediate Jeopardy was removed on 12/08/21. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy, after verification of the facility's immediate corrective actions. Findings: Cross reference F689 Resident #61, an [AGE] year-old male, was admitted to the facility from the hospital on 7/09/21. His primary diagnosis was metabolic encephalopathy, which is brain damage or disease that can lead to an altered mental state and confusion (retrieved on 12/21/21 from WebMD at www.webmd.com). Additional diagnoses included nicotine dependence, dementia, emphysema, and Chronic Obstructive Pulmonary Disease. The admission Observation dated 7/09/21 revealed resident #61's history was obtained from the medical record. There was no documentation by the admission nurse or input from his family regarding the resident's social or medical history. The admission evaluation data for resident #61 did not include a smoking risk assessment despite his diagnosis of nicotine dependence. The Minimum Data Set (MDS) admission assessment with assessment reference date of 7/16/21 revealed resident #61 had a Brief Interview for Mental Status score of 8, which indicated he had moderate cognitive impairment. Section F of the MDS assessment showed resident #61 felt it was very important to participate in his favorite activities and Section J1300 Current Tobacco Use was answered affirmatively. Review of the medical record revealed a care plan for smoking was initiated on 7/09/21 with a goal that resident #61's risk for smoking-related injuries would be minimized by compliance with the smoking policy. The approaches directed staff to complete scheduled smoking assessments, inform the resident and responsible party of the smoking policy, observe for compliance, and ensure the resident smoked safely in the designated area. Resident #61's initial Smoking Risk (Acuity) evaluation was done on 10/14/21, approximately three months after he was admitted to the facility. A care plan initiated on 10/14/21 indicated the resident chose to continue smoking and was at risk for health complications and injury. The approaches remained the same as those noted on the admission care plan dated 7/09/21 and did not reflect any increased knowledge of resident #61's preferences and care needs. On 12/06/21 at 1:52 PM, after the discovery of resident #61 smoking in his room, the Unit 1 Unit Manger (UM) explained she was aware of past issues related to resident #61's access to smoking materials. She said, Previously, when he was first admitted , the family would leave matches and lighter with him after they visited. She stated the family was reminded not to provide the resident with smoking materials. On 12/07/21 at 11:13 AM, the UM confirmed there was an incident when a staff member gave her matches which had been retrieved from resident #61. She recalled educating the resident's daughter about not providing matches and also informed his granddaughter, the previous Director of Nursing (DON). She explained the previous DON permitted her grandfather to keep his cigars. The UM stated she could not explain why resident #61's care plan had never been updated to include interventions to keep the resident safe, such as checking his room for smoking materials. She did not recall writing a progress note or an incident report, nor participating in Interdisciplinary Team (IDT) discussion about the resident's access to matches. On 12/07/21 at 11:57 AM, the MDS Coordinator reviewed the process for development of a smoking care plan. She explained a nurse or Unit Manager would complete a smoking evaluation for every newly admitted resident. The admission data would be discussed the following day by the IDT in the scheduled daily clinical meeting. The MDS Coordinator stated she would create a smoking care plan during that meeting. She stated the IDT would determine the level of supervision the resident needed and communicate information to the assigned members of the nursing team via the care plan. The MDS Coordinator stated she did not know resident #61 smoked until she conducted his care conference in October 2021. She could not explain why resident #61 had a care plan for smoking created on admission if there was no smoking evaluation done at that time. The MDS Coordinator stated resident #61's granddaughter, the previous DON, was present at the care conference meeting and there was no mention of safety issues or noncompliance with the smoking policy. On 12/07/21 at 12:17 PM, the Lead MDS Coordinator explained resident #61 had a care plan for smoking created on admission because he had a history of smoking. She did not recall any discussion related to resident #61's inappropriate access to smoking materials including cigars, matches and lighters. She stated nurses could not revise or update care plans, but if they wrote a progress note, created an incident report, or provided information verbally, MDS staff would make revisions to address identified concerns. The Lead MDS Coordinator confirmed a care plan was important to provide the correct, appropriate interventions for each resident. When informed resident #61 had cigars in his room, she said, If I knew before, I would have put in an intervention to check his room. The job description for Resident Assessment/Care Plan Coordinator (undated) revealed functions included coordinating the development of a written plan of care that involved input from residents and/or their family members, and ensuring all assigned staff were aware of the care plan and checked it prior to administering daily care. Review of the policy and procedure Care Plans, Comprehensive Person-Centered revised in November 2020, revealed the IDT would develop and implement a person-centered care plan in conjunction with the resident and family. The care plan should include personal preferences, necessary services to maintain the resident's highest practicable well-being, and identify problem areas with associated risk factors. The policy read, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. On 12/08/21 at 11:02 AM, in a telephone interview, resident #61's daughter M, stated prior to admission to the facility, her father lived at home and his regular daily routine included smoking after every meal. On 12/08/21 at 11:15 AM, in a telephone interview, resident #61's daughter N stated to her knowledge, her father smoked almost every day. She confirmed her father kept his cigars in the drawer of his bedside table. Daughter N did not recall any conversation or education from the facility regarding her father not being allowed to keep cigars in his room. She stated her father might have taken a lighter from her purse, which she left open on his bed during her last visit. Review of resident #61's medical record revealed no progress notes by nursing, social services, activities or administrative staff that addressed the confirmed violations of the smoking policy, education provided for family members and the resident, nor interventions to prevent continued noncompliance and promote safe smoking. The medical record did not include documentation of interviews with the family regarding the resident's preferred smoking schedule nor collaboration with family to develop interventions that ensured he smoked safely. On 12/09/21 at 2:21, the Director of Nursing (DON) acknowledged there was no documentation regarding resident #61's noncompliance with the facility's smoking policy related to keeping smoking materials in his room. She stated staff should have created progress notes if smoking materials were observed in the room and also when they were confiscated. The DON stated resident #61's care plan should reflect behaviors and communicate appropriate approaches and intervention. She stated his smoking safety concerns had not been brought to the IDT before he smoked in his room. Review of the facility's Assessment Tool updated on 11/02/21, indicated facility staff would provide person-centered care such as getting to know residents, identifying preferences and routines, and ensuring assigned staff had this information. The Assessment Tool revealed the facility would identify hazards and risks that were unique to each resident. Review of immediate measures implemented by the facility revealed the following, which were verified by the survey team: * On 12/06/21 at 1:15 PM, facility staff responded to a report of resident #61 smoking in his room. The smoking paraphernalia was removed, and the resident's room searched for additional smoking materials. The smoking policy was reiterated to the resident and his representative/family. *On 12/06/21, resident #61 was re-assessed and his smoking risk score increased from 1 to 8. The facility revoked his smoking privileges for noncompliance with the smoking policy. *On 12/07/21, the Assistant Director of Nursing (ADON) initiated an in-service for licensed nurses on the accurate completion of assessments. There were 25 of 34 licensed nurses (73%) who had received the education as of 12/08/21. The ADON and Staff Coordinator will ensure any licensed nurse who has not received the education will not be permitted to work until the education is completed. Review of in-service attendance sheets and reconciliation with staff roster validated education was completed. *On 12/08/21, the facility held a Quality Assurance meeting, attended by the Medical Director, Administrator, DON, ADON/Risk Manager and nine additional committee members. Performance Improvement Plans were developed by the committee and approved by the Medical Director. The MDS Coordinator will conduct daily audits from a random list of residents to monitor the facilities compliance with the accuracy and completion of assessments. * On 12/08/21, Social Services assisted with resident #61's discharge placement to another facility at the request of his family. *On 12/08/21, a facility-wide baseline smoking questionnaire was completed on all residents to ensure all smokers were identified. One additional resident was identified as a smoker. The resident was re-assessed for smoking risk, provided with another copy of the facility's smoking policy, and the care plan was updated. *On 12/09/21, interviews conducted with 2 Licensed Practical Nurses, and 3 RNs revealed they were knowledgeable of the smoking risk assessments and required documentation standards. *The sample was expanded to include the only additional smoker, resident #262. Interview and record review revealed no concerns related to accuracy of the resident's smoking risk evaluation and appropriateness of care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct an admission smoking risk evaluation; failed to maintain smoking materials in a secure location to ensure a safe environment; and failed to provide appropriate supervision for 1 of 2 residents reviewed for accidents, of a total sample of 51 residents, (#61). These failures contributed to resident #61 smoking inside his room and placed him and others at risk for serious injury/impairment/death. While resident #61 smoked in his room with an oxygen concentrator nearby, there was likelihood he could have suffered and/or caused burn injuries and/or death from unsafe smoking practices or oxygen combustion. On 12/06/21 at 12:35 PM, resident #61 informed a staff member he wanted to smoke. He was instructed to wait until someone was available to supervise him in the smoking area. Although the staff member was aware resident #61 habitually kept a cigar in his pocket and had a history of inappropriate access to smoking materials including matches and lighters, she left the resident to wait unattended. Approximately 40 minutes later, a strong smell of smoke was noted in the hallway outside the resident's room. Resident #61 was inside his room, seated in a wheelchair with a lighter on his lap. He was a few feet away from his wife who had oxygen infusing, and a distinct odor of cigar smoke emanated from the partially open bathroom door. The facility's failure to evaluate smoking risk on admission and ensure a physically and cognitively impaired resident did not have access to smoking materials placed all nearby residents at risk. This failure resulted in Immediate Jeopardy starting on 12/06/21. The Immediate Jeopardy was removed on 12/08/21. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy, after verification of the facility's immediate actions. Findings: Cross reference F656 Resident #61, an [AGE] year-old male, was admitted to the facility from the hospital on 7/09/21. His primary diagnosis was metabolic encephalopathy, which is brain damage or disease that can lead to an altered mental state and confusion (retrieved on 12/21/21 from WebMD at www.webmd.com). Additional diagnoses included nicotine dependence, dementia, emphysema, and Chronic Obstructive Pulmonary Disease. The admission Observation dated 7/09/21 revealed resident #61's history was obtained from the medical record. There was no documentation by the admission nurse of input from his family regarding the resident's social or medical history. The admission evaluation data for resident #61 did not include a smoking risk assessment despite his diagnosis of nicotine dependence. Review of resident #61's medical record revealed a Resident Face Sheet with demographic information that read, Smoking Status: Current every day smoker. The Minimum Data Set admission assessment with assessment reference date (ARD) of 7/16/21 revealed resident #61 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated he had moderate cognitive impairment. The MDS assessment showed the resident had highly impaired hearing, unclear speech, difficulty communicating some words and he missed some part or intent of messages. Section F indicated resident #61 felt it was very important to participate in his favorite activities. He required extensive assistance for bed mobility, transfers and locomotion around his room and in the hallway. The resident did not walk and used a wheelchair for mobility. The MDS assessment Section J1300 Current Tobacco Use was answered affirmatively. Review of the medical record revealed a care plan for smoking was initiated on 7/09/21 with a goal that resident #61's risk for smoking-related injuries would be minimized by compliance with the smoking policy. The approaches directed staff to complete scheduled smoking assessments, inform the resident and responsible party of the smoking policy, observe for compliance, and ensure the resident smoked safely in the designated area. Resident #61's initial Smoking Risk (Acuity) evaluation was done on 10/14/21, approximately three months after he was admitted to the facility. The evaluation revealed resident #61 smoked cigars less than daily, did not beg, steal, or borrow smoking materials from others, nor smoke in unauthorized areas. The document indicated the resident had a minimal problem related to Careless with Smoking Materials - Drops cigarette/cigar butts or matches on the floor, furniture, self, or others; burns finger tips; smokes near oxygen. Despite resident #61's diagnoses of encephalopathy and dementia, and BIMS score of 8, the evaluation showed he had no problem understanding the facility's smoking policy and was capable of following the requirements. The section of the document for mobility indicated resident #1 had no problems although he required extensive assistance for mobility, transfers, and locomotion. The evaluation resulted in a smoking risk score of 1 on a scale which showed scores of 0 to 9 denoted a safe smoker. On 12/06/21 at 12:35 PM, resident #61 propelled himself in his wheelchair from his room towards the Unit 1 nurses' station. He got the attention of the Unit 1 Unit Manager (UM) and was able to communicate that he wanted to be taken outside to smoke. Resident #61 requested assistance by using hand motions in combination with Spanish words. The UM informed the resident there were no staff members available to accompany him to the smoking area at that time and instructed him to wait near the nurses' station. The UM explained resident #61 was the only Unit 1 resident who smoked, and she would ask a Certified Nursing Assistant (CNA) who smoked to take him outside after lunch. The UM stated the resident was not an independent smoker but was permitted to smoke with supervision. She explained resident #61 always carried a cigar in the pocket of his shirt and pointed to the resident's chest. When asked if the resident was allowed to keep his smoking materials, the UM stated he kept his cigars but did not have access to a lighter. She stated there had been issues in the past related to resident #61's family members leaving smoking materials with him. On 12/06/21 at 1:14 PM, a strong smell of smoke was noted outside resident #61's room. On entering the room, State Survey Agency staff observed the resident seated in his wheelchair with a pink lighter on his lap, partially hidden by a surgical mask. He was approximately six to eight feet away from an oxygen concentrator that provided oxygen for his wife who was in bed. The UM was alerted, entered the room and frantically began searching for a possible smoldering cigar as the source of the smell. She opened the bathroom door, and the distinct odor of cigar smoke escaped into the room. While the UM searched the room, the Assistant Director of Nursing (ADON) removed resident #61 from the room and asked him to hand over the lighter. The resident had a tightly clenched fist and initially denied having a lighter. He then defiantly refused to give the lighter to the ADON and repeated, It's mine! It's mine! several times in Spanish. Resident #61 agreed to relinquish the lighter only after the ADON emphasized how dangerous it was to smoke near oxygen, and that he could have caused great harm to his wife. Inside the room, the Unit Manager removed ten cigars from the resident's bedside table drawer, one of which was partially smoked and had a black burnt end. Photographic evidence was obtained. Review of the Smoking Policy and Procedure revised in March 2020 revealed the facility's goal to maintain . a healthy and safe environment for its residents, staff and visitors while respecting individual choice. The procedure provided instructions for administration and all nursing personnel regarding completion of smoking assessments to determine safe smoking status, the need to escort and supervise any resident who wanted to smoke, and the designation of a lock box to store smoking materials. The policy read, All residents must forfeit all smoking materials, including, but not limited to cigarettes, cigars, lighters, matches . Smoking paraphernalia stored in residents' rooms is strictly prohibited. The procedure revealed smoking materials provided by family were to be delivered to staff, and the facility retained the right to conduct regular room inspections for potential fire hazards. The policy indicated violations could result in discharge from the facility, notification to appropriate governing agencies, and loss of attending physician services. On 12/06/21 at 1:52 PM, the UM stated resident #61's smoking evaluation form indicated he was a safe smoker but even if deemed safe, the facility's policy was all residents should be supervised when smoking. The UM explained resident #61 was the grandfather of the facility's previous Director of Nursing (DON) and he also had two daughters who visited on the weekends. When asked about issues related to resident #61's access to smoking materials, the UM said, Previously, when he was first admitted , the family would leave matches and lighter with him after they visited. She stated the family was reminded not to provide the resident with smoking materials. The UM validated the potential for fire and burn injuries to occur from smoking near oxygen. She stated resident #61's wife shared his room, and she was one of the four residents on Unit 1 who used oxygen. The UM confirmed the resident was not assisted outside to smoke at lunchtime when he asked, as the staff member who was to supervise him was on lunch break. The UM said, I can't believe he lights up a cigar on the day the surveyors are in the building. On 12/07/21 at 10:18 AM, the Activities Director stated the facility's smoking schedule was dependent on the number of smokers in the building and the frequency they desired. She confirmed resident #61's family usually visited on one to two days every weekend. The Activities Director acknowledged she had seen resident with a cigar in his shirt pocket as he headed towards the smoking area. On 12/07/21 at 10:33 AM, CNA G stated she confiscated resident #61's smoking materials on two or three occasions and gave them to the weekend supervisor and the UM. CNA G said, The [resident's] family are very difficult, and they keep bringing in cigars. I saw cigars and lighter about three months ago. I took a full packet of cigars and a lighter to the Unit Manger. She explained despite education, the resident's family continued to leave smoking materials with him. CNA G was aware resident #61 carried a cigar in the pocket of his shirt. On 12/07/21 at 10:49 AM, CNA H stated she had occasionally been assigned to care for resident #61 but was never informed he smoked. On 12/07/21 at 11:03 AM, CNA I confirmed she was regularly assigned to care for resident #61 during the past couple months but never knew he smoked. She stated neither his assigned nurse nor the off going CNA informed her during shift change report that the resident lit a cigar in his room the previous day. CNA I stated she did not know where the facility secured residents' smoking materials. On 12/07/21 at 11:13 AM, the UM confirmed there was an incident when a staff member gave her matches retrieved from resident #61. She recalled educating the resident's daughter about not providing matches and also informed his granddaughter, the previous DON. When asked why she allowed the resident to keep cigars in his room and on his person, the UM stated she was previously under the impression that matches and lighters were the only items prohibited in rooms. She explained the previous DON was her supervisor, so she never challenged the decision to allow resident #61 to keep cigars. The UM said, Since yesterday I was educated that cigars are also categorized as smoking materials. The UM confirmed she conducted a smoking risk assessment after resident #61 smoked in his room. During review of the Smoking Risk (Acuity) form dated 12/06/21 at 2:56 PM, the UM verified she obtained a score of 8 that still deemed him to be a safe smoker. The UM stated the result did not make sense to her as the resident's actions on the previous day did not support that conclusion. A detailed review of the UM's responses on the form revealed she did not select risk factors such as the resident carried a lighter, stole smoking materials from others, did not understood the smoking policy and had mobility issues. Review of resident #61's medical record revealed no progress notes by nursing, social services, activities or administrative staff that addressed the confirmed violations of the smoking policy, education provided for family members and the resident, nor interventions to prevent continued noncompliance and promote safe smoking. On 12/07/21 at 1:58 PM, the Social Services Director stated she reviewed the department's records and grievance log but did not encounter any grievances filed or education provided regarding the failure of resident #61 and his family members to adhere to the requirements of the smoking policy. On 12/08/21 the resident's two daughters were interviewed by telephone. At 11:02 AM, the first daughter explained her father had dementia and behavioral problems. She stated prior to admission to the facility, her father lived at home and his regular daily routine included smoking after every meal. She acknowledged her father's access to cigars and lighters could have resulted in a serious incident. At 11:15 AM, the second daughter stated to her knowledge, her father smoked almost every day. She stated she visited her parents on the weekends and her last visit was the previous Saturday. She confirmed her father kept his cigars in the drawer of his bedside table. She did not recall any conversation or education from the facility regarding her father not being allowed to keep cigars in his room. She denied providing her father with a lighter but stated he might easily have taken one from her purse, which she left open on his bed during her last visit. On 12/08/21 at 2:29 PM, Registered Nurse (RN) J stated resident #61's family situation posed challenges for staff such as demands that nothing in his room be touched. RN J described constant tension surrounding issues with resident #61 because the previous DON was his granddaughter. RN J stated the resident openly carried a cigar in his pocket or held it between his fingers and said, The family used to dare staff to do anything if they complained. He acknowledged resident #61 smoking in his room near the wife's oxygen concentrator was very dangerous and could be like a bomb. On 12/08/21 at 3:55 PM, the ADON stated on the day of admission, the facility was not aware resident #61 smoked. She explained staff were surprised on the following day when the previous DON stated she was going to take her grandfather outside to smoke. The ADON said, This was a complicated situation because of the resident's relationship with the previous DON. The ADON confirmed all smoking materials should be secured in a lock box, retrieved at residents' request and used under staff or family supervision. She stated she provided verbal education to staff on how to monitor smokers but had no written documentation of this training. The ADON explained all CNAs, especially those assigned to care for smokers should be aware of the need to escort and supervise them when requested. She validated on the day resident #61 smoked in his room he should not have been asked to wait. Instead, any available staff including CNAs, managers or housekeeping staff could have taken him to the designated smoking area on the patio. On 12/08/21 at 6:11 PM, CNA O stated she was not aware resident #61 smoked although she was occasionally assigned to care for him. She stated she relied on nurses to provide that information. On 12/09/21 at 12:42 PM, the facility's Medical Director stated she was informed that resident #61 lit a cigar in his room with oxygen nearby. She validated the dangers of smoking near oxygen and stated her expectation was staff would follow the facility's safe smoking policy. On 12/09/21 at 2:21 PM, the Administrator and DON discussed the facility's investigation related to resident #61 smoking in his room. The DON stated the resident explained daughter M provided him with cigars and a lighter. The DON confirmed a CNA confiscated smoking materials from resident #61 in the past, but there was no documentation of the incident. She stated her investigation showed staff were uncomfortable challenging the previous DON. However, she acknowledged nobody had brought the smoking safety issue and policy violations to her attention in the month since the previous DON left. She stated her expectation was staff should have notified her or any member of administration about prohibited items in resident #61's room, and progress notes should have been created to reflect any noncompliance or incidents. The DON stated all staff received mandatory education and additional in-services on smoking safety. However, she acknowledged they failed to implement the policy did not demonstrate understanding and competency. The DON confirmed the facility did not complete a smoking risk evaluation for resident #61 on admission and he therefore smoked for three months before being assessed for safety. Review of the job description for Nurse Supervisor/Unit Manager (undated), revealed a primary purpose of assisting with supervision of the day-to-day activities of the facility. Responsibilities included reviewing nurses' notes to ensure they were informative, accurate and descriptive; implementing procedures for reporting hazardous conditions; and ensuring all staff involved in providing care were aware of residents' care plans. Review of the job description for Registered Nurse/Floor Nurse (undated), revealed responsibilities included completing and submitting incident reports as necessary; conducting thorough admission assessments; promptly responding to requests for assistance; and ensuring CNAs were aware of and implemented residents' care plans. Review of the job description for Nursing Home Administrator (undated) revealed duties and responsibilities included ensuring facility staff, residents and visitors followed safety regulations including those related to smoking. Review of the facility's Assessment Tool updated on 11/02/21, revealed the facility was able to care for residents with common conditions including dementia and behaviors that required interventions. The document indicated staff would provide person-centered care such as getting to know residents, identifying preferences and routines, and ensuring assigned staff had this information. The Assessment Tool revealed the facility would identify hazards and risks that were unique to each resident. Review of immediate measures implemented by the facility revealed the following, which were verified by the survey team: * On 12/06/21 at 1:15 PM, facility staff responded to a report of resident #61 smoking in his room. The smoking paraphernalia was removed, and the resident's room searched for additional smoking materials. The smoking policy was reiterated to the resident and his representative/family. *On 12/06/21, resident #61 was re-assessed and his smoking risk score increased from 1 to 8. The facility revoked his smoking privileges for noncompliance with the smoking policy. *On 12/07/21, the facility initiated in-services to cover the following information: Facility's smoking policy; Requirement to respond to a resident's request to smoke timely; Notification of management of any problems or change in condition that would affect the Resident's ability to smoke safely; Non-compliance with the smoking policy. A total of 136 Employees will be educated; A total of 68 % were educated as of 12/08/21. The ADON and Staff Coordinator will ensure any employee who has not received education will not be permitted to work until the education is completed. Review of in-service attendance sheets and reconciliation with staff roster validated education was completed using the facility's smoking policy. The policy was made available in English and Spanish to promote optimal comprehension. *On 12/08/21, the facility held a Quality Assurance meeting, attended by the Medical Director, Administrator, DON, ADON/Risk Manager and nine additional committee members. Performance Improvement Plans were developed by the committee and approved by the Medical Director. Topics include: All residents will be assessed on admission to identify if they smoke; Residents identified to be smokers will be provided a copy of the Facility's Smoking Policy; The Unit Managers will conduct audits weekly to ensure smoking assessments are complete and accurate. Findings will be submitted to the DON; Residents known to smoke will be re-assessed monthly and as necessary; Residents who smoke will have room searches for smoking paraphernalia Q shift, with Resident/Representative permission, as specified in the Facility Smoking policy; Room audit documentation will be collected by the DON daily for review and tracking of resident compliance with the smoking policy. * On 12/08/21, Social Services assisted with resident #61's discharge placement to another facility at the request of his family. *On 12/08/21, a facility-wide baseline smoking questionnaire was completed on all residents to ensure all smokers were identified. One additional resident was identified as a smoker. The resident was re-assessed for smoking risk and provided with another copy of the facility's smoking policy. *On 12/09/21, interviews conducted with 21 facility staff including 12 CNAs, 2 Licensed Practical Nurses, 3 RNs, 2 Patient Care Attendants, 1 Physical Therapist and 1 housekeeper revealed they were knowledgeable of the smoking policy and procedure, including the need to respond to residents' requests in a timely manner and report any unsecured smoking materials. *The sample was expanded to include the only additional smoker, resident #262. Interview and record review revealed no concerns related to accuracy of the resident's smoking risk evaluation and appropriateness of care plan interventions.