**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility Administration failed to utilize its resources effectively to ensure safe smoking practices, including assessment and supervision of residents who smoke tobacco products to protect residents from serious injury, impairment, or death. On 6/4/23 staff observed Resident #65 smoking in his room with the oxygen concentrator on. The facility failed to reassess Resident #65's ability to adhere to safe smoking precautions and allowed the resident to keep, and store smoking materials. Resident #65 and other residents who required supervision to smoke were observed smoking unsupervised. The smoking area was observed with an overfilled pole cigarette receptacle and the surrounding area littered with cigarette butts. The floor of a clearly marked nonsmoking area had scattered cigarette butts. Residents observed smoking unsupervised in the nonsmoking area with no ashtray. The facility administration's failure to ensure safe smoking practices created a likelihood of serious injury, impairment, or death from thermal burns and fire and resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 6/4/23. On 6/23/23 at 11:58 a.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The facility census was 105 and included 11 residents who smoke tobacco products. The findings included: Cross reference F689. The Administrator's job description signed on 3/13/23 noted in the position purpose, Leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents . Major duties and responsibilities . Performs rounds to observe residents and ensure overall needs are being met. Practices management by walking around . Manages and minimizes facility risk through a team approach to achieve desired outcome in customer service . other areas as identified. Additional tasks . Follows appropriate safety . measures at all times to protect residents and themselves . The Director of Nursing's job description signed on 2/3/23 included, Plans, develops, organizes, implements, evaluates, and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations. Performs rounds to observe residents and ensure nursing needs are being met . Review of the facility's Resident Smoking policy implemented on 10/01/22 state the facility will provide a safe and health environment for residents, visitors, and employees, including safety related to smoking and safety protections apply to smoking and non-smoking residents. The policy further noted, All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS (Medical Data Set) assessment process . Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all . All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. Review of the clinical record for Resident #65 revealed an admission date of 4/13/22 and a readmission date of 5/19/23. Diagnoses included Congestive Obstructive Pulmonary Disease (COPD) requiring the use of oxygen. Resident #65 smoked tobacco products. On 5/19/23, a smoking evaluation documented the resident was able to smoke independently. The evaluation noted the resident was able to safely hold a cigarette, and the resident was able to properly dispose of ashes or cigarette butts. Review of the progress notes revealed on 6/4/23 staff observed Resident #65 smoking in his room. The oxygen concentrator was on at the bedside but not in use. The staff confiscated the cigarettes. Resident #65 denied having a lighter. The clinical record lacked documentation the resident's ability to adhere to safe smoking practices was reassessed. On 6/20/23 at 12:08 p.m., Resident #65 was observed in bed. The resident had cigarettes and a lighter with him. He said he smoked independently. The oxygen concentrator was in the room but not turned on at the time of the observation. The facility provided a new smoking evaluation completed on 6/20/23 at 3:42 p.m., which noted Resident #65 had unsafe smoking habits and a history of sharing/selling cigarettes or smoking materials. The evaluation noted the resident had a decline in functionality and determined Resident #65 required supervised smoking. On 6/20/23 at 4:20 p.m., Resident #65 was observed smoking unsupervised in the designated smoking area. On 6/22/23 at 1:05 p.m., the Director of Nursing (DON) verified a new evaluation was not completed on 6/4/23 after Resident #65 was found smoking in his room with the oxygen concentrator on. She said from that point on, he was put on supervised smoking which meant all his smoking materials needed to be kept at the nurses' station. She said the information was passed on verbally between staff members. On 6/21/23 at 5:40 p.m., the Assistant Maintenance said since she's been employed at the facility a year ago, she has picked up cigarette butts from the floor every day. She said she observed Resident #70, #10 and #30 throwing cigarette butts on the floor. She has told them over and over to discard the cigarette butts in the ashtray to no avail. She said she reported the unsafe smoking practices to the Administrator who said she educated the residents. She said she has not seen any changes. The facility provided the survey team with a list of 11 current smokers. Review of the clinical records for a sample of smokers revealed the following: Resident #70 was a smoker admitted to the facility on [DATE]. Review of the clinical record showed a smoking evaluation with an effective date of 12/6/22 and signed by the DON on 1/20/23 noted the resident required supervised smoking. The resident's care plan dated 12/19/22 noted the resident was a smoker and the resident would smoke only in authorized areas while supervised. No other smoking evaluation was noted in the clinical record after 12/6/22. On 6/20 /23 at 10:25 a.m., and 12:46 p.m., Resident #70 was observed smoking unsupervised in the designated smoking area. The designated smoking area had an overfilled ashtray, and the floor of the wooden gazebo was littered with multiple cigarette butts. On 6/21/23 at 12:30 p.m., an unidentified resident was observed smoking in a covered patio clearly marked with a large nonsmoking sign. The patio did not have an ashtray. Several cigarette butts were observed littering the floor of the nonsmoking patio area. Photographic evidence obtained On 6/21/23 at 4:45 p.m., Resident #70 said he was aware smoking was not allowed in the nonsmoking patio but, we do it all the time. Resident #10 was a smoker admitted to the facility on [DATE] and a readmission date of 5/14/23. Review of Resident #10's clinical record revealed the most recent smoking evaluation completed on 1/19/23 noted the resident used oxygen and required supervised smoking due to safety of others and past behavior. No other smoking evaluation was completed after 1/19/23. Resident #30 was a smoker with an initial admission date of 6/28/21. The resident was discharged with return anticipated and on 6/15/23. The most recent admission was 6/20/23. Review of the clinical record on 6/20/23 showed the last smoking evaluation completed on 1/19/23 noted due to past behavior of choosing to not follow facility policy regarding smoking, supervised smoking was required. Resident #43 was a smoker admitted to the facility on [DATE]. Review of the clinical record showed the last smoking evaluation was completed on 1/20/23. The evaluation noted Resident #43 required supervised smoking. There was no other evaluation completed after 1/20/23. On 6/20 /23 at 10:25 a.m., and 12:46 p.m., Resident #43 was observed smoking unsupervised in the designated smoking area. On 6/22/23 at 1:05 p.m., the Administrator (AD) and Director of Nursing (DON) said the department heads conduct weekly rounds and fill out a form which covers multiple areas. The Administrator and Director of Nursing both said since they have been employed at the facility, respectively in February and March of 2023, no one had voiced concerns related to unsafe smoking practices. The Administrator said she was not aware residents were smoking in nonsmoking areas. The DON said as of 6/4/23 Resident #65 was the only resident who required supervision. She said a smoking evaluation is completed upon admission, on a quarterly basis and as needed. The DON verified staff did not consistently complete the smoking evaluation to address any change in condition placing residents at risk of thermal burns or fire due to unsafe smoking practices. The Immediate Jeopardy was removed on 6/23/23 after surveyor verification of an approved removal plan which included: On 6/21/2023 a Root Cause Analysis (RCA) on the smoking practices in the center to ensure safe smoking practices are in place to protect residents from serious injury, impairment or death was completed by the [NAME] President of Clinical Operations (VPCO), Administrator, Director of Nursing and Medical Director. Documentation of the RCA was put on the RCA Tool and will be included in the next Quality Assurance Performance Improvement (QAPI) meeting. The survey team verified through record review. On 6/23/2023, the VPCO educated the Administrator on ensuring the Center has a system in place to ensure safe smoking habits and practices are in place. Education included making sure staff in knowledgeable about habits that violate safe smoking practices and report them to administration when they occur. The survey team verified through record review. On 6/23/2023, the VPCO educated the Director of Nursing on conducting smoking assessments on residents that smoke on admission, quarterly and when they experience a change in condition that will affect smoking habits and competency. Education also included updating and individualizing plan of care of residents that smoke to reflect current assessment. The survey team verified through record review. On 6/23/23 all 11 smokers had an updated smoking evaluation. On 6/23/2023, the VPCO reviewed job descriptions for Administrator and Director of Nursing to ensure that they understand their duties and responsibilities. Review shows that Administrator and DON are capable of carrying out the job duties. The survey team verified through record review and interview of the Director of Nursing and Administrator. On 6/23/2023, the Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting on 6/23/2023 with DON, VPCO and Medical Director to review the Root Cause Analysis of Res #65 smoking risk event, center smoking practices & Performance Improvement Plan put in place to address areas of opportunities. The survey team verified through record review. Administrator implemented after review of RCA a (PIP) on residents smoking assessments and plan of care, 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 on 6/23/2023. The survey team verified through record review of smoking schedules and observation of supervised smoking in the designated smoking area. The SDC or designee re-educated Nursing, Social Services, Housekeeping, Dietary, Therapy, and Maintenance employees on the Smoking Policy and Procedure beginning 6/22/2023 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. Staff re-education: Nursing staff 39/44 (89%); Non nursing staff 15/15 (100%); Therapy 13/13 (100%); Dietary 9/10 (90%); Housekeeping/Laundry 11/11 (100%). Agency staff not currently educated will be educated on this plan prior to working their scheduled assignment. The survey team verified through record review, and interview of three nurses, and two Certified Nursing Assistants. Effective 6/22/2023, designated smoking times will be implemented for all residents who smoke. Cigarette paraphernalia and smoking aprons will be stored in a secure designated smoking storage cart. Additionally, documentation outlining individualized safety measures will be based on the smoking assessment and located on or inside the smoking storage boxes. Designated smoking aide will be added to daily staffing assignment. The survey team verified through record review and observation of supervised smoking at the designated smoking times. Effective 6/22/2023, Director of Nursing and/or designee will review new admissions during the Clinical Meeting to identify smokers and validate a smoking assessment has been completed and a plan of care is in place to maintain resident safety. The survey team verified through record review. If a resident is observed as being non-compliant with smoking, a care plan meeting will be scheduled with resident and/or legal representative. Smoking privileges may be revoked. Any further non-compliance may result in the issuance of an immediate discharge notice and/or a 30-day notice for discharge. The survey team verified through record review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 6/20/23, review of the clinical record for Resident #43 revealed an initial admission date of 8/20/21. The Annual MDS assessment with an assessment reference date of 8/23/22 noted the resident had current tobacco use. Diagnoses included Dementia. The most recent smoking evaluation was dated 1/20/23 and was completed by the DON. The DON answered No to the question Does the resident have dementia?. The evaluation noted, Supervised smoking is required. No other smoking evaluation was noted in the clinical record. The care plan initiated on 8/20/21 and revised on 2/23/23 noted the resident was a current smoker with a goal to remain safe from injury. The interventions included, A smoking history and safe smoking assessment will be completed upon admission/readmission, quarterly, annually, and/or with a change in smoking habits. Resident must have cigarettes/lighters locked up at all times other than smoking time. Resident will smoke only in authorized areas while being supervised. On 6/20/23 at 10:52 a.m., Resident #43 was observed smoking unsupervised in the designated smoking Gazebo. Resident #43 had cigarettes and a lighter. He said he keeps his cigarettes and lighter in his room and smokes when he feels like it. The smoking patio was observed with a large plastic garbage container within proximity of an ashtray mounted to the pole of the gazebo of the smoking area. The garbage container was approximately filled 75% with items including paper items and Styrofoam cups. Multiple cigarette butts were observed on the wooden floor of the gazebo, on the grass surrounding the smoking area and around a pole cigarette receptacle which was overfilled with cigarette butts. Photographic evidence obtained. The wall mounted metal box containing the fire blanket had sharp rusted pieces. Photographic evidence obtained. There were cigarette butts next to the wooden walkway leading to the gazebo. Photographic evidence obtained. On 6/20/23 at 1:11 p.m., and 6/21/23 at 9:43 a.m., on the 400-hall patio, there was a nonsmoking sign on the door leading to the outside covered patio. The nonsmoking area did not have an ashtray and multiple cigarette butts were observed on the floor. On 6/21/23 at 12:30 p.m., an unidentified resident was observed smoking in the covered patio clearly marked with a large nonsmoking sign. 5. On 6/20/23, review of the clinical record for Resident #10 revealed an admission date of 11/11/2017 and a readmission date of 5/14/23. The care plan initiated on 5/17/21 and revised on 6/19/23 noted the resident was a smoker and non-compliant with smoking protocol. The goal was for the resident to not suffer injury from unsafe smoking practices. The interventions included instructing resident about the facility policy on smoking, locations, times, safety concerns and wait for assistance from staff. Resident #10's care plan also noted the resident had poor impulse control, had the potential to be physically aggressive, hitting out at staff/residents related to anger, altering oxygen orders per physician's order at bedside. The most recent smoking evaluation was dated 1/19/23 and noted the resident required supervised smoking, due to the safety of other and past behavior. No other smoking evaluation was completed after 1/19/23. On 6/20/23 at 9:13 a.m., Resident #10 was observed lying in bed. He said he usually kept his cigarettes and lighter with him. He said he dropped them on the floor and could not find them. Based on observation, record review, staff and resident interviews, the facility failed to implement processes to ensure accurate assessment and supervision of residents who smoke tobacco products to protect each resident's individual's safety and the safety of other residents. The facility failed to comprehensively assess and implement adequate interventions to minimize falls for 1(Resident #71) of 1 resident reviewed for falls. On 6/4/23 staff observed Resident #65 smoking in his room with the oxygen concentrator on. The facility failed to reassess Resident #65's ability to adhere to safe smoking precautions and allowed the resident to keep, and store smoking materials. Resident #65 and other residents who required supervision to smoke were observed smoking unsupervised. The smoking area was observed with an overfilled pole cigarette receptacle and the surrounding area littered with cigarette butts. The floor of a clearly marked nonsmoking area had scattered cigarette butts. Residents observed smoking unsupervised in the nonsmoking area with no ashtray. The facility failure to ensure safe smoking practices created a likelihood of serious injury, impairment or death from thermal burn and fire, and resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of pattern (K) starting on 6/4/23. On 6/23/23 at 11:50 a.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. The findings included: Cross Reference to F835. The facility policy Resident Smoking (revised 9/12/22) documented It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking and non-smoking residents. Policy Explanation and Compliance Guidelines: 1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. 2. Safety measures for the designated smoking area will include, but not limited to: a. Protection from weather conditions (i.e. covered). b. Provision of ashtrays made of noncombustible material and safe design. c. Accessible metal containers with self-closing covers into which ashtrays can be emptied. d. Accessible fire extinguisher. e. Prohibition of oxygen use in the smoking area. f. Located outdoors from main entrances and exits, and common space utilized by other residents in order to protect non-smoking residents from second hand smoke. 4. All residents and family members will be notified of this policy during the admission process and as needed. 5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) assessment process. 6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke will be allowed to smoke in designated areas (weather permitting) at designated times, and in accordance with his/her care plan. 12. Smoking materials of residents will be maintained by the centers designated associate. 1. Review of the clinical record revealed Resident #65 had an admission date of 4/13/22 with diagnoses including major depressive disorder, anxiety, schizophrenia, and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #65's cognitive skills for daily decision making were intact. Resident #65 frequently experienced moderate pain which limited his day-to-day activities. The assessment noted the resident was receiving oxygen therapy. The care plan initiated 4/20/22 and revised on 1/19/23 noted Resident #65 was a current smoker. The care plan documented, supervised smoker; chooses at time to not follow facility policy regarding smoking and may require more encouragement. The goal was, The resident will not put other residents/staff at risk secondary to smoking. The interventions included, A smoking history and safe smoking assessment will be completed upon admission/readmission, quarterly, annually, and/or with a change in smoking habits and care smoking care plan will be initiated. Encourage/ educate resident to use safety while smoking; assessed found to be at risk. Resident refuses- - A fire retardant smoking apron must be worn while smoking. Initiated: 01/20/2023 Resident will smoke only in authorized areas while supervised. Smoking education has been provided to resident including not smoking in facility; designated smoking areas; locking up cigarettes/lighters; cigarettes brought in by family/friends must be locked up; only facility ashtrays may be used. Violation of smoking rules or disregard for safety rules my result in revocation of smoking privileges. Smoking rules will be reviewed with the resident upon admission. Date Initiated: 01/20/2023. The care plan initiated on 8/12/22 and revised on 2/2/23 noted the resident had the behavior of picking up cigarettes from the floor and out of the garbage. The interventions included monitoring the resident's behavior and for staff to notify maintenance to ensure there were no remaining cigarette on the floor in the smoking area. The Smoking Evaluation completed by the Unit Manager and dated 5/19/23 noted, Independent smoking is allowed. The Unit Manager entered No to the questions Does the resident use oxygen?, and Does the resident have unsafe smoking habits? Review of the nurse's progress note dated 6/4/23 documented Resident #65 was found to be smoking in his room by certified nursing assistant (CNA). She ensured that he put it out and he put it out on restroom door ledge. This nurse immediately notified, room smells like smoke and resident's oxygen concentrator is on at bedside but not in use while resident was by the restroom. Resident denies that he was smoking educated by nurse and ADON (Assistant Director of Nursing). Cigarettes confiscated and placed in smoker box, resident denies having a lighter. Monitored frequently via 15-minute checks. Will continue to monitor. The smoking evaluation and care plan were not revised to reflect Resident #65's unsafe smoking incident. On 6/20/23 at 9:25 a.m., CNA Staff C said Resident #65 was a smoker and propelled himself to the smoking area several times a day. Staff C said the smoking area was always monitored, and no resident was allowed to smoke independently. On 6/20/23 at 12:08 p.m., Resident #65 was observed in bed with a lighter and cigarettes. An oxygen concentrator was observed in the room. Resident #65 said he smoked daily. He said he had been feeling drained with no energy in the last few weeks but was able to transfer himself and go outside to smoke on his own. On 6/20/23, the facility provided a new smoking evaluation completed on 6/20/23 at 3:42 p.m., which noted Resident #65 used oxygen, had unsafe smoking habits, and a history of sharing/selling cigarettes or smoking materials. The evaluation noted the resident had a decline in functionality and determined Resident #65 required supervised smoking. On 6/20/23 at 3:48 p.m., the Director of Nursing (DON) said the nurse had planned to complete another smoking assessment for Resident # 65 due to significant change in his status and physical decline. On 6/20/23 at 4:20 p.m., Resident #65 was observed propelling himself to the smoking area with cigarettes and a lighter. The resident was observed smoking unsupervised. On 6/20/23 at 4:20 p.m., the designated smoking area was observed with an overfilled pole cigarette receptacle with multiple cigarette butts littering the surrounding area. Photographic evidence obtained. Cigarette butts were observed on the floor of the smoking area of the wooden gazebo. Photographic evidence obtained. On 6/21/23 at 9:41 a.m., Licensed Practical Nurse Unit Manager Staff E said the smoking materials were kept at the nursing station in a box behind the desk. Staff E said the process was independent smokers can go out when they choose, there were no scheduled smoking times. She said the independent smokers did not require supervision and they come to the desk to get their cigarettes and lighter. Staff E said all staff were responsible to ensure the cigarettes and lighter were returned to the nursing station. Staff E said Resident #65 now required supervision with smoking. Staff E said the CNA was told to go out with the resident when he wants to smoke. Staff E said there was no set time or CNA assigned to assist Resident #65 with smoking. On 6/22/23 at 1:05 p.m., the DON verified a new evaluation was not completed on 6/4/23 after Resident #65 was found smoking in his room with the oxygen concentrator on. She said from that point on, he was put on supervised smoking which meant all his smoking materials needed to be kept at the nurses' station. She said the information was passed on verbally between staff members. 2. Review of the clinical record for Resident #70 revealed an admission date of 12/6/22. The admission MDS assessment with an assessment reference date of 12/13/22 noted the resident's diagnoses included Dementia. The most recent smoking evaluation signed on 1/20/23 with an effective date of 12/6/22 noted the DON answered No to the question, Does the resident have dementia?. The facility determined Supervised smoking is required for Resident #70. No other smoking evaluation was completed after 1/20/23. The care plan initiated on 12/19/22 and revised on 6/19/23 noted, Resident will smoke only in authorized areas while supervised. On 6/20/23 at 10:25 a.m., and 12:46 p.m., Resident #70 was observed smoking unsupervised in the designated smoking area. On 6/21/23 at 4:45 p.m., Resident #70 said smoking was not allowed in the nonsmoking patio but, we do it all the time. 3. Resident #30 was a smoker with an initial admission date of 6/28/21. The resident was transferred to an acute care hospital on 6/15/23 and returned to the facility on 6/20/23. The care plan initiated on 12/7/23 and revised on 1/19/23 noted the resident was a smoker and, Resident chooses to not follow facility protocol regarding smoking at times. The interventions included as of 12/7/21, The resident can smoke unsupervised. Review of the clinical record on 6/20/23 showed the last smoking evaluation completed on 1/19/23 noted due to past behavior of choosing to not follow facility policy regarding smoking, supervised smoking was required. No other evaluation was found in the clinical record after 1/19/23. The care plan was not updated to reflect the resident required supervised smoking. On 6/21/23 at 5:40 p.m., Assistant Maintenance Director Staff B said, I have picked up cigarette butts daily for the last year, they are always on the ground. The management team educates the residents on safe disposal of cigarettes, but I have seen the residents' throwing butts on the ground. Every morning I am picking up butts off the ground. Staff B said I have observed Resident #70, #10 and #30 throwing cigarette butts onto the ground and I tell them over and over to put them in the ashtray. I have spoken to management about the concerns. I have not seen residents smoking on the non-smoking patio but every morning I pick up the cigarette butts. I check every morning at the gazebo area, and I use a reacher and a broom to pick up all the butts from the ground. Staff B said, what you have seen out there was two days' worth of cigarette butts because I did not get to it today. I am responsible to empty the ashtrays and last Friday the 16th was the last time I emptied it. There was no certain time the residents are able to smoke, they smoke all day long. There is a red metal bucket outside by the fence for cigarettes and I empty it daily. I have never emptied the [NAME] bottle ashtray (pole cigarette receptacle). There are butts around the [NAME] ashtray in the rocks and I pick them up every day. I sweep the grass with a broom to try and get them up. Staff B said she had spoken to administration about the cigarette butts being put out on the ground and they spoke to the residents about using the ashtrays and not throwing them on the ground. Staff B said, I have not seen any changes since the Administrator said she educated the residents, they still throw them (cigarette butts) on the ground. On 6/22/23 at 1:05 p.m., the Administrator (AD) and Director of Nursing (DON) said the department heads conduct weekly rounds and fill out a form which covers multiple areas. The Administrator and Director of Nursing both said since they have been employed at the facility, respectively in February and March of 2023, no one had voiced concerns related to unsafe smoking practices. The Administrator said she was not aware residents were smoking in nonsmoking areas. The DON said as of 6/4/23 Resident #65 was the only resident who required supervision. She said a smoking evaluation is completed upon admission, on a quarterly basis and as needed. The DON verified staff did not consistently complete the smoking evaluation to address any change in condition placing residents at risk of thermal burns or fire due to unsafe smoking practices. 5. Resident #71 was admitted to the facility on [DATE] with a history of hypertension, Cognitive communication deficit, Being unsteady on her feet, muscle weakness, Dementia, and Schizophrenia. On 1/23/23 the quarterly Minimum Data Set (MDS) showed Resident #71 had severe cognitive deterioration with a Brief Interview for Mental Status score of 2. On 6/19/23 at 10:55 a.m., Resident #71 was observed lying in the bed sleeping. There was a single floor mat noted on the side of the bed of window and wall. On 6/20/23 at 2:00 p.m. Resident #71 was observed lying in the bed sleeping. The same single floor mat was noted on the floor. On 6/21/23 at 11:10 a.m. Resident #71 was observed lying in the bed sleeping. The same single floor mat was noted on the side of the bed. On 6/22/23 at 1:20 P.M. Resident #71's daughter said she was concerned about her mother falling. She stated her mother had fallen two times at the facility where she had to be sent to the hospital due to her injuries. Resident #71's daughter said she was concerned because she did not think the facility had interventions in place to prevent her mother from continuing to fall. An incident report shows on 2/24/23 at 9:30 p.m. Resident #71 fell in her room and hit her head causing her to go to the hospital for treatment. According to the incident report the fall was witnessed by a certified nursing assistant whose statement is recorded as, room [ROOM NUMBER] was sitting up on the bed. I asked is she was ok, and she said OK. When she got up from the bed I asked her where are you going? She told me stop as she was getting up she lost her balance and stumbled and fell down and hit her head on the wall. I was sitting in the room with 301. On 2/24/23 at 10:13 p.m. documentation on the Fall Risk Assessment V2.0 shows Resident #71 was assessed to be a low risk for falls with a score of 9. The form reads a score greater than 10 is considered a risk for falls. On 4/14/23 at 5:45 p.m. an incident report shows Resident #71 had a fall after being put in her bed. The nurse who reported the incident wrote, At the beginning of the shift, resident was sitting in her wheelchair, and became increasingly agitated and combative. Assisted patient back to bed for safety. Bilateral fall matts in place. Bed in low position. Non skid socks in place. At about [5:45 p.m.] got called by staff to resident's room. Resident observed laying on the floor, face down in a moderate to large amount of bright blood. Resident responded to name calling by moaning, attempting to lift self from the floor. [vital signs] stable. Resident lifted off the floor by paramedics. The resident was transported to the hospital on 4/14/23. Resident #71 was diagnosed with a fractured nasal bone on 4/15/23. Resident #71's Had a fall care plan initiated on 1/26/22/ and it was last revised on 4/26/23. Interventions included in the care plan were ensure secure bilateral footwear for safety, Encourage and assist resident to lay down for naps, Review information on past falls and attempt to determine cause of falls. There was no intervention listed on the care plan for a floor mat or bilateral floor mats while the resident is in the bed. On 6/23/23 at approximately 1:30 p.m. the Administrator said if there was one fall mat it should be on the side of the bed toward the door where the resident gets out of bed. The Administrator was referred to the incident report on 4/14/23 where the resident had bilateral floor mats prior to her fall. On 6/23/23 at approximately 2:30 p.m. The administrator said they were removing the floor mat because the resident did not have a physician's order to have them. The Administrator was asked about the potential injury to the resident if she fell from her bed again. The Administrator stated she would have to get back with me. On 6/23/23 at 5:30 p.m. The administrator had not followed up as to whether the facility would continue with floor mats for Resident #71. The Immediate Jeopardy was removed on 6/23/23 after surveyor verification of an approved removal plan which included: A comprehensive skin assessment was completed by nurse manager/ charge nurse on Resident #65 on 6/5/23; 6/6/23; 6/7/23 and 6/23/2023, no new or old areas of skin impairment noted. The survey team verified through record review. The nurse manager examined Resident #65 clothes for signs of burn, none noted on same dates as skin assessment. The survey team verified through record review. On 6/21/2023 Nurse Manager searched Resident #65 room for smoking paraphernalia, cigarettes and lighter confiscated and placed in a lock box at the west wing nursing station. The survey team verified through observation of the locked box at the west nursing station. The Nurse Manager completed a smoking re-assessment on Resident #65 on 6/23/2023 and revised plan of care to include supervised smoking during assigned smoking times in designated smoking area and to wear an apron while smoking. The survey team verified through record review. Resident #65 was placed on supervised smoking on 6/23/2023. Supervised smoking consists of direct staff observation during designated smoking times in designated smoking area with smoking apron. The survey team verified through record review. The Social Service Director re-educated Resident #65 on smoking policy and procedure on 6/20/2023. Education included adherence to the smoking times, smoking allowed only with staff supervision, smoking only in designated smoke areas only, smoking aprons, discarding of cigarette butts, and turning in cigarette paraphernalia to staff after smoking. Resident #65 signed the policy and procedure contract as good faith to adhere to the policy. The survey team verified through record review. The Administrator hosted an Ad Hoc Quality Assurance Performance Improvement meeting with Medical Director engagement on 6/21/2023 to discuss Smoking Policy and specific emphasis on Implementation of smoking 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. The survey team verified through record review. Administrator and/or designee conducted a room search of residents that smoke to search for and confiscate cigarette paraphernalia. Cigarettes and lighters were retrieved and placed in lock boxes at the west wing nurse's station. Only Nursing and/or Ancillary staff will have access to the storage boxes. The survey team verified through observation of the locked box at the nurse's station. Nurse Manager and/or designee completed a smoking assessment on all residents that smoke on 6/21/2023. All residents that were identified as needing supervised smoking plan of care was updated to reflect smoking supervision. The survey team verified through record review. All residents who smoke plan of care was revised on 6/23/2023 to include smoking allowed only during designated times in designated smoking location. The survey team verified through record review. Social Service Director and/or designee re-educated all residents that smoke on the Smoking Policy and Procedure on 6/21/2023. 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. The survey team verified through record review. A Smoking Contract on the policy and procedure was initiated with all residents who smoke 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 6/21/2023. The survey team verified through record review. Interdisciplinary Team thoroughly checked clothing for all resident identified as smokers to ensure no holes or burns were observed on 6/22/2023. No concerns were identified. Center staff on 6/21/2023 did grounds search and picked up cigarettes' butts and emptied ashtrays. Maintenance assistance will be responsible to make sure ash trays are frequently emptied, cigarette butts or evidence of smoking are not discarded in undedicated areas but in fire receptacles and re-educated to report noncompliance on 6/22/2023. The survey team verified through observation, record review and interview with the maintenance assistant and the Administrator. Maintenance assistance completed an audit of the smoking area on 6/22/2023 to validate availability of smoking blanket, fire receptacles, fire extinguishers and aprons. Effective 6/23/2023, smoking aprons will be in the designated smoking area. The survey team verified through observation. Maintenance assistance and/or designee validated no smoking signage is posted in non-smoking areas on 6/22/2023. The survey team verified through observation. Social Service Director and/or designee re-educated all residents that smoke on the Smoking Policy and Procedure on 6/22/2023. 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. The SDC or designee re-educated Nursing, Social Services, Housekeeping, Dietary, Therapy, and Maintenance employees on the Smoking Policy and Procedure beginning 6/22/2023 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. The survey team verified through record review and interview of random staff, including licensed Nurses and CNAs. Any employee on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. Staff re-education: Nursing staff 39/44 (89%); Non nursing staff 15/15 (100%); Therapy 13/13 (100%); Dietary 9/10 (90%); Housekeeping/Laundry 11/11 (100%). Agency staff not currently educated will be educated on this plan prior to working their scheduled assignment. The survey team verified through record review. Effective 6/22/2023, designated smoking times will be implemented for all residents who smoke. Cigarette paraphernalia and smoking aprons will be stored in a secure designated smoking storage cart. Additionally, documentation outlining individualized safety measures will be based on the smoking assessment and located on or inside the smoking storage boxes. Designated smoking aide will be added to daily staffing assignment. The survey team verified through record review. Effective 6/22/2023, Director of Nursing and/or designee will review new admissions during the Clinical Meeting to identify smokers and validate a smoking assessment has been completed and a plan of care is in place to maintain resident safety. If a resident is observed as being non-compliant with smoking, a care plan meeting will be scheduled with resident and/or legal representative. Smoking privileges may be revoked. Any further non-compliance may result in the issuance of an immediate discharge notice and/or a 30-day notice for discharge. The survey team verified through record review. Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting on 6/23/2023 with Department Managers and reviewed with the Medical Director on the center's Smoking Policy and the performance improvement measures outlined in this document. The survey team verified through record review.