**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. Review of the EMR for R25 revealed he was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, lack of coordination, mood and psychotic disorders, hypertension (HTN), and anxiety. Review of the quarterly MDS dated [DATE] documented a BIMS score of five, indicating severe cognitive impairments. Section J revealed resident was not coded as a current tobacco user; however, the 3/24/2024 annual MDS revealed resident was coded as a current tobacco user. A review of the smoking assessment dated [DATE] revealed due to R25's behavior and score with smoking assessment, resident will need supervision with smoking and he requires someone to light/extinguish the cigarette. A review of R25's care plan initiated on 11/5/2021 revealed R25 is an unsafe smoker and will not smoke without supervision. Resident was found smoking in his room and was documented that he will only smoke in appropriate area under direct supervision. Further review documented removal of all smoking devices from resident room and store in locked container. Observation on 9/24/2024 at 10:06 am, R25 was outside in the dementia care smoking area smoking unsupervised. There were no staff members outside at this time. Interview on 10/7/2024 at 10:08 am, R25 stated he smokes two to three times a day and revealed that he keeps his own cigarettes and lighter in his room. During further interview, he stated nobody helps him with his cigarettes and lighter, and states that he can do it on his own. C. Review of the EMR for R19 revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, malignant neoplasm of lower gastrointestinal tract, diabetes, end stage renal disease (ESRD), hypertension, and depression. A review of the quarterly MDS dated [DATE] revealed a BIMS score of six which indicated that the resident had severe cognitive impairment. Section J on the 12/23/2023 annual MDS revealed resident was not coded as a current tobacco user. A review of the smoking assessment dated [DATE] revealed R19 requires supervision with retrieval of smoking supplies. A review of R19's care plan revised 10/6/2024 revealed resident is a smoker and requires supervision and will not have injury related to smoking. Interventions to care include smoking assessment per facility protocol, staff supervision during smoking, and staff to maintain/store all smoking materials. Observation and Interview on 10/7/2024 at 12:03 pm, R19 observed smoking outside in the front smoking area unsupervised. Resident was noted to be wearing a pair of pants with one visible burn hole on them. Interview with resident at this time confirmed that he had a burn hole in his pants. He stated that he keeps his cigarettes and lighter with him. E. Review of the EMR for R111 revealed he was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder. A review of the annual MDS dated [DATE] revealed a BIMS score of two, indicating the resident is severely cognitively impaired. Section J revealed resident was not coded as a current tobacco user. A review of the smoking assessment dated [DATE] revealed that residents safety awareness was good and no supervision required, which is conflicting with his current plan of care. A review of R111's care plan revised 7/9/2025 revealed resident is a smoker and he will not suffer injury from unsafe smoking practices and will not smoke without supervision. Interventions to care include resident requires supervision while smoking. Observation on 10/6/2024 at 3:58 pm, R111 on the memory care unit, pulled a cigarette out of his right pocket and a lighter out of his left pocket. He lit the cigarette and began smoking, inside the building. Surveyor informed Medical Records Clerk (MRC) MM that R111 had lit a cigarette and began to smoke it while inside the building, and she went down the hall and took the cigarette and lighter from him. F. Review of the EMR for R118 revealed he was admitted to the facility on [DATE] with diagnoses including acute kidney failure, metabolic encephalopathy, paraplegia, right/left hand contractures, hypertension and major depressive disorder. A review of the quarterly MDS assessment dated [DATE] revealed a BIMS was coded as 15, which indicated no cognitive impairment. Section J revealed resident was not coded as a current tobacco user. A review of the smoking assessment dated [DATE] revealed the question does resident use smoking/tobacco/nicotine products? Response was documented no-stop here. A review of R118's care plan revised on 3/29/2022 revealed he did not have a care plan to address resident's smoking preference. He did have a care plan addressing a focus that R118 chooses to leave the facility for social interactions with friends, including alcohol consumption and drugs. Interview on 10/7/2024 at 9:10 am, R118 stated he was an occasional smoker and he smokes once or twice every two to three months. Interview on 10/7/2024 at 2:20 pm, with MDS Regional Coordinator indicated that residents that use any type of tobacco/nicotine products are required to have a smoking assessment and a care plan addressing their smoking status. She confirmed R118's smoking assessment documented that he was not a smoker. Observation on 10/7/2024 at 2:49 pm, R118 was observed outside front of the facility smoking, without wearing a smoking apron. 2. Review of the EMR for R172 revealed he was admitted to the facility on [DATE] with diagnoses that included seizures, encephalopathy, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, which indicates the residents cognitive status cannot be determined. No moods or behaviors exhibited. Resident has medically complex conditions, including PTSD. A review of R172's care plan initiated on 10/2/2024 revealed focus areas documenting resident receives antidepressant medication and has impaired cognitive function/dementia or impaired thought processes related to impaired decision making and long and short-term memory loss. Further review of the care plan did not address a focus area or interventions addressing residents diagnosis of PTSD. Interview on 10/5/2024 at 4:10 pm, the Regional Director of Clinical Reimbursement (RDCR) revealed that information for the completion of the MDS is gathered from resident hospital records, EMR, staff, resident, and family interviews. The RDCR stated that the interdisciplinary team (IDT) team is responsible for the developing resident comprehensive person-centered care plans. During further interview, she stated the MDS is updated quarterly, annually, or for a significant change in condition. The RDCR confirmed that R172 did not have a care plan addressing how to care for a resident with PTSD. Review of the psychotherapist notes for resident R172 revealed that resident had periods of agitation during visits and experienced episodes of depression and being withdrawn. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility failed to develop a comprehensive person-centered care plan for residents R25, R145, R111, R19, R71, R118, R266 and R365. On 10/9/2024 the Regional Nurse Consultant and Director of Nursing reviewed and revised each of their smoking care plans to ensure that they are person centered and comprehensive. 2. The Regional Director of Operations on 10/9/2024 in-serviced the Director of Nursing, Assistant Director of Nursing, Minimum Data Set nurses and Regional Nurse Consultant on the smoking policy, ensuring that smoking care plans are followed and completed timely, and importance of accurate smoking assessments. The Administrator will be in-serviced prior to returning to work by the Regional Director of Operations. 3. Regional Director of Operations on 10/9/2024 in-serviced the MDS nurses on reviewing for complete and accurate comprehensive person-centered smoking care plans for all residents who smoke. 4. On 10/9/2024 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking policy, all residents on Dementia Unit will be required to wear smoking aprons, smoking times, and on the smoking monitors will be present at all smoke breaks (Registered Nurse 10 of 10, Licensed Practical Nurse 33 of 34, Certified Nurse assistant 62 of 67, Certified Medication Aides 7 of 8, Respiratory Therapist 1 of 2, Dietary 14 of 25, Therapy 8 of 13, Administrative 18 of 1 8, Maintenance 4 of 4, Housekeeping 30 of 37, Activities 3 of 4 staff). The current percentage of staff educated is 86% at this time. In addition, clinical staff are being in serviced on importance of following smoking care plans and completing timely and accurate smoking assessments. 5. Currently 10 of 10 Registered Nurses, 33 of 34 Licensed Practical Nurses, 62 of 67 Certified Nurse assistants, and 7 of 8 Certified Medication Aides have been in serviced on importance of following care plans. There is currently 94% in serviced completion. 6. On 10/9/2024 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking monitors will be present at all smoke breaks. 7. All new licensed staff will be in-serviced on these items above during the orientation process by the Assistant Director of Nursing and/or Director of Clinical Education. 8. We have no agency staff currently. 9. AD Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed on 10/10/2024 for policy review and root cause analysis was determined staffing education was needed. Attendance to the meeting was Regional Director of Operations, Director of Nursing, Regional Nurse, [NAME] President of Quality, business office manager, dietary manager, dietary assistant manager, medical supply clerk, transportation coordinator, Director of Rehab, Social Worker, and Unit Managers. The Medical Director was notified by phone. 10. Corrective actions will be completed by 10/10/2024. Alleged date of IJ removal: l0/11/2024 The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Care Plan and Smoking Assessment Review : R25 - Unsafe smoker, Care plan revised on 10/9/2024, Smoking assessment was completed on 10/9/2024- requires supervision. R145 - is a safe smoker however was observed lighting cigarettes for other residents. R145 is a safe smoker 10/9/2024- R111- is an unsafe smoker. 10/9/2024-requires supervision and an apron. R19 - is an unsafe smoker 10/11/2024- needs supervision and an apron. R71- is an unsafe smoker. Resident solicits to residents, staff, and/or visitors when cigarettes are not available. Resident has a history of being non-compliant with smoking policy - 10/9/2024-requires supervision and an apron. R118 - is unsafe smoker, 10/9/2024 - requires apron, cigarette holder, someone to light and extinguish and supervision. R266- Resident is a safe smoker. 10/9/2024- no supervision, R365- is a safe smoker; however, sometimes non-compliant with the smoking policy. History of lighting other resident's cigarettes 10/9/2024-independent smoker. 2. In an interview on 10/11/2024 at 4:09 pm, with Regional Director of Operations (RDO) revealed in-service education was conducted by her and Training and Development Coordinator, Licensed Practical Nurse (LPN) Unit Manager (UM) GGGG. She stated her in-service included ensuring the residents have their smoking aprons, smoking times, and direct supervision over all smokers safe and unsafe. In an interview on 10/11/2024 at 4:29 pm, with Regional Nurse Consultant (RNC) revealed her most recent in-service education was on 10/9/2024 by the RDO and LPN UM GGGG. She stated the in-service education she received was relating to the smoking policy, abiding by smoking times and ensuring all smokers are care planned. She stated she learned once a person who wants to smoke is identified a smoking assessment is completed. In an interview on 10/11/2024 at 4:49 pm, the Director of Nursing (DON) revealed she received in-service from her Regional Director of Operations on 10/9/2024. She stated she was educated on the new smoking times, smoking policy and creating safe smoking habits for residents. She stated she was taught smoking assessments must be done quarterly and as needed (PRN) and all care plans must be updated to ensure they are in alignment with the assessment. She revealed she was taught to ensure unsafe smokers will not have their equipment on them, instead they will be locked in a lock box. In an interview on 10/11/2024 at 5:14 pm, the Assistant Director of Nursing (DON) revealed she received in-service education on 10/9/2024 and 10/11/2024 relating to all the smokers in the building. She stated she learned the smokers cannot smoke anytime they like and that they are not allowed to hold their own smoking material. She stated her in-service education consisted of smoker's policy, timely assessments and care plans. She stated each resident must be supervised every 2 hours, and a smoking list kept at each nursing section. 3. Interview on 10/11/2024 at 4:49 pm, the Minimum Data Set nurse JJJJJ revealed she received in-service education on 10/9/2024 and 10/11/2024 from the Regional Director of Operations. She stated the RDO covered topics such as updating care plans, the smoking policy and smoking assessments for all residents that smoke. 4. Interview on 10/11/2024 with LPN KKKK at 4:20 pm, stated she received in-service on smoking last week and this week. She signed the in-service sign in sheet. The training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. She continued to state the Unit Manager KKKK gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station. Interview on 10/11/2024 at 4:37 pm, the Scheduling Manager revealed she received smoking in-service training. She stated everyone on Magnolia Hall is consider unsafe. She continued to state apron should be on, they are not to have cigarettes or lighters on person. Smoking box is kept at the nursing station. Further, the nursing keeps the list of the smokers, also list in the smoke box upstairs. The fire blankets are kept in the boxes in both locations up and down stairs. Additionally, the smoking assessment must be done by the nurses, clinical manager or MDS personnel. Once the assessment is completed it is put in the care plan. Interview on 10/11/2024 at 4:29 pm, with Certified Nursing Assistant (CNA) MMMM, stated she received smoking in-service recently. The in-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. She continued to state the nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision. 5. Review of the in-service training for the removal plan determined all numbers are accurate. 6. Interview on 10/11/2024 at 4:20 pm, with LPN KKKK stated she received in-service on smoking last week and this week. She signed the in-service sign in sheet. The training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. She continued to state the Unit Manager gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station. Interview on 10/11/2024 at 4:25 pm, with CNA NNNN stated she did receive in-service pertaining to smoking. In-service referred to the up-to-date policy, safe smokers, and unsafe smokers. She stated the safe smoker do not have to have an apron on versus the unsafe smokers don't have to have an apron. Nurses are the ones who do the smoking assessment. The updated list is found at the nurse station. Unit upstairs smokes every two hours and downstairs on Magnolia start at 10:00 am - 6:00 pm. Interview on 10/11/2024 at 4:29 pm, with CNA MMMM stated she received smoking in-service recently. The in-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. She continued to stated nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision. Interview on 10/11/2024 at 4:32 pm, with LPN OOOO revealed she has received the in-service training for smoking. She stated the training pertained to safe and unsafe smoker, the smoking aprons, light the cigarettes and monito them. If the resident is deemed safe still monitor. She continued to state nurses can do the assessment for smoking. All Magnolia residents are monitored at all times during smoking times. In addition, to keep the cigarettes locked in the smoke box which is located in the Activities office. If any new staff, the staff can show them the list that is posted at the nurse's station. 7. Interview with Regional Director of Operations and Regional Nurse Consultant on 10/11/2024 at 3:35 pm, both stated new onboarding employees will review the smoking policy as part of their orientation process. During this onboarding process the smoking components are: There is a new Smoking Schedule, and all staff should direct residents to the times. Smoking Assessment will be conducted as soon as the resident is identified as a smoker with care plan. All unsafe smokers should have a care plan, assessment, supervised residents will have on a smoking apron at all times. All residents on Magnolia are required to wear a smoking apron. Smoking Monitors should be present at all schedule smoking break times. Importance of following smoking care plans and accurately completing smoking assessment in a timely manner. Ensure smoking aprons are on correctly, residents are not allowed to light other resident cigarettes. Residents not on the smoking list are not allowed to smoke until the Charge Nurse, Administrator, or Director of Nursing have been notified and Smoking Assessment is completed. 8. We have no agency staff currently. 9. Record Review of the AD HOC QAPI Meeting confirmed the root cause was determined and that education to staff and residents on the smoking policy and expectations was needed, and a set smoking schedule established. Record Review revealed the removal plan binder with printed sheets in large bold print of the smoking schedule for the designated smoking area in courtyard and downstairs courtyard outside of Magnolia. Smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks. Interview on 10/11/2024 at 3:58 pm, with Regional Director of Operations assisted in verifying and identifying the staff that was present at the AD HOC QAPI Meeting: - Regional Nurse Consultant was present - Vice President of Quality was present - Business Office Manager was present - Dietary Manager was present - Dietary Assistant Manager was present - Medical Supply Clerk was present - Transportation Coordinator was present - Director of Rehabilitation was present - Social Worker was present - Unit Managers IIII, GGGG, CC, ZZ were present - Medical Director was present Record review of the AD HOC QAPI Meeting Log revealed Medical Director was notified over the phone. Phone Interview on 10/11/2024 at 4:11 pm, with Medical Director confirmed he attended the AD HOC QAPI meeting over the phone. Record review of the AD HOC QAPI Meeting Log for F835 confirmed all stated staff was present at the AD HOC QAPI Meeting. No other concerns identified. Based on observations, record review, resident and staff interviews, and review of the policy titled Comprehensive Care Plans, the facility failed to develop and/or implement the person-centered care plan for six residents (R) (R71, R266, R19, R25, R111, R118) reviewed for smoking. In addition, the facility failed to develop a care plan for one resident (R172) related to Post Traumatic Stress Disorder (PTSD). The facility's failures created potential risks for the safety and well-being of the residents. The sample size was 102 residents. On 10/9/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Corporate Regional Director of Operations, Corporate Regional Nurse Consultant (RNC), and Director of Nursing (DON) was informed of an Immediate Jeopardy (IJ) on 10/9/2024 at 3:11 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/22/2024. Upon survey entrance to the facility, residents were observed sitting out front of the facility, smoking unsupervised. Throughout the duration of the survey, the facility failed to monitor the smoking practices by not maintaining accurate smoking assessments, allowing residents to keep smoking materials in their possession, not supervising residents while smoking, and allowing a resident in the dementia care unit to smoke inside the facility. A Credible Allegation of Compliance was received on 10/11/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/11/2024. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding facility smoking practices, to include smoking assessments, and following care plans related to smoking. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: 1. A review of the facility policy titled Comprehensive Care Plans reviewed 10/1/2024 indicated the Policy Statement: Facility will develop and implement a comprehensive-person centered care plan for each resident. Consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, mental and psychosocial needs. Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. Policy Explanation and Compliance Guidelines: Number 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. Number 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Number 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. A. Review of the electronic medical record (EMR) for R71 revealed an admission date of 3/22/2016 with diagnosis that include conversion disorder with seizures or convulsions, traumatic brain injury (TBI), muscle weakness, unspecified intellectual disabilities, dysphagia, lack of coordination, other specified forms of tremor, and lattice degeneration of retina. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated moderate cognitive impairment. Section J on the 3/26/2024 annual MDS revealed resident was coded as a current tobacco user. A review of the smoking assessments dated 3/22/2024, 3/28/2024, 7/4/2024, and 10/5/2024 for R71 documented that resident should only smoke during morning, afternoon, and evening smoke breaks, should wear an apron, requires supervision- including retrieval of supplies, and needs someone to light/extinguish cigarette. Review of R71's smoking assessments revealed yes to the question, does resident smoke? A review of R71's care plan initiated 6/11/2021 and revised 10/5/2024 revealed that resident was an unsafe smoker, she is non-compliant with smoking policy - resident was observed smoking in her bathroom (10/10/2017), she solicits smoking materials from other residents, staff, and visitors (2/17/2016), she refused to wear smoking apron (3/7/2024). Interventions to care include educate and provide safety awareness for smoking, instruct resident about the facility policy on smoking: locations, times, safety concerns, resident requires a smoking apron, and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observation on 10/4/2024 at 12:09 pm, R71 was outside smoking and not wearing a smoking apron. She is observed to have burn holes in her shirt as she is seen wiping the ashes off of her clothes. B. Review of the EMR for R266 revealed he was admitted to the facility on [DATE] with diagnoses including pneumonia, protein calorie malnutrition, sacral pressure ulcer, deep vein thrombosis, and sepsis due to escherichia coli (e-coli). A review of the admission MDS dated [DATE] revealed a BIMS was coded as 14, which indicated no cognitive impairment. Section J revealed resident was not coded as a current tobacco user. A review of the smoking assessments dated 10/6/2024 revealed the question does resident use smoking/tobacco/nicotine products? Response was documented no-stop here. A review of R266's care plan revised on 9/20/2024 revealed resident did not have a care plan for smoking. He has a behavior care plan which documented R266 was observed smoking in his room on 9/19/2024, without an intervention to address his smoking. Observation on 10/10/2024 at 2:18 pm, R266 was outside smoking in his wheelchair. There were no staff members supervising the resident during the smoke break.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E. Review of the clinical record revealed R25 was admitted to the facility on [DATE]with diagnoses including dementia, cognitive communication deficit, lack of coordination, atherosclerotic heart disease, mood and psychotic disorders, and generalized muscle weakness. Review of the quarterly MDS dated [DATE] documented a BIMS score of five, indicating severe cognitive impairments. Section J on the 3/24/2024 annual MDS revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R25's name was on the list of residents identified as a tobacco user. Review of R25's documentation related to the smoking assessments revealed that the most recent assessment was completed on 9/12/2024. The smoking assessment revealed he prefers to smoke morning, afternoon, and evening. Further review revealed due to resident's behavior and score with smoking assessment, resident will need supervision with smoking and he requires someone to light/extinguish the cigarette. Record review of R25's care plan initiated on 11/5/2021 revealed R25 is an unsafe smoker and will not suffer injury from unsafe smoking practices and will not smoke without supervision. Resident was found smoking in his room and was documented that he will only smoke in appropriate area under direct supervision. Interventions to care include provide direct supervision while smoking, staff to light/extinguish cigarette and supervision including retrieval of cigarettes and lighter, educate resident about smoking risks and hazards, instruct on facility policy on smoking including locations, times, and safety concerns, remove all smoking devices from resident room and store in locked container, and notify Charge Nurse if it is suspected resident has violated facility smoking policy. Observation on 9/24/2024 at 10:06 am, R25 was outside in the dementia care smoking area smoking unsupervised. There were no staff members outside at this time. Observation on 10/7/2024 at 10:04 am, Activity Assistant (AA) WWW was supervising the smoke break with no safety smoking tools outside with the residents. Interview on 10/7/2024 at 10:08 am, R25 stated he typically smokes two to three times a day and revealed that he keeps his own cigarettes and lighter in his room. During further interview, he stated nobody helps him with his cigarettes and lighter, and states that he can do it on his own. the facility failed to ensure that the environment and facility were free from potential accident hazards for residents and staff. Specifically: 1. Immediate Jeopardy was identified for facility's failure to enforce the smoking policy and Banned Item List for eight of 44 sampled residents reviewed for smoking (R) (R71, R266, R145, R365, R25, R111, R118, R19); 2. Failed to ensure three residents (R83, R60, and R91) were not allowed to keep hazardous materials in their rooms; 3. Failed to maintain safe and comfortable water temperatures below 120 degrees Fahrenheit in 18 rooms on five of five units (E111, E112, E108, E107, E102, E101, W134, W129, W124, G217, G224, G229, D215, D206, D203, M109, M101, M118); and 4. Failed to properly secure a portable oxygen cylinder in one resident room (W132). The facility's failures created potential risks for the safety and well-being of the residents, staff, and any visitors in the building. On 10/9/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Corporate Regional Director of Operations, Corporate Regional Nurse Consultant (RNC), and Director of Nursing (DON) was informed of an Immediate Jeopardy (IJ) on 10/9/2024 at 3:11 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/22/2024. Upon survey entrance to the facility, residents were observed sitting out front of the facility, smoking unsupervised. Throughout the duration of the survey, the facility failed to monitor the smoking practices by not maintaining accurate smoking assessments, allowing residents to keep smoking materials in their possession, not supervising residents while smoking, and allowing a resident in the dementia care unit to smoke inside the facility. A Credible Allegation of Compliance was received on 10/11/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/11/2024. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding facility smoking practices, to include smoking assessments, and following care plans related to smoking. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: 1. A review of the facility policy titled Smoking Policy - Residents revised August 2022 revealed Policy Statement: This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation: Number 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Number 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Number 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; d. ability to smoke safely with or without supervision (per completed Safe Smoking Evaluation). Number 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. Number 9. Any smoking-related privileges, restrictions, and concerns (need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Number 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Number 12. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. Number 13. Residents are not permitted to give smoking items to other residents. Number 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. A review of the facility policy titled Resident Smoking Policy revised 3/21/2024 revealed Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, as related to smoking. Policy Explanation and Compliance Guidelines: Number 5. Residents who smoke will be 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. Number 7. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas, at designated times, and in accordance with his/her care plan. Number 9. All safe smoking measures will be documented on each residents care plan Supervision will be provided as indicated on each residents care plan. Number 11. If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures. Number 12. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. A review of the undated facility document titled Banned Item List revealed the following items: Cigarettes and cigarette lighters, smokeless tobacco, and vapes. Observation on 9/22/2204 at 1:15 pm, upon survey entrance revealed approximately 12 residents crowded in the front of the building smoking. No staff members were present in the area and no residents had on aprons. Observation on 9/24/2024 at 10:06 am to 10:17 am, revealed there were five residents smoking unsupervised outside the dementia care/behavior unit smoking area. There was no evidence of facility staff members outside monitoring the residents smoking during this time frame. A. Review of the clinical record revealed R71 was admitted to the facility on [DATE] with diagnoses including seizure disorder, traumatic brain injury (TBI), schizoaffective disorder, depression and age-related bilateral cataracts. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated moderate cognitive impairment. Section J on the 3/26/2024 annual MDS revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R71's name was on the list of residents identified as a tobacco user. Review of the facilities Smoking List dated 9/23-with no year indicated, revealed R71's name was on the list of residents identified as a tobacco user. Review of R71's documentation related to the smoking assessments revealed that the most recent assessment was completed on 10/5/2024. The smoking assessment revealed she prefers to smoke morning, afternoon, and evening. Further review revealed she requires an apron, someone to light/extinguish the cigarette, and supervision. Review of R71's care plan initiated 6/11/2021 and revised 10/5/2024 revealed that she was an unsafe smoker, she is non-compliant with smoking policy - resident was observed smoking in her bathroom, she solicits smoking materials from other residents, staff, and visitors. Interventions to care include educate and provide safety awareness for smoking, instruct resident about the facility policy on smoking: locations, times, safety concerns, resident requires a smoking apron. Observation on 10/4/2024 at 11:09 am, R71 was observed during smoke break to be wearing a smoke apron, but she does not have the apron on correctly. The apron is hanging around her neck off the shoulders and between her legs. She smokes with the assistance of both hands using one hand to hold the cigarette and the other hand to move her hand up and down from her mouth. Further observation revealed there are visible burn holes (approximately two centimeters) in her green shirt from the cigarettes. Observation on 10/4/2024 at 12:09 pm, R71 is back outside smoking and does not have on a smoking apron on this time. She is observed to have burn holes in her shirt as she is seen wiping the ashes off of her clothes. B. Review of the clinical record revealed R266 was admitted to the facility on [DATE] with diagnoses including pneumonia, protein calorie malnutrition, sacral pressure ulcer, deep vein thrombosis, and sepsis due to escherichia coli. Review of the admission MDS dated [DATE] revealed a BIMS was coded as 14, which indicated no cognitive impairment. Section J revealed resident was not coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R266's name was not on the list of residents identified as a tobacco user. Review of R266's documentation related to the smoking assessments revealed that the most recent assessment was completed on 10/6/2024. The smoking assessment revealed the resident does not use smoking/tobacco/nicotine products. Review of R266's care plan revised 9/21/2024 revealed no evidence addressing residents desire to keep a cigar in his possession to dry puff (a puff taken before lighting a cigar to taste the cigar's flavors). Observation on 10/7/2024 at 11:00 am, revealed resident with an un-lit cigar in his mouth. Interview with resident at this time stated he does not smoke it; he just dryly puffs on it because he is trying to quit smoking. C. Review of the clinical record revealed R145 was admitted to the facility on [DATE] with diagnoses including depression. Review of the annual MDS assessment dated [DATE] revealed a BIMS was coded as 13, which indicated no cognitive impairment. Section J revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R145's name was on the list of residents identified as a tobacco user. Review of R145's documentation related to the smoking assessments revealed that the most recent assessment was completed on 7/12/2024. The smoking assessment revealed the resident was assessed as an independent smoker at any time morning, afternoon and evening. Review of R145's care plan revised 7/21/2024 documented that resident was a safe smoker and will not have any injury related to smoking. Interventions to care include smoking assessment per facility protocol. Further review revealed resident would adhere to all smoking policies. Observation on 10/4/2024 at 11:09 am, revealed R145 outside in smoking area, retrieved a lighter from his pants pocket and lit the cigarette for another resident. He then walked towards a bush, took a pack of cigarettes out of his pants pocket, removed a cigarette from the pack, lit it, and walked to his rollator sat down and began smoking. R145 has another new pack of cigarettes in his shirt pocket and gives one cigarette from the pack to another resident. D. Review of the clinical record revealed R365 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis with joint contractures, depression, and gastroesophageal reflux disease (GERD). There is no MDS data available for this resident. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R365's name was on the list of residents identified as a tobacco user. Review of R365's documentation related to the smoking assessments revealed that the most recent assessment was completed on 9/18/2024. The smoking assessment revealed she prefers to smoke morning, afternoon, and evening. Further review documented her ability to hold and handle smoking/tobacco/nicotine products was poor with weakness and contractures. Review of R365's care plan initiated 6/20/2024 revealed that she was a smoker and that she will not suffer injury from unsafe smoking practices. Interventions to care include instruct resident about smoking risks and hazards and facility policy, including locations, times, and safety concerns. Observation on 9/25/2024 at 11:09 am, revealed R365 goes out to the smoking area to smoke. She has her cigarette in her hand and pulls her lighter from the seat of her rollator. Observation on 9/25/2024 at 3:30 pm, revealed R365 smoking outside under the small, covered portion in front of the building with no staff in sight. The resident had her cigarettes and a lighter in her possession. She was observed to be lighting other residents cigarettes. Interview on 10/5/2024 at 11:33 am, Activity Assistant (AA) LL, revealed that each smoking area has a smoke box that has the residents' smoking materials. Activity Assistant LL stated some residents are allowed to keep their own cigarettes with them, but they are not allowed to keep any lighters. When asked how she identifies which residents are allowed to keep their cigarettes, she revealed the Director of Nursing (DON) does an assessment to determine if they are safe or not safe. She stated if they are assessed to be safe smokers, then they can keep their own cigarettes. During further interview, she stated if there was an issue with the residents during smoking breaks, she would report the concern to the DON or the Social Services Director. She stated if the staff see the residents with lighters, they will ask the resident for the lighters. C. Review of the clinical record revealed R60 was admitted to the facility on [DATE] with diagnoses including schizophrenia, major depressive disorder, anxiety disorder, bipolar disorder, macular degeneration, and age-related cataract. Review of the quarterly MDS dated [DATE] documented a BIMS score of 15, indicating no cognitive impairment. No moods or behaviors exhibited. Further review of the MDS documented resident had a decline in behavior symptoms with delusions. Review of R60's current care plan revised 9/24/2024 revealed no evidence that resident had a care plan to keep Isopropyl (rubbing) alcohol at bedside. Observation on 9/24/2024 at 10:23 am, revealed in R60's room revealed one bottle of 70% Isopropyl (rubbing) alcohol was found sitting on resident bed side table. Interview on 10/2/2024 at 10:44 am, LPN XX stated she was not aware that R60 had a bottle of rubbing alcohol, and stated she was not supposed to have it in her room. LPN XX stated staff are supposed to check residents' rooms every shift, and if they find anything they are not supposed to have, they should be removing it from the room. During further interview, she stated they are to keep the residents safe by removing hazardous materials from their rooms. Interview on 10/2/2024 at 11:00 am, Regional Nurse Consultant (RNC) revealed R60 is allowed to have rubbing alcohol on her bedside table. RNC stated the facility educates the residents, and that R60 is supposed to be care planned for having rubbing alcohol on her bed side table. RNC further stated the resident is educated and they do frequent monitoring. There is no evidence that resident had a care plan to keep rubbing alcohol at her bedside. Interview on 10/2/2024 at 11:03 am, the Director of Nursing (DON) stated that R60 is not allowed to have rubbing alcohol on the bedside table. DON stated that R60 checks herself out of the facility and it was a possibility that she bought it somewhere outside of the facility. RNC then re-iterated to the DON that residents are allowed to have whatever they want if they are care planned, educated and monitored. The DON then proceeded to agree with the RNC that residents are allowed to have anything they want. Interview on 10/3/2024 at 2:23 pm with the Director of Operations (DO) confirmed that any hazardous items should be locked and stored away. 3. Review of the policy titled Safe Water Temperatures revised on 3/1/2024, indicated it is the policy of this facility to maintain appropriate water temperatures in resident care areas. Policy Explanation and Compliance Guidelines: Number 1. Direct care staff will monitor residents during prolonged exposure to warm or hot water for any signs or symptoms of burns and will respond appropriately. Number 4. Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperature (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff. Number 5. Water temperatures will be set to a temperature of no more than 110 ° F, or the state's allowable maximum water temperature. Number 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. Number 7. Documentation of testing will be maintained and kept in the maintenance office. Observation on 9/22/2024 at 1:32 pm, in East Hall room [ROOM NUMBER] revealed the water from the sink felt hot to touch, with visible steam as water was running. Maintenance Technician (MT) RR confirmed the water from the sink was hot to touch. He tested water temperature with facility thermometer at this time and measured to be at 124 degrees Fahrenheit (°F). Maintenance Technician (MT) QQ and MT RR stated a facility wide water temperature check would be conducted. Observation on 9/22/2024 from 3:34 pm to 4:31 pm, environmental rounds with MT RR, using facilities thermometer revealed water temperatures between 110 -123 degrees °F in the following rooms: East Hall room [ROOM NUMBER] - 9/22/2024 at 3:34 pm water temperature was 122 °F. East Hall room [ROOM NUMBER] - 9/22/2024 at 3:36 pm water temperature was 121 °F. East Hall room [ROOM NUMBER] - 9/22/2024 at 3:41 pm water temperature was 116 °F. East Hall room [ROOM NUMBER] - 9/22/2024 at 3:44 pm water temperature was 117 °F. East Hall room [ROOM NUMBER] - 9/22/2024 at 3:47 pm water temperature was 120 °F. East wing room [ROOM NUMBER] - 9/22/2024 at 3:49 pm water temperature was 118 °F. West Hall room [ROOM NUMBER] - 9/22/2024 at 3:53 pm water temperature was 114 °F. West Hall room [ROOM NUMBER] - 9/22/2024 at 3:55 pm water temperature was 114 °F. West Hall room [ROOM NUMBER] - 9/22/2024 at 3:58 pm water temperature was 117 °F. Georgia Hall room [ROOM NUMBER] - 9/22/2024 at 4:06 pm water temperature was121 °F. Georgia Hall room [ROOM NUMBER] - 9/22/2024 at 4:08 pm water temperature was 123 °F Dogwood Hall room [ROOM NUMBER] - 9/22/2024 at 4:15 pm water temperature was 115°F. Dogwood Hall room [ROOM NUMBER] - 9/22/2024 at 4:18 pm water temperature was 113 °F. Magnolia Hall room [ROOM NUMBER] - 9/22/2024 at 4:31 pm water temperature was 116°F. Interview on 9/22/2024 at 2:31 pm, MT QQ revealed he tests the water temperatures for the facility twice a month, and that the water temperature logs are in the computer. MT QQ stated the rooms that are closer to the boiler room (hot water heater) are normally hotter and as you travel down the hall away from the boiler (hot water heater) the water temperature decreases. Interview on 9/22/2024 at 2:32 pm, MT RR stated he heard from someone that the water temperatures should be between 110 °F and 140 °F. A request for the water temperature logs was made. Review of the facility's Water Temperature Logs dated May 2024, June 2024, July 2024, and August 2024 revealed the following water temperatures over 110° F : *Week 5/20/2024: six rooms (G222, E117, E110, W138, W130, W115) were between 112 -131° F. The temperatures were checked by MT QQ and there was no corrective action documented. *Week 5/28/2024: two rooms (E111 and E116) were between 115 -116° F. The temperatures were checked by MT QQ and there was no corrective action documented. *Week 6/3/2024: five rooms (D209, G219, E113 W138, M115) were between 112 -115° F. The temperatures were checked by MT QQ and there was no corrective action documented. *Week 6/10/2024: seven rooms (G209, G220, E113, E103, W143, W134, M119) were between 112 -122° F. The temperatures were checked by MT QQ and there was no corrective action documented. *Week 6/17/2024: four rooms (E117, E110, W137, W131) were between 115 -117° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 6/24/2024: six rooms (E113, E112, W137, W141, M108, M113) were between 113 -116° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 7/3/2024: two rooms (M119, G213) were between 115 -116° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 7/8/2024: three rooms (E118, E110, E113) were between 113 -121° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 7/15/2024: two rooms (E113, W133) were between 115 -118° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 7/22/2024: three rooms (E112, E113, W134) were between 111 -117° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 8/5/2024: five rooms (D208, E113, E110, W135, W134, M108, M113) were between 111 -125° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 8/12/24: six rooms (D213, E113, E112, W137, W132, M113) were between 112 -126° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *No date Provided: eight rooms (W139, W132, E113, E109, D208, G118, M108, M113) were between 112 -131° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 8/26/2024: six rooms (G221, E113, E108, W137, W134, M113) were between 113 -116° F. There is no information of who tested the temperatures this week and there is no corrective action documented. *Week 8/30/2024: Room: Kitchen - temp 138 ° F Room: Laundry - temp 167 ° F Observation and interview on 9/22/2024 at 4:32 pm, the Regional Maintenance Director revealed the facility currently does not have a maintenance director. He stated he is in the city once a week visiting facilities. During a walkthrough of the boiler room revealed: West Hall water heater temperature was 120 °F Laundry room water heater temperature was 130 °F East Hall water heater temperature was 125 °F Interview on 9/24/2024 at 2:53 pm, the Administrator revealed she did not know what the water temperatures for residents' rooms was supposed to be. The Administrator stated she thinks it's around 110 to 140 °F. The Administrator stated her expectations are that room water temperatures are within normal range, to avoid possible injury to the resident. During further interview, she stated the Maintenance Techs should be checking water temperatures monthly. The Administrator was made aware of the hot water concerns and stated it was going to be fixed as soon as possible. A follow-up walk-through on 9/24/2024 at 4:54 pm with the Administrator revealed all previously elevated water temperatures are now under 110°F, after water temperatures were adjusted. A second follow-up walk-through on 10/4/2024 at 9:10 am with Regional Maintenance Director revealed all previously elevated water temperatures are now under 110°F, after water temperatures were adjusted. 4. Review of the facility policy titled, Oxygen Storage dated 5/1/2023, revealed A. Oxygen storage locations shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secure against unauthorized entry. C. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts; approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty. L. Protect cylinders from contamination with dust and dirt. Cylinder-valve protection caps, where provided, shall be kept in place, except when cylinders are in use or connected for use. Observation on 9/22/2024 at 3:42 pm, revealed in room [ROOM NUMBER] on the [NAME] Wing, one oxygen cylinder in bedroom corner wedged between wall and a three-drawer dresser, not properly stored in a stand or rack. Observation and interview on 9/24/2024 at 9:24 am, with Registered Nurse (RN) CCC confirmed the oxygen cylinder in room [ROOM NUMBER] on the [NAME] Wing was not properly stored and stated the resident is not using oxygen. RN CCC removed the oxygen cylinder from the room and placed in oxygen storage room. Interview on 10/7/2024 at 2:36 pm, the RNC confirmed the resident in room [ROOM NUMBER] on the [NAME] Wing was not currently using oxygen. The RNC stated it is possible that someone put the oxygen in there; while offering care and maybe the nurse forgot and left the oxygen in the room, but life happens, we are not perfect. The TNC emphasized it was an honest mistake, but eventually we would have seen it. Interview on 10/9/2024 at 9:53 am, the Director of Operations stated she will have unit managers to do more rounds, re-educate staff but emphasized this is not our practice. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility failed to address: A. Resident R25's and R365 smoking unsupervised. On 10/9/2024 the Regional Director of Operations and Director of Nursing instituted smoking times for all residents who smoke. The smoke breaks times are as follows and will be supervised: Courtyard smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks. B. Resident R145 and R365 observed lighting other residents' cigarettes. Updated smoking assessment was completed on 10/9/2024 identifying both residents as safe smokers. Education was provided to resident R145 and R365 on smoking expectations, and not assisting other residents with cigarettes. The list of residents who choose to smoke was compiled by Director of Nursing and Regional Nurse on 10/9/2024, and residents identified as safer smokers are able to keep smoking materials in their possession. C. Resident R111 observed lighting a cigarette in the building. The Director of Nursing completed a new smoking assessment on 10/9/2024 identifying him as an unsafe smoker, and a lighter and cigarettes were confiscated. D. Resident R19 observed what appeared to be cigarette burns on clothes. List of residents who need smoking aprons was compiled by Director of Nursing and Regional Nurse on 10/9/2024. E. Resident R71 observed with smoking apron on incorrectly on one instance and one time without a smoking apron on. The list of residents who need smoking aprons was compiled by DON and Regional nurse on 10/9/2024. The list will be available at each nursing station and updated accordingly by the Director of Nursing. F. Resident R118 observed with no smoking apron, no smoking assessment, and no smoking care plan. On 10/9/2024 the resident's smoking assessment was completed by the Director of Nursing and the smoking care plan was completed by Minimal Data Specialist. List of residents who need smoking aprons was compiled by Director of Nursing and Regional Nurse on 10/9/2024. G. Resident R266 observed with no smoking apron and staff were unaware he is a smoker. Director of Nursing completed a new smoking assessment for the resident on 10/9/2024. 2. On 10/9/2024 the Director of Nursing, Assistant Director of Nursing, Unit Manager, Minimal Data Specialist, and/or Regional Nurse completed a smoking assessment on all residents to identify any residents who are smokers not already known, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures. 3. On 10/9/2024 the Director or Nursing and Regional Nurse Consultat compiled a list of unsafe smokers, safe smokers and those residents who require a smoking apron. The list will be available at each nursing station for the smoking monitors to reference. The Director of Nursing will be responsible for updating the list accordingly. 4. The Regional Director of Operations on 10/9/2024 in serviced the Director of Nursing, Assistant Director of Nursing, Minimal Data Specialist and Regional Nurse Consultant on the smoking policy, ensuring that smoking care plans are followed and completing timely and accurate smoking assessments. The Administrator will be in-serviced prior to returning to work by the Regional Director of Operations.

Based on observations, record review, interviews, review of the Administrator Job Description and Director of Nursing Job Description, and review of the policy titled Smoking Policy - Residents, the facility administration failed to provide oversight and monitoring of the facility operations related to enforcement of its smoking policy and failed to ensure that licensed nursing staff were knowledgeable and competent to assess residents and implement care plans for smoking. The facility's failures created potential risks for the safety and well-being of the residents. The census was 210 residents. Specifically 1. Facility Administrator and Director of Nursing (DON) failed to perform duties of their job descriptions that facilitated providing a safe environment to the residents of the facility. 2. Administration failed to enforce the facility smoking policy by allowing residents to keep smoking materials on their person, allowed residents to smoke unsupervised, and failed to maintain accurate smoking assessments that correlated to person-centered care plans. Cross Refer F689 3. Facility Administration failed to develop and/or implement the smoking care plans for six identified residents (R) R71, R266, R19, R25, R111, R118. Cross Refer F656 On 10/9/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Corporate Regional Director of Operations, Corporate Regional Nurse Consultant (RNC), and Director of Nursing (DON) was informed of an Immediate Jeopardy (IJ) on 10/9/2024 at 3:11 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/22/2024. Upon survey entrance to the facility, residents were observed sitting out front of the facility, smoking unsupervised. Throughout the duration of the survey, the facility failed to monitor the smoking practices by not maintaining accurate smoking assessments, allowing residents to keep smoking materials in their possession, not supervising residents while smoking, and allowing a resident in the dementia care unit to smoke inside the facility. A Credible Allegation of Compliance was received on 10/11/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/11/2024. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding facility smoking practices, to include smoking assessments, and following care plans related to smoking. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: Review of the undated and un-signed document titled Administrator Job Description, indicated the position purpose is to lead, guide, and direct 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 Major Duties and Responsibilities: *Plans, develops, organizes, implements, evaluates, and directs the overall operations of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. *Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. *Evaluates key performance indicators with department heads to determine the need for action from leadership and/or management such as re-education or revisions relayed to the facility's outcomes, regulatory compliance and/or customer satisfaction. *Leads and coordinates daily, weekly, monthly management team meetings to discuss priorities and develop solutions with facility leaders. *Evaluates work performance of department heads and maintains accountability across all departments. *Knows and understands general nursing practices and procedures, ONRA regulations, Code of Federal Regulations, Appendix PP State Operations Manual, reimbursement processes, Life Safety Code regulations, applicable labor relations law, and all other regulatory entities. *Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services. Responds and resolves complaints and concerns when necessary. *Reads and stays informed regarding regulatory, business practices and other changes influencing facility outcomes; thereby, facilitating continued success for all. *Reports any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to appropriate regulatory entities. Protects resident from abuse and cooperates with all investigations. Review of the undated and un-signed document titled Director of Nursing Job Description, indicated the position purpose is to plan, organize, develop, and direct the overall operations of the Nursing Services Department in accordance with local, state, and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical director, to provide appropriate care and services to the residents. Major duties and Major Duties and Responsibilities: *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. *Interprets and communicates policies and procedures to nursing staff, and maintains staff practices and implementations. *Participates in daily or weekly management team meeting to discuss census changes, resident changes in status, complaints ot concerns. *Participate in Quality Assurance Performance Improvement (QAPI) or facility assessment activities as needed, such as carrying out duties assigned as part of a performance improvement committee. *Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units, general cleanliness, and maintaining optimal resident functions. *Collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify and resolve issues and improve the quality of services. *Performs rounds to observe resident and ensure nursing needs are being met. *Monitors, assists and implements the infection control program in accordance with current infection control guidelines to prevent the development and transmission of disease and infection. *Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services and respond to and resolve complaints and concerns. *Oversees resident incidents and concerns daily to identify and unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate ations. *Monitors for allegations of potential abuse or neglect, misappropriations of resident property and participates in the investigative process. A review of the facility policy titled Smoking Policy - Residents revised August 2022 revealed Policy Statement: This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation: Number 2. Smoking is permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Number 9. Any smoking-related privileges, restrictions, and concerns (need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Number 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Number 13. Residents are not permitted to give smoking items to other residents. Number 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. Observation on 9/22/2024 at 1:15 pm, upon survey entrance revealed approximately 12 residents crowded in the front of the building smoking. No staff members were present in the area and no residents were wearing smoking aprons. Observation on 9/24/2024 at 10:06 am to 10:17 am, revealed there were five residents smoking unsupervised outside the dementia care/behavior unit smoking area. There was no evidence of facility staff members outside monitoring the residents smoking during this time frame. Observation on 10/4/2024 at 11:09 am, resident outside in smoking area, observed to have possession of lighter and cigarettes. Resident gave another resident a cigarette and lit it for him. Observation on 10/5/2024 at 3:58 pm, resident on the memory care unit, lit a cigarette and began smoking, inside the building. Observation on 10/7/2024 at 10:04 am, the Activity Assistant (AA) WWW was supervising the smoke break with no safety smoking aprons outside with the residents. Interview on 10/6/2024 at 5:53 pm, with the Corporate Representative stated everyone will be re-assessed in the building, its according to the assessment and the policy whether or not they can be automatically deemed as a responsible smoker. It largely depends on where they are. Interview on 10/6/2024 at 5:53 pm with the Corporate Representative stated everyone will be re-assessed in the building, its according to the assessment and the policy whether or not they can be automatically deemed as a responsible smoker. It largely depends on where they are. Interview on 10/7/2024 at 10:08 am, the Activities Director (AD) LLL revealed there are three Activity Assistants who rotate monitoring during the smoke breaks. She described the training as a walk through in order to train the Activity Assistants, then she will observe them do what she has shown them. During further interview, she revealed staff would know which residents smoke and whether they need any special supervision, the more they work with the residents. She stated rhe nursing department gives the activity department the smoking list and then she will give it to her assistants. Interview on 10/7/2024 at 5:33 pm, the DON and Regional Nurse Consultant (RNC) indicated residents who are unsafe smokers must abide by the scheduled smoking times. They revealed that it is the responsibility of the nursing staff to complete resident smoking assessments, on admission and quarterly thereafter. During further interview, both the DON and the RNC stated residents are not allowed to smoke inside the building, and that will automatically make a resident be put on the unsafe smoking list. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility failed to address: A. Resident #25 and #365 smoking unsupervised. On 10/9/2024 the Regional Operations and Director of Nursing instituted smoking times for all residents who smoke. The smoke breaks will be supervised by smoking monitors who will be staff assigned daily. The smoke breaks times are as follows: Courtyard smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total. of five (5) smoking breaks. B. Resident #145 and #365 observed lighting other residents' cigarettes. A smoking assessment was completed on two hundred and twelve (212) residents and identified sixty-one (61) residents that chose to smoke. Residents #145 and #365 outcome was a safe smoker. Education on only lighting their own cigarettes was provided to both residents. List of residents who choose to smoke was compiled by the Director of Nursing and Regional Nurse on 10/9/2024. The list contains sixty-one (61) residents with twenty-seven (27) residents who are identified on the list as needing smoking aprons. C. Resident #111 observed lighting a cigarette in the building. The Director of Nursing completed a new smoking assessment on 10/9/2024 and confiscated the residents lighter and cigarettes making him an unsafe smoker. D. Resident #19 observed what appeared to be cigarette burns on clothes. List of residents who need smoking aprons was compiled by Director of Nursing and Regional Nurse on 10/9/2024. Residents that require a smoking apron are identified by the resident's name on the list available at each nursing station and updated accordingly by the Director of Nursing. E. Resident #71 observed with smoking apron on incorrectly on one instance and one time without a smoking apron on: Smoking monitoring assigned will be responsible for ensuring smoking aprons are used correctly. F. Resident #118 observed with no smoking apron, no smoking assessment, and no smoking care plan. The residents' smoking assessment was completed by the Director of Nursing and the smoking care plan was completed by Minimal Data Specialist on 10/9/24. G. Resident #266 observed with no smoking apron and staff were unaware he is a smoker. Director of Nursing completed a smoking assessment for the resident on 10/9/2024. List of residents that are identified beside their name as unsafe require smoking aprons. H. The facility failed to develop a comprehensive person-centered care plan for residents #25, #145, #111, #19, #71, #118, #266 and #365. On 10/9/2024 the Regional Nurse and Director of Nursing reviewed and revised eight (8) of eight (8) residents smoking care plans to ensure that they are person centered and comprehensive. 2. On 10/9/2024 the Director of Nursing, Minimal Data Specialist, and/or Regional Nurse began reviewing and revising all sixty-one (61) smoking care plans to ensure that they are person centered and comprehensive. 3. On 10/9/24 the Director of Nursing, Assistant Director of Nursing, Unit Manager, Minimal Data Specialist, and/or Regional Nurse completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Smoking assessments were conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures. 4. On 10/9/24 the Director of Nursing and Regional Nurse compiled a list of unsafe smokers, safe smokers and those residents who require a smoking apron. The list of sixty-one (61) residents will be available at each nursing station for the smoking monitors to reference. The list will be updated accordingly by the Director of Nursing. 5. The Regional Operations on 10/9/2024 in-serviced the Director of Nursing, Assistant Director of Nursing, Minimal Data Specialist and Regional Nurse on the smoking policy, ensuring that smoking care plans are followed and completing timely and accurate smoking assessments. The Administrator will be in service prior to returning to work by the Regional Operations. 6. Regional Operations on 10/9/2024 in-serviced the Minimal Data Specialists on reviewing and completing accurate comprehensive person-centered smoking care plans for all residents who smoke. 7. On 10/9/2024 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional Operations, and/or Regional Nurse began in-servicing all staff (Registered Nurse 10 of 10, Licensed Practical Nurse 33 of 34, Certified Nurse assistant 62 of 67, Certified Medication Aides 7 of 8, Respiratory Therapist 1 of 2, Dietary 14 of 25, Therapy 8 of 13, Administrative 18 of 18, Maintenance 4 of 4, Housekeeping 30 of 37, Activities 3 of 4 staff) on the smoking policy. The current percentage of staff educated is 86% at this time. 8. All residents on the Dementia Unit will be required to wear a smoking apron, all residents will adhere to the set smoking times for designated areas, designated staff will be assigned daily as smoking monitors and will be present at all smoke breaks, ensuring that smoking care plans are followed and completing timely and accurate smoking assessments. 9. The Director of Nursing, Assistant Director of Nursing and/or Regional Nurse began in person educating on 10/9/2024 with all staff on education for daily assigning of smoking monitors, and expectations on ensuring that smoking aprons are donned correctly, residents are not allowed to help other residents light their cigarettes and to ensure that all residents who require smoking aprons have one on. They also instructed the smoking monitors that any residents that are not listed on the smokers list should not be allowed to smoke. If any residents not on the list are attempting to smoke, they must notify the Charge Nurse, Director of Nursing, Administrator or Assistant Director of Nursing so that they can complete a smoking assessment. They were also in-serviced that all residents downstairs on the Downstairs Dementia unit will be required to wear a smoking apron during their monitored smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks. 10. The Regional Operations on 10/9/2024 decided that all resident's downstairs on the Downstairs Dementia Unit will be required to wear a smoking apron during their monitored smoke breaks. She instructed the Director of Nursing and Regional Nurse on this directive. 11. On 10/9/2024 the Regional Operations and Director of Nursing instituted smoking times for all residents who smoke. The smoke breaks will be supervised, and times as follows: Courtyard smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks. 12. All new Staff will be in serviced on these items during the orientation process by the Assistant Director of Nursing and/or Director of Clinical Education. 13. We have no agency staff currently. 14. Job descriptions of Director of Nursing and Administrator were reviewed by the Regional Operations, Regional Nurse, [NAME] President of Quality. Director of Nursing and Administrator (contacted via phone) were educated and voiced understanding of responsibilities and job duties. 15. AD Hoc QAPI meeting was completed on 10/10/2024 for policy review and root cause analysis. The root cause was determined that education to staff and residents on the smoking policy and expectations was needed, and a set smoking schedule established. Attendance to the meeting was Regional Director of Operations, Director of Nursing, Regional Nurse, [NAME] President of Quality, business office manager, dietary manager, dietary assistant manager, medical supply clerk, transportation coordinator, Director of Rehab, Social Worker, and Unit Managers. The Medical Director was notified by phone. 16. Corrective actions will be completed by 10/10/2024. Alleged date of IJ removal: 10/11/2024 The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A. Record Review on 10/11/2024 at 3:50 pm revealed the removal plan binder with printed sheets in large bold print of the smoking schedule for the designated smoking area in courtyard and downstairs courtyard outside of Magnolia. Smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm -6:30 pm for a total. of five (5) smoking breaks. Observation on 10/11/2024 at 4:45 pm revealed smoking schedules posted with large bold letters of the smoking schedule for the designated smoking areas and hanging on a wall board outside of elevator and near front entrance receptionist desk. B. Interview on 10/11/2024 at 6:07 pm with R365 confirmed she received education to only light her own cigarette by Social Worker RRR. Furthermore, R365 revealed she feels like she is a safe smoker. Interview on 10/11/2024 at 6:10 pm with R145 confirmed he received education to only light his own cigarette but does not remember who provided the education. Furthermore, R145 revealed he feels like he is a safe smoker. C. Interview on 10/11/2024 at 6:00 pm with R111 revealed he never had any cigarettes on him. He stated he does not have any cigarettes or cigars currently on him. He stated the Unit Manager educated him on the safety of smoking and especially not smoking inside of the building. He stated that he wears an apron when he is on his smoking break. D. Record Review on 10/11/2024 at 5:30 pm revealed the residents that are required to have a smoking apron and are identified by the resident's name on the list available at each nursing station and updated by the Director of Nursing. E. Interview on 10/11/2024 at 6:05 pm with R71 confirmed she wears an apron when she goes on her smoking break, and she further confirmed a smoking apron is provided. F. Record Review on 10/11/2024 at 5:30 pm revealed the residents' smoking assessment was completed by the Director of Nursing and the smoking care plan was completed by Minimal Data Specialist on 10/9/2024. G. Interview on 10/11/2024 at 6:10 pm with R266 revealed he is a smoker but just started smoking not too long ago. He stated he is offered an apron; however, he is considered a safe smoker. He stated he smokes during the designated smoking break. Interview on 10/11/2024 at 6:20 pm with Licensed Practical Nurse (LPN) Unit Manager (UM) CC revealed R266 was assessed as a safe smoker because he can light his own cigarette, hold it steady and dispose of his ashes. H. Record Review on 10/11/2024 at 5:30 pm revealed the following: Care Plan and Smoking Assessment Review: R25- Unsafe smoker, Care plan revised on 10/9/2024. Smoking assessment was completed on 10/9/2024- requires supervision. R145- is a safe smoker; however, was observed lighting cigarettes for other residents. R145 is a safe smoker 10/9/2024- R111- is an unsafe smoker. 10/9/2024-requires supervision and an apron. R19- is an unsafe smoker 10/11/2024- needs supervision and an apron. R71- an unsafe smoker. Resident solicits to residents, staff, and/or visitors when cigarettes are not available. Resident has a history of being non-compliant with smoking policy-10/9/2024-requires supervision and an apron. R118- is unsafe smoker, 10/9/2024-requires apron, cigarette holder, someone to light and extinguish and supervision. R266- Resident is a safe smoker. 10/9/2024- no supervision, R365 - is a safe smoker; however, sometimes non-compliant with the smoking policy. History of lighting other resident's cigarettes 10/9/2024-independent smoker. 2. Interview on 10/11/2024 at 6:55 pm with, the Director of Nursing confirmed she reviewed and revised all sixty-one (61) smoking care plans to ensure that they are person centered and comprehensive Interview on 10/11/2024 at 6:58 pm with, Minimum Data Specialist (MDS) BBB confirmed she reviewed and revised all sixty-one (61) smoking care plans to ensure that they are person centered and comprehensive. Record review on 10/11/2024 of all sixty-one (61) smoking residents confirmed smoking care plans to ensure that they are person centered and comprehensive. 3. Interview on 10/11/2024 at 6:55 pm, with DON, confirmed she completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, DON confirmed a smoking assessment was conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures. Interview on 10/11/2024 at 7:02 pm, with Assistant Director of Nursing (ADON), confirmed she completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, ADON confirmed a smoking assessment was conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures Interview on 10/11/2024 at 7:00 pm with. LPN UM IIII confirmed he completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, UM confirmed a smoking assessment were conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures Interview on 10/11/2024 at 6:55 pm, with Regional Nurse Consultant (RNC), confirmed she completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, RNC confirmed a smoking assessment was conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures Interview on 10/11/2024 at 6:58 pm with MDS Data Specialist BBB confirmed she completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, MDS confirmed a smoking assessment was conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures Record review on 10/11/2024 confirmed smoking assessments on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, record review confirmed smoking assessment were conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures. 4. Record Review on 10/11/2024 of Plan of Correction Binder confirmed a master list of unsafe smokers, safe smokers and those residents who require a smoking apron. Confirmation on 10/11/2024 at 4:39 pm confirmed a list of sixty-one (61) residents who smoke on [NAME] Wing nurses' station. Confirmation on 10/11/2024 at 4:45 pm confirmed a list of sixty-one (61) residents who smoke on East Wing nurses' station. Confirmation on 10/11/2024 at 4:51 pm confirmed a list of sixty-one (61) residents who smoke on Dogwood and Georgia Hall's nurse's station. Confirmation on 10/11/2024 at 4:55 pm confirmed a list of sixty-one (61) residents who smoke on Magnolia Hall's nurses' station. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: 5. Interview on 10/11/2024 at 7:00 pm with VP of Quality has in-serviced all staff making sure the staff are all aware of the smoking list and aware of the smoking carts. All staff have been randomly quizzed on the in-service. They are by hall and unit it is in the care plan since all staff have access to it. Have made staff aware of who is an unsafe smoker vs who is. Educated staff on assisting the residents on wearing the aprons appropriately and that they should be over the resident clothes. There is a designated area of smoking area for staff. Staff had a quiz they took about the smoking times and areas. Made sure all the administrative positions who are not currently in the building will be educated before they come back on shift. Lighters and cigarettes are secured, and residents know they cannot be in their rooms. If there is a resident who wants to smoke after hours, then that would be a 1:1 for the residents. Is unaware of a disposable safety lighter but will find out to see if it is beneficial for them. 6. Regional Operations on 10/9/2024 in-serviced the Minimal Data Specialists on reviewing and completing accurate comprehensive person-centered smoking care plans for all residents who smoke. 7. A review of the Ad Hoc Quality Assurance Performance Improvement (QAPI) Smoking Policy dated 10/9/2024 detailed four areas that were reviewed. Area one identified issues or concerns. Area two identified steps to immediate correct issue. Area three how are you going to prevent it from happening in future. Area four how will facility monitor compliance with smoking policy. There is an attached sign in form where names are printed, signature, date attended, department, and shift. There are a total of 26 names on the list including those from Administration, Nursing department, Dietary, Social Work, Medical Records, and housekeeping. 8. Observation on 10/11/2024 from 4:00 pm to 4:25 pm at designated smoking area for Dementia Unit. eight residents went outside, they were assisted by three staff members (2 nurses and 1 Activities assistant). At 4:10 pm all residents received smoking aprons and staff members helped each to put apron on to ensure that residents' clothing is protected. Cigarettes were distributed from plastic container labeled cigarettes for each resident. Staff lighted cigarettes for each resident. At the end of smoking break all cigarettes buds were collected by the staff and disposed. Observed blue binder at nursing station on the Dementia Unit and verified that binder has a list of all smoking residents from that unit. All smoking resident from Dementia Unit were marked unsafe smokers, requiring supervision and smoking aprons. Interview on 10/11/2024 at 4:40 pm with Regional Director of Operations for Georgia revealed that staff received education on how to supervise residents during smoking times. Facility created a Quiz about safety during smoking times and keep quizzing all staff. Observation on 10/11/2024 at 4:00 pm revealed five staff member assisting residents with putting on a smoke apron and lighting resident's cigarettes. There are six residents with aprons. The aprons were on the residents fully covering their clothes while they smoked. There were three smokers with no aprons. Residents with aprons are being assisted by staff with lighting their cigarettes. When the residents were finished smoking, the aprons were observed being disinfected, aired out, folded, then put in a bag. Observation on 10/11/2024 at 4:34 pm revealed staff collecting lighters from the residents without aprons who were given lighters to light their cigarettes. The remaining residents were unsafe smokers and did not have lighters in their possession and went back into the building after the smoke break was complete. 9. Interview on 10/11/2024 at 7:00 pm, with VP of Quality has in serviced all staff making sure the staff are all aware of the smoking list and aware of the smoking carts. All staff have been randomly quizzed on the in-service. They are by hall and unit it is in the care plan since all staff have access it. Have made staff aware of who is an unsafe smoker vs who