Based on observations, interviews and record reviews, the facility failed to ensure the resident's environment remained free of accident/hazards, identify and eliminate the risk of accident hazards to keep a resident free from elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents investigated for accidents/hazards. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 12/23/2024 at 8:50 a.m., when Resident #1 who was ordered a WanderGuard transmitter (a personal safety device that will alert facility staff when the resident approaches an exit and/or has left the building) exited the facility through Exit b. On 12/23/2024 at 9:25 a.m., Resident #1 was found 0.4 miles away from the facility with a skin tear to the back of his head. Resident #1 was then transferred via Emergency Medical Services (EMS) to the emergency department (ED) where he was diagnosed with a right temporal bone fracture and a right subdural hematoma (brain bleed). The IJ situation continued on 01/02/2025 at 12:30 p.m. when S10 Assistant Administrator used a secondary reset code that should have only been used by S1Administrator to open exits f and i; when using the secondary reset code, door exits f and i failed to alarm when a WanderGuard transmitter was placed near the door. The IJ situation continued on 01/02/2025 at 1:01 p.m. when S7CNA was observed using the secondary reset code that disabled the alarm. The IJ situation continued on 01/02/2025 at 1:30 p.m. when S3CNA was observed using the secondary reset code to unlock exit d. The IJ situation continued on 01/02/2025 when interviews of S3CNA, S4Maintenance, S5CNA and S6CNA verified they all used the secondary reset code to open exits f and d and that using this code disabled the alarm system. S1Administrator/Regional Administrator was notified of the Immediate Jeopardy on 01/02/2025 at 4:48 p.m. This deficient practice had the likelihood to cause more than minimal harm to the 6 residents identified by the facility as being at risk for elopement. Findings: Review of the facility's policy effective 07/31/2019 titled, Elopement, Resident Policy and Procedure revealed, in part, the facility would provide at least one of the following safety precautions for residents who are at risk for elopement: door alarms on facility exits, a personal safety device that will alert facility staff when the resident has left the building without supervision, and staff supervision. Further review revealed at no time shall a personal safety alarm or door alarm be turned off without the continual supervision of the exit. Further review revealed all staff shall be trained on preventing and responding to an elopement. Further review revealed staff training would include risk factors and interventions for prevention of elopement. Review of WanderGuard's (Door GUARDIAN) Installation Manual dated 03/11/2016 revealed, in part, if a nursing staff member was required to escort a resident with a WanderGuard transmitter out of the protected area, an escort code (secondary reset code) can be entered into the door panel/monitor to allow both the transmitter to pass through the perimeter without creating an alarm. Further review revealed the secondary reset code was used to escort a resident with a WanderGuard transmitter through the monitored door. Resident #1 Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #1 had moderate cognitive impairment. Review of Resident #1's Elopement Risk Evaluation dated 12/09/2024 revealed in part, Resident #1 wandered aimlessly. Further review revealed Resident #1 had an elopement score of 1, which indicated Resident #1 was at risk for elopement. Review of Resident #1's nurse's note dated 12/23/2024 revealed, in part, Resident #1 was noted to have been found by staff outside of the facility and lying on the ground. Further review revealed Resident #1 had a small skin tear to his posterior head with minimal bleeding. Resident #1 was sent to the ED. Review of the facility's incident investigation dated 12/23/2024 revealed, in part, on 12/23/2024 at 8:50 a.m., Resident #1 was observed to unsuccessfully exit through door b. Resident #1 was then observed engaged in conversation with another resident, attempted to open door b again, and successfully opened door b and walked away from the facility. Subsequently, on 12/23/2024 at 9:25 a.m., Resident #1 was found 0.4 miles away from the facility and on the ground. Resident #1 was then transported via EMS to the ED where he was diagnosed with a right temporal bone skull fracture and a right subdural hematoma (a collection of blood outside the brain that are usually caused by severe head injuries). Review of Resident #1's hospital record dated 12/23/2024, revealed, in part, Resident #1 reportedly absconded (escaped) from his nursing home and was found after a ground level fall several blocks away. Review further revealed a Computed Tomography Scan (CT) (a type of scan that shows detailed images of the body) of Resident #1's head revealed a Non-displaced right temporal bone skull fracture and a right subdural hematoma. In a telephone interview on 01/03/2025 11:41 a.m., a 3rd party WanderGuard vendor staff member indicated the facility's original WanderGuard transmitters had a sleep mode function that would activate if a resident remained motionless for 20 to 30 seconds. Review of the facility's Elopement Binder located at Nursing Station j revealed a list dated 12/30/2024 of the following residents who required a WanderGuard transmitter and were considered at risk for elopement: Resident #2, #3, #R4, #R5, #R6, and #R7. Review of the facility's schedule dated 01/02/2025 revealed S7CNA provided direct care to #R4 and #R7. In an interview on 01/02/2025 at 1:01 p.m., S7CNA indicated Resident #R7 was the only resident at risk for elopement in her room assignment. S7CNA failed to identify Resident #R4 as a resident at risk for elopement. In a telephone interview on 01/02/2025 at 3:25 p.m., S7CNA indicated she used the secondary reset door code to open exit f. In an interview on 01/02/2025 at 1:15 p.m., S1Administrator/Regional Administrator indicated that he was the only person who used the secondary reset door code because it bypassed the WanderGuard panel/monitor security alert; if an elopement risk resident were to attempt to exit the facility the door would not alarm. S1Administrator/Regional Administrator confirmed the secondary reset door code should not be used by staff to open the facility's exit doors. Observation on 01/02/2025 at 1:30 p.m. revealed S3CNA used the secondary reset door code to unlock exit d. In an interview on 01/02/2025 at 1:32 p.m., S3CNA confirmed she used the secondary reset door code to unlock exits d and f. In an interview on 01/02/2025 at 1:40 p.m., S4Maintenance indicated the secondary reset door code was the code used to unlock both exits d and f. In an interview on 01/02/2025 at 1:41 p.m., S5CNA indicated the secondary reset door code was used to unlock both exits d and f. In an interview on 01/02/2025 at 1:45 p.m., S6CNA indicated the secondary reset door code was used to unlock both exits d and f. In an interview on 01/02/2025 at 2:27 p.m., S2Director of Nursing (DON) indicated Resident #1 obtained the right temporal bone (a bone in the skull) fracture and a right subdural hematoma after he eloped from the facility. S2DON further indicated Resident #1 should not have been able to get out the facility. The Immediate Jeopardy was removed on 01/03/2025 at 11:55 a.m., after it was verified through observations, interviews, and record reviews that the provider implemented an acceptable Plan of Removal prior to the survey exit. A Plan of Removal was accepted on 01/03/2025 at 11:55 a.m. which included the following actions to correct the deficient practice: Immediately after the elopement on 12/23/2024 at approximately 10:00 a.m., S2Director of Nursing and designees performed a census check to ensure all residents with WanderGuard transmitters were accounted for and that the WanderGuard transmitters were functioning properly. All residents were accounted for and all WanderGuard transmitters were checked by 10:20 a.m. On 12/13/2024 S1Administrator/Regional Administrator contacted a 3rd party WanderGuard vendor to inspect the facility's WanderGuard system. The inspection was completed on 12/23/2024 with no issues. S1Administrator/Regional Administrator discovered on 12/23/2024 at 10:00 a.m. that some WanderGuard transmitters have a sleep mode feature. S1Administrator/Regional Administrator immediately verified that the WanderGuard transmitters actively used by the facility's residents did not have the sensor with the sleep mode function. S1Administrator/Regional Administrator also ordered additional WanderGuard transmitters without a sleep mode on 12/23/2024 and received the new WanderGuard transmitters on 12/26/2024 at 9:00 a.m. S1Administrator/Regional Administrator immediately locked all entrances on 12/23/2024 at approximately 10:00 a.m. and they will remain locked indefinitely. Immediately after the elopement on 12/23/2024, S2DON and designees began in-servicing all staff on the WanderGuard system and appropriate monitoring for WanderGuard transmitter residents. S2DON also placed binders at each nurses' station identifying WanderGuard residents so that staff would be aware. Staff were in-serviced on the binders. S1Administrator/Regional Administrator, S2DON, S8Assistant DON and S9Assistant DON randomly completed follow up interviews with staff to ensure they had understanding of the WanderGuard system and appropriate monitoring of residents. On 12/23/2024 S2DON, S8Assistant DON and S9Assistant DON placed every 1 hour monitoring to WanderGuard transmitter residents' electronic Medication Administration Record for increased supervision. S2DON and designees also began hourly visual checks on WanderGuard residents. Starting on 12/23/2024, S10Assistant Administrator and designee began performing daily WanderGuard system checks to ensure proper functioning. On 12/23/2024 S1Administrator/Regional Administrator sent a letter to resident family members educating them on not opening entries for residents allowing them to leave the facility. On 01/02/2025 at approximately 2:00 p.m. S1Administrator/Regional Administrator reset all primary and secondary door codes that will remain confidential. All staff have access to the primary code and department head staff have access to the secondary code. On 01/02/2025 at approximately 5:00 p.m. S1Administrator/Regional Administrator and designees began in-servicing staff on how to identify WanderGuard transmitter residents and ensuring WanderGuard transmitter residents were not allowed to exit the facility. All staff would be in-serviced via phone or in person upon arriving for their shift. The in-servicing of all staff would be completed by 01/03/2025. The likelihood of serious harm to any resident related to elopement no longer existed as of 01/03/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations, the facility failed to ensure residents who had a history of unsafe use of smoking materials were supervised and did not have smoking materials in their possession for 4 (Resident #33, Resident #83, Resident #86, and Resident #568) of 4 (Resident #33, Resident #83, Resident #86, and Resident #568) sampled residents reviewed for smoking. The deficient practice resulted in an Immediate Jeopardy situation on 07/19/2023 for Resident #568, a severely cognitively impaired resident, when Resident #568 had a cigarette lighter removed from his possession by S9Licensed Practical Nurse after Resident #568 attempted to enter the facility with a lit cigarette in his mouth and the facility failed to reassess the resident as an unsafe smoker and implement new interventions to prevent future smoking incidents. On 09/16/2023, Resident #568 sustained 2nd degree facial burns and required hospital emergency medical attention due to unsafely igniting a lighter in his room while using oxygen. Resident #33, Resident #83, and Resident #86 had a history of unsafe smoking in the facility and were assessed to need their smoking materials kept by staff. Observation on 09/20/2023 at 7:01 p.m. on the smokers' patio revealed Resident #33 requested Resident #86's blue lighter to light her cigarette. Observation revealed Resident #86 (a resident with a history of lighting a cigarette inside the facility) gave Resident #33 (a cognitively impaired resident who required supervision to ensure smoking in designated areas) his lighter and Resident #33 began to light her cigarette without staff supervision. Observation on 09/21/2023 at 9:55 a.m. revealed Resident #83 (a resident with a history of smoking in undesignated areas) was lying in his bed and was in possession of smoking materials. S1Administrator was notified of the Immediate Jeopardy on 09/21/2023 at 2:32 p.m. The Immediate Jeopardy was removed on 09/21/2023 at 5:56 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. The facility's Plan of Removal included the following: 1. Corrective actions were taken for the resident (Resident #33, Resident #83, Resident #86, and Resident #568) by the alleged deficient practice by: -S1Administrator began in-servicing staff on 09/21/2023 at 3:00 p.m. on the following: (will in-service staff prior to working shift on day, evening and night shift) the facilities smoking policy, -All smoking incidents (resident is caught lighting a cigarette in the facility, sharing cigarettes and lighters with unsafe smokers, etc.) must be reported to S1Administrator, S2Director of Nursing or the immediate supervisor immediately, It was absolutely forbidden to purchase or share cigarettes/lighters with all residents, and if a staff member was caught it would result in reprimand up to termination. -S32Assistant Administrator and Staff Development Nurse completed rounds on 09/21/2023 to ensure Resident #33, Resident #83, Resident #86, and Resident #568 were not in possession of smoking materials. -The Minimum Data Set Department completed smoking assessments on all residents that smoke on 09/21/2023 to determine safe and unsafe smokers. Resident #76 was also identified as unsafe. S5Corporate Nurse placed a nursing intervention on Resident #33, Resident #83, Resident #86, Resident #568, and Resident #76 electronic medication administration record to be signed off every shift informing nursing staff that these residents need their smoking materials held by staff. -S1Administrator performed resident council meeting on 09/21/2023 with residents that smoke informing them of the facilities smoking policies. -S1Administrator sent a group-cast communication on 09/21/2023 to the resident's responsible parties on ensuring smoking materials are given to the facility staff rather than to residents when delivering smoking materials. -A designated employee will be responsible for supervising unsafe smokers while smoking every shift starting on 09/21/2023. 2. All residents with a history of unsafe use of smoking materials have the potential to be affected by the alleged deficient practice. 3. Measures put in place to ensure the alleged deficient practice will not recur are: - Starting on 09/21/2023, S2Director of Nursing or designee will perform quality assurance rounds twice a day to ensure Resident #33, Resident #83, Resident #86, and Resident #568, and any other resident identified as an unsafe smoker, are not in possession of smoking materials and are appropriately supervised until 10/12/2023. -The Minimum Data Set Department was to ensure smoking assessments are completed on residents at admission, readmission and as needed. The Minimum Data Set Team is to communicate to the Interdisciplinary Team any smokers identified as unsafe or needing materials to be held by staff. - Starting 09/21/2023, S2Director of Nursing or designee to spot check smoking assessments at random twice a week to ensure compliance until 10/12/2023. - S5Corporate Nurse placed a nursing intervention on Resident #33, Resident #83, Resident #86, Resident #568, and Resident #76's electronic medical record to be signed off every shift informing nursing staff that these residents need their materials held by staff. - S2Director of Nursing or designee to place nursing intervention on any unsafe smoker identified after 09/21/2023. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: - Starting on 09/21/2023, S2Director of Nursing or designee will perform quality assurance rounds twice a day to ensure Resident #33, Resident #83, Resident #86, Resident #568, and Resident #76 and any other resident identified as an unsafe smoker are not in possession of smoking materials and are appropriately supervised. 5. The likelihood of serious harm to Resident #33, Resident #83, Resident #86, Resident #568 and Resident #76 no longer existed after 4:30 p.m. on 09/21/2023. The deficient practice has the potential to cause more than minimum harm to any remaining unsafe smokers in the facility. Findings: Review of the facility's Smoking Policy and Procedure revealed, in part, safe smoking assessment and/or Interdisciplinary (ID) Team will determine if resident is safe to smoke. Residents deemed unsafe will be discussed with ID Team to determine protocol to be implemented on individual basis (ex. smoking apron needed, cigarettes stored at nurses station, lighter removed from resident from resident possession, direct supervision needed, etc.). Safe smoking assessments will be completed on residents who smoke upon admission, re-smoking assessments will be completed on residents who smoke upon admission, readmission, quarterly, annually, significant changes, and as needed. Further review revealed no documented evidence for the protocol of when direct supervision was required for unsafe smokers. Resident #568 Review of Resident #568's medical record revealed Resident #568 was admitted to the facility on [DATE] with diagnoses of depression, latent syphilis, CHF, COPD, alcohol dependence, hypertension, tobacco use, dependence on supplemental oxygen and nicotine dependence cigarettes. Review of Resident #568's Quarterly MDS with ARD of 06/28/2023 revealed, in part, Resident #568 had BIMS score of 7 which indicated severe impaired cognition. Review of Resident #568's Assessment for Safe smoking with a completion date of 06/28/2023 revealed, in part, memory ok and modified independence with decision making. Further review revealed, in part, Resident #568 is an occasional smoker and is considered a safe smoker. Review of Resident #568's Comprehensive Care plan, with a start date of 06/28/2023, revealed, in part Resident #568 was a safe smoker. Further review revealed, Resident #568's care plan was updated 09/16/2023 and indicated Resident #568 now an unsafe smoker because Resident #568 received burns from lighting a lighter in his room with oxygen in place. Further review revealed the following interventions, in part, Resident #568 will be reminded to smoke in designated smoking areas, Resident #568 will have cigarettes and lighter be administered to him and Resident #568 will need to be taken to the designated smoking areas at times. Review of Resident #568's nursing progress notes completed on 07/19/2023 at 1:31 p.m. by S9LPN revealed Resident #568 came from the back patio with a lit cigarette from his mouth, and S9LPN immediately removed the cigarette from Resident #568's mouth and put it out. S9LPN further indicated Resident #568's lighter was taken from him. ADON notified. Review of Resident #568's medical record revealed no documentation of a safe-smoking assessment or re-assessment following the resident's attempt to enter the facility with a lit cigarette on 07/19/2023. In an interview on 09/20/2023 at 2:55 p.m., S9LPN stated on 07/19/2023 Resident #568 had activated the automatic door to enter the facility through vestibule from designated smoking area and had a lit cigarette in his mouth. S9LPN stated she stopped Resident #568 prior to him entering the doorway and extinguished his cigarette and took his lighter away. S9LPN stated she took Resident #568's lighter because she felt he was unsafe to be in possession of his smoking material due to his cognitive status and other behaviors that displayed Resident #568's safety awareness was impaired. S9LPN stated Resident #568 was sent out to an inpatient psychiatric facility on 07/20/2023 for inappropriate sexual behaviors. S9LPN further stated she notified S4Assistant Director of Nursing of the unsafe smoking incident on 07/19/2023. In an interview on 09/20/2023 at 3:00 p.m., S4Assistant Director of Nursing stated she did not recall being told about the incident with Resident #568 on 07/19/2023. Review of Resident #568's nursing progress note completed on 07/20/2023 at 9:34 pm revealed Resident #568 was sent to inpatient psychiatric facility. Review of Resident #568's nursing progress note completed on 07/28/2023 at 12:37 p.m. revealed Resident #568 returned to the facility from the hospital. Further review of Resident #568's medical record revealed no documentation that a safe smoking re-assessment was completed upon the Resident's 07/28/2023 readmission. In an interview on 09/20/2023 at 3:20 p.m., S2DON stated the Assessment for Safe Smoking is completed upon admission, readmission, and quarterly and as needed. S2DON confirmed Resident #568 returned from hospital on [DATE] and an Assessment for Safe Smoking was not completed. S2DON stated they did not deem Resident #568 an unsafe smoker after the incident on 07/19/2023 because he did not enter the facility with a lit cigarette. In an interview on 09/20/2023 at 4:00 p.m., S21Minimum Data Set (MDS) nurse stated the Assessment for Safe Smoking are not done on readmission unless there is a need for a MDS to be done. S21MDS Nurse confirmed Resident #568 did not have a smoking assessment done on 07/28/2023 when he returned from the hospital. S21MDS Nurse stated she was not aware the facility Smoking policy stated Assessment for Safe Smoking are supposed to be completed on readmission. Review of Resident #568's nursing progress notes completed on 09/16/2023 at 1:33 p.m. revealed strong smoke smell noted on hallway. Resident #568 up in wheelchair on hallway outside of doorway with black soot noted to his face. Nurse asked Resident #568 what happened and Resident #568 stated he was playing with a lighter with his oxygen on with a nasal cannula in his nose. Resident #568 says he was just flicking the lighter. Nurse asked Resident #568 why he would do that and he stated he knows he is not supposed to smoke with oxygen. Resident #568 stated because I'm an idiot and started laughing. Nurse took lighter from Resident #568 and nurse checked Resident #568's belongings for more cigarettes and cigarettes were removed out of the room. Resident #568 was noted with black soot inside nostrils on bilateral cheeks and eyebrows. Nurse cleaned Resident #568's face with wet towel and applied ice and cold wet compresses to face. Redness noted to Resident #568's face. Nurse notified MD and an order obtained to send to the hospital for evaluation and call placed to Resident #568's daughter. Review of Resident #568's After Visit Summary from hospital emergency visit completed on 09/16/2023 revealed Resident #568's reason for visit was facial burn and diagnosis of facial burn, second degree. Review of Resident #568's Wound Assessment Report completed on 09/16/2023 revealed, in part, Resident #568 with a burn to upper lip, left cheek and right cheek measuring 7.00 cm x 11.00 cm. Burn type was thermal. Burn depth was superficial partial thickness. In an interview on 09/18/2023 at 12:56 p.m., Resident #568 stated he lit his face on fire with a lighter on 09/16/2023 when he was attempting to smoke. Resident #568 further stated when he went to light his cigarette it caught his mustache on fire. Observation on 09/20/2023 at 8:30 a.m. revealed Resident #568 up in his wheelchair rolling around in designated smoking area asking other residents for cigarettes and was unable to obtain one. Resident #568 then rolled back into the facility. In an interview on 09/20/2023 at 11:45 a.m., S26Certified Nursing Assistant (CNA) stated she was here on 09/16/2023 when Resident #568 caught his face on fire. S26CNA stated in regards to Resident #568's incident on 09/16/2023, she and the nurse were doing rounds, smelled something burning and Resident #568 came into the hallway with soot on his face. S26CNA further stated Resident #568 stated he was playing with a lighter with oxygen on. In an interview on 09/20/2023 at 11:48 a.m., S9LPN stated they are informed about unsafe smokers in a binder that is kept at the nursing station. S9LPN stated for residents who are unsafe smokers, the nurses hold their smoking materials and staff have to supervise them when they smoke. S9LPN stated there is a designated smoking area but there are no designated smoking times. S9LPN stated Resident #568 is an unsafe smoker and is not allowed to have cigarettes and lighters in his personal belongings. In an interview on 09/20/2023 at 12:50 p.m., S2Director of Nursing stated unsafe smokers are not allowed to have their cigarettes or lighters, these items are held by the nurse and they are supervised by staff members when they go out to smoke. Resident #33 Review of Resident #33's face sheet revealed, in part, Resident #33 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease. Review of Resident #33's Minimal Data Set (MDS) with an Assessment Reference Date of 08/13/2023 revealed, in part, Resident #33's Brief Interview for Mental status score was 5 which indicated Resident #33 had severe cognitive impairment. Review of Resident #33's assessment for safe smoking with a completion date of 08/14/2023 revealed, in part, Resident #33 was an unsafe smoker. Review of this assessment revealed, Resident #33 was deemed an unsafe smoker related to having a diagnosis of Dementia. Review revealed Resident #33 had been known to light cigarettes in her room and in her restroom. Review revealed Resident #33's cigarettes were to be kept on the nursing cart and were to be distributed to Resident #33 by the floor nurse. Further review revealed Resident #33 was to be monitored by staff in the designated smoking area. Review of Resident #33's Comprehensive Care Plan, with a start date of 03/16/2023, revealed, in part, Resident #33 had a history of smoking in unauthorized areas. Review revealed Resident #33 needed her cigarettes and lighter administered to her. Further review revealed Resident #33 needed to be redirected to the authorized smoking areas. In an interview on 09/21/2023 at 12:55 p.m. S5Corporate Nurse stated the interventions on Resident #33's care plan are the interventions that should be followed for Resident #33 when she was smoking. Observation on 09/20/2023 at 3:55 p.m. revealed Resident #33 sitting outside in the designated smoking area holding two cigarettes. Observation revealed Resident #33 placed one cigarette in the right side of her bra, requested a light from a random resident, and began smoking a brown cigarette without staff supervision. In an interview on 09/20/2023 at 4:06 p.m., Resident #33 stated she enjoys smoking. Resident #33 further stated, she likes to smoke in the evening because staff do not bother her in the evening. In an interview on 09/20/2023 at 4:58 p.m. Resident #33's family member stated Resident #33 had a history of smoking in the her room and her bathroom. Resident #33's family member stated Resident #33 is not allowed to have smoking materials on her person per the facility's administration team. In an interview on 09/20/2023 at 6:56 p.m., Resident #33 stated she was going outside to smoke. Observation on 09/20/2023 at 6:57 p.m. revealed Resident #33 removed 2 cigarettes from her bra and proceeded to the nurse's station. Observation revealed Resident #33 informed S25Ward Clerk and S24Licensed Practical Nurse she was going outside to smoke. Further observation revealed Resident #33 proceeded outside to the designated smoking area without staff present. Observation on 09/20/2023 at 7:01 p.m. revealed, Resident #33 requested Resident #86's blue lighter to light her cigarette. Observation revealed Resident #86 gave Resident #33 his lighter and Resident #33 began to attempt to light her cigarette without staff supervision. In an interview on 09/20/2023 at 7:03 p.m., S25Ward Clerk stated Resident #33 required supervision when smoking. S25Ward Clerk stated the facility does not have an assigned person in place to supervise residents who smoke. S25Ward Clerk further stated the certified nursing assistants on shift and the facility's ward clerks try to alternate supervising the residents who smoke, but they are not able to do it all the time. In an interview on 09/20/2023 at 7:10 p.m., Resident #110, a resident with a BIMS score of 13 indicating Resident #110 was a cognitively intact resident, stated Resident #33 smoked multiple times a day, mainly in the evening time. Resident #110 stated she does not smoke, but enjoyed sitting outside in the designated smoking area with Resident #33. Resident #110 stated Resident #33 received her cigarettes from the nurse's cart or other residents. Resident #110 stated once Resident #33 received a lighter from other residents that have their lighter in the designated smoking area. Resident #110 stated staff do not supervise Resident #33 when she is smoking. Resident #110 further stated she supervised Resident #33 smoke and made sure she was safe. In an interview on 09/21/2023 at 1:00 p.m., S1Adminstrator stated residents who require assistance are not unsafe smokers. S1Administrator stated residents who smoke all have specific interventions specified on their careplan and smoking assessments that outlines the reason they require assistance. S1Administrator further stated residents who have smoked in the facility should be considered an unsafe smoker. S1Administrator stated to his knowledge, Resident #33 was not an unsafe smoker. S1Administrator further stated he was not informed of the prior incidents mentioned above. In an interview on 09/21/2023 at 2:42 p.m., S34Minimum Data Set Nurse stated smoking assessments are completed on admission and quarterly. S34Minimum Data Set Nurse further stated Resident #33 should have had a smoking assessment completed in June 2023 when her quarterly MDS was completed and she did not. Resident #83 Review of Resident #83's medical record revealed admitted to the facility on [DATE] with diagnoses of neuropathy, major depressive disorder, attention deficit hyperactivity disorder, peripheral vascular disease, insomnia, pain in leg, chronic pain, tobacco use, polyneuropathy, anxiety disorder, and opioid dependence. Review of Resident #83's Quarterly Minimum Data Set (MDS) with Assessment Reference Date of 07/31/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Review of Resident #83's Assessment for Safe Smoking for 07/31/2023 revealed, in part, Resident #83 is a frequent smoker and was considered an unsafe smoker because of reports of Resident #83 lighting cigarettes in the facility. Further review revealed Resident #83's smoking material is held at nurses' station and is given to him by the nurse. Review of Resident #83's Comprehensive Care Plan with start date of 03/07/2023, updated on 05/31/2023 and 07/31/2023 revealed, in part, Resident #83 was a safe smoker but had a history of smoking in undesignated areas and required staff to keep Resident #83's cigarettes and give them to him when it was time to smoke. Further review revealed Resident #83 would be reminded to smoke in designated smoking areas and may need supervision when smoking. Review of the facility's smoker's list with a date of 09/19/2023 revealed Resident #83 was a safe smoker who required smoking materials be held for him. Observation on 09/21/2023 at 8:34 a.m. revealed Resident #83 wheeling his wheelchair in the hallway with brown cigar lying on his lap. In an interview on 09/21/2023 at 8:34 a.m., Resident #83 stated he was going outside to smoke. Observation on 09/21/2023 at 9:43 a.m. revealed Resident #83 outside in designated smoking area smoking a brown cigarette without staff present. Observation on 09/21/2023 at 9:55 a.m. revealed Resident #83 lying in bed and resident showed this surveyor a gray scripto lighter he had in his pants waist band. In an interview on 09/21/2023 at 9:55 a.m., Resident #83 stated he is a smoker and his uncle brings him a carton of Santa Fe filtered cigars every one and a half weeks. Resident #83 further indicated he stores his cigars in his dresser drawer. Resident #83 stated he only has the one gray scripto lighter which is in his waist band of pants but he usually buys his lighters from a staff member. Resident #83 stated he has always been able to hold his cigarettes and lighters and has never had to be supervised by staff while he smoked. In an interview on 09/21/2023 at 9:57 a.m., S9Licensed Practical Nurse (LPN) stated Resident #83 has always had his cigarettes and lighter on him and nursing staff have never had to hold his cigarettes and lighter for him. S9LPN stated she was not aware Resident #83 was listed on Smoker list dated 09/19/2023 as a Smoker whose material must be held. Resident #86 Review of Resident #86's face sheet revealed, in part, Resident #86 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease, and Tobacco Use. Review of Resident #86's Minimal Data Set with an Assessment Reference Date of 08/23/2023 revealed, in part, Resident #86's Brief Interview for Mental status score was 12 which indicated Resident #86 was moderately cognitively impaired. Review of Resident #86's assessment for safe smoking with a completion date of 08/23/2023 revealed, in part, Resident #86 was a safe smoker. Further review revealed, Resident #86 had to have his cigarettes administered to him due to lighting a cigarette in the facility. Review of Resident #86's Comprehensive Care Plan, with a start date of 02/01/2023, and a revision date of 08/18/2023 revealed, in part, staff were currently holding Resident #86's cigarettes. Further review revealed, staff were to report any unsafe smoking and/or smoking in unauthorized area to nursing staff. Review of the facility's smoker's list with a date of 09/19/2023 revealed Resident #86 was a safe smoker, but needed his smoking materials held by facility staff. Review of Resident #86's assessment for safe smoking with a completion date of 08/23/2023 revealed, in part, Resident #86 was a safe smoker. Further review revealed, Resident #86 had to have his cigarettes administered to him due to lighting a cigarette in the facility. Observation on 09/20/2023 at 3:56 p.m. revealed Resident #86 was outside with a pack of cigarettes and a cigarette lighter in his possession, smoking in the designated smoking area, without staff supervision. Observation on 09/20/2023 at 7:00 p.m. revealed, Resident #86's in the designated smoking area in possession of a blue lighter and cigarettes. Observation revealed Resident #86 gave Resident #33 his blue lighter when Resident #33 requested it to light her cigarette. In an interview on 09/21/2023 8:45 a.m., Resident #86 stated he had one incident in the past where he smoked in the facility. Resident #86 stated the facility never informed him he was considered an unsafe smoker or he was not allowed to keep his smoking materials. Resident #86 stated prior to last night, he was able to keep his own cigarettes and lighter. Resident #86 stated he shares his lighter with other residents and he was unaware that was unsafe smoking practices. In an interview on 09/21/2023 at 10:05 a.m., S9Licensed Practical Nurse stated worked at the facility on day shift. Resident #86 became an unsafe smoker as of 09/21/2023. S9Licensed Practical Nurse stated prior to 09/21/2023, she did not keep Resident #86's smoking material on her cart, because she was unaware he was an unsafe smoker. In an interview on 09/21/2023 at 11:15 a.m., S23Minimum Data Set Nurse stated she completed Resident #86's Assessment For Safe Smoking dated 08/23/2023 because she was informed by another staff member that Resident #86 lit a cigarette in his room and attempted to smoke.S23MDS Nurse further stated the safe smoking assessment was the facility's tool for identifying whether a resident was a safe smoker or an unsafe smoker. In an interview on 09/21/2023 at 11:20 a.m. S1Adminstrator stated to his knowledge, Resident #86 had no previous incidents with smoking material prior to 09/20/2023. S1Adminstrator further stated any resident that was caught smoking in the facility should be deemed an unsafe smoker and should not smoke unsupervised nor have smoking materials in their possession without staff supervision. S1Administrator further stated he was not informed of the previous unsafe smoking incidents listed above.

The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to provide the necessary administrative oversight to ensure systems were in-place and implemented for residents who had a history of unsafe use of smoking materials were supervised and did not have smoking materials in their possession for 4 (Resident #33, Resident #83, Resident #86, and Resident #568) of 4 (Resident #33, Resident #83, Resident #86, and Resident #568) sampled residents reviewed for smoking. The deficient practice resulted in an Immediate Jeopardy situation on 07/19/2023 for Resident #568, a severely cognitively impaired resident, when Resident #568 had a cigarette lighter removed from his possession by S9Licensed Practical Nurse after Resident #568 attempted to enter the facility with a lit cigarette in his mouth and the facility failed to reassess the resident as an unsafe smoker and implement new interventions to prevent future smoking incidents. On 09/16/2023, Resident #568 sustained 2nd degree facial burns and required hospital emergency medical attention due to unsafely igniting a lighter in his room while using oxygen. Resident #33, Resident #83, and Resident #86 had a history of unsafe smoking in the facility and were assessed to need their smoking materials kept by staff. Observation on 09/20/2023 at 7:01 p.m. on the smokers' patio revealed Resident #33 requested Resident #86's blue lighter to light her cigarette. Observation revealed Resident #86 (a resident with a history of lighting a cigarette inside the facility) gave Resident #33 (a cognitively impaired resident who required supervision to ensure smoking in designated areas) his lighter and Resident #33 began to light her cigarette without staff supervision. Observation on 09/21/2023 at 9:55 a.m. revealed Resident #83 (a resident with a history of smoking in undesignated areas) was lying in his bed and was in possession of smoking materials. S1Administrator was notified of the Immediate Jeopardy on 09/21/2023 at 2:32 p.m. The Immediate Jeopardy was removed on 09/21/2023 at 5:56 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. The facility's Plan of Removal included the following: 1. Corrective actions were taken for the residents (Resident # 33, Resident # 83, Resident # 86 and Resident # 568) by the alleged deficient practice by: -S5Coorporate Nurse in-serviced administrative staff (S2Director of Nursing, S1Administrator, S32Assistant Administrator, S4Assistant Director of Nursing, Minimum Data Set Department) on 09/21/2023 on ensuring the safety of unsafe smokers. -Facility audit performed on 09/21/2023 revealed that Resident # 33, Resident # 83, Resident # 86, and Resident # 568, and Resident # 76 were not in possession of smoking materials. 2. All residents with the history of unsafe smoking habits have the potential to be affected by the alleged deficient practice. 3. Measures put in place to ensure the alleged deficient practice will not reoccur are: -S5Coorporate Nurse in-serviced administrative staff on 09/21/2023 on ensuring the safety of unsafe smokers. -Facility audit performed on 09/21/2023 revealed that Resident # 33, Resident # 83, Resident # 86 and resident # 568 and Resident # 76 were not in possession of smoking materials. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: - Beginning on 09/21/2023 S6Regional Director or designee will perform Quality Assurance Administration audits once a week until 10/12/23 to ensure the facility is being administered in a manner that uses resources to effectively and efficiently meet the needs and safety of unsafe smokers. S6Regional Director will monitor the facility administrator weekly to ensure the S1Administrator is providing appropriate monitoring and supervision for unsafe smokers. - Beginning on 09/21/2023 S5Coorporate Nurse or designee will perform Quality Assurance Administration nursing audits two times per week until 10/12/2023 to ensure the facility is being administered in a manner that uses resources to effectively and efficiently meet the needs and safety of unsafe smokers. -S5Cooporate Nurse or designee to review S2Director of Nursing audits once per week to ensure compliance until 10/12/2023. 5. The likelihood of serious harm to Resident # 33, Resident # 83, Resident # 86, Resident # 568 and Resident # 76 no longer existed after 4:30 p.m. on 09/21/2023. The deficient practice has the potential to cause more than minimum harm to any remaining unsafe smokers in the facility. Findings: Cross Reference F-689. In an interview on 09/21/2023 at 11:20 a.m., S1Adminstrator stated to his knowledge, Resident #86 had no previous incidents with smoking material prior to 09/20/2023. S1Adminstrator further stated any resident, including Resident #33, Resident #83, and Resident #86, and Resident #568, caught smoking in the facility should be deemed an unsafe smoker and should not smoke unsupervised nor have smoking materials in their possession without staff supervision. Further, when this surveyor asked S1 Administrator, what was the facility's process to ensure unsafe smokers are supervised while smoking and do not have smoking materials in their possessions, S1Administrator declined to answer. In an interview on 9/21/2023 at 11:20 a.m., when this surveyor asked S5Corporate Nurse, what was the facility's process to ensure unsafe smokers are supervised while smoking and do not have smoking materials in their possessions, S5Corporate Nurse declined to answer.