**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents, who had a history of unsafe smoking used a safety smoking device and was supervised while smoking for 3 (Resident #31, Resident #15 and Resident #53) of 3 (Resident #15, Resident #31, and Resident #53) sampled residents reviewed for unsafe smoking. This deficient practice resulted in an Immediate Jeopardy situation on 12/16/2024 at 9:50 a.m. when Resident #31, a resident identified by the facility as an unsafe smoker with moderate cognitive impairment, was observed smoking without the use of a smoking apron (a safety device which provides protection against burns to clothing and/or skin) and without staff supervision. Resident #31's care plan, initiated on 10/02/2024, included Resident #31 was an unsafe smoker, was required to wear a smoking apron, and required staff supervision while smoking. S1Administrator was notified of the Immediate Jeopardy situation on 12/16/2024 at 5:52 p.m. This deficient practice had the likelihood to cause more than minimum harm to all 3 residents (Resident #15, Resident #31, and Resident #53) identified by the facility as unsafe smokers who required safety smoking devices and/or supervision while smoking. Findings: Review of the facility's policy titled Smoking Policy, updated 07/04/2024, revealed in part, residents that smoke would be assessed for the safety of smoking unattended and if determined unsafe, would not be allowed to have smoking paraphernalia in their possession, and would be care planned for the amount of supervision needed while smoking. Further review revealed the administrator was responsible for enforcing the designated smoking area, the nursing staff was responsible for keeping and distributing smoking paraphernalia for residents who were identified as unsafe smokers, and the ward clerk was responsible to monitor an active unsafe smoker list. Resident #31 Review of the facility's smoking list revealed, in part, Resident #31 was identified by the facility as unsafe smoker. Review of Resident #31's medical record revealed, in part, Resident #31 was admitted to the facility on [DATE] with diagnoses of, in part, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting his right dominant side. Review of Resident #31's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/10/2024 revealed, in part, Resident #31 had a Brief Interview of Mental Status (BIMS) score of 9, which indicated Resident #31 had moderate impaired cognition. Further review revealed Resident #31 was identified as a tobacco user. Review of Resident #31's quarterly MDS with ARD of 05/10/2024 revealed, in part, Resident #31 had a BIMS score of 10 which indicated Resident #31 had moderate impaired cognition. Further review revealed Resident #31 was identified as a tobacco user. Review of Resident #31's Comprehensive Care Plan, with an initiation date of 10/02/2024 revealed, in part, Resident #31 was actively an unsafe smoker who was required to wear a smoker's apron, and required staff supervision while smoking. Review of Resident #31's physician orders with a start date of 07/01/2024 revealed, in part, Resident #31 was an unsafe smoker and was required to wear a smoker's apron at all times while smoking. Observation on 12/16/2024 at 9:00 a.m., revealed Resident #31 was sitting in his wheelchair in his room with two burn holes in his shirt, one unlit cigarette under his left leg, and a lighter attached to a retractable device on his jacket. Observation on 12/16/2024 at 11:07 a.m., revealed Resident #31 was rolling in his wheelchair down hall c, with two burn holes in his shirt and a lighter attached to a retractable device on his jacket. In an interview on 12/16/2024 at 11:08 a.m., Resident #31 indicated he does not need anyone to go outside with him to smoke. Observation on 12/16/2024 at 12:18 p.m., revealed Resident #31 wheeled himself down hall c, with two burn holes in his shirt, and a lighter attached to a retractable device on his jacket. In an interview on 12/16/2024 at 12:19 p.m., Resident #31 indicated he was going to smoke. Observation on 12/16/2024 at 12:24 p.m., revealed Resident #31was outside on the facility's smoking patio, unsupervised and without a smoker's apron on. Further observation revealed Resident #31 removed a pack of cigarettes out of his jacket, removed the cigarette lighter attached to a retractable device on his jacket, and lit a cigarette using the lighter. Observation on 12/16/2024 at 12:39 p.m., S1Administrator witnessed and confirmed Resident #31 was identified as an unsafe smoker, was on the facility's smoking patio unsupervised, without a smoker's apron on, and was in possession of a cigarette and a lighter. There was no documented evidence and the facility could not provide any documented evidence there was a list of identified unsafe smokers located at the nurses' station. In an interview on 12/17/2024 at 9:03 a.m., S2Director of Nursing (DON) indicated Resident #31, an unsafe smoker, was observed smoking unsupervised, without a smoker's apron on, and in possession of smoking paraphernalia. S2DON further indicated administrative staff was aware of unsafe smokers smoking unsupervised, without a smoker's apron on and in possession of smoking paraphernalia. In an interview on 12/17/2024 at 10:35 a.m., S5CNA indicated she was not aware Resident #31 was an unsafe smoker who required a smoker's apron with supervision while smoking. S5CNA further indicated she had not been aware that Resident #31 had smoking paraphernalia in his possession. Resident #15 Review of Resident #15's annual MDS with ARD of 06/11/2024 revealed, in part, Resident #15 was identified as a tobacco user. A review of the facility's smoking list revealed, in part, Resident #15 was identified by the facility as an unsafe smoker. Observation on 12/16/2024 at 3:30 p.m., revealed Resident #15 sitting in his wheelchair in hall c with an opened full pack of cigarettes between his legs. Review of Resident #15's care plan revealed Resident #15 was care planned for unsafe smoking. Further, safe smoking interventions revealed in part; Resident#15 is an unsafe smoker, must wear a smoker's apron while smoking, cigarettes and lighter must be locked in the nurse's cart and Resident #15 must be supervised while smoking in the designated smoking location. In an interview on 12/17/2024 at 9:56 a.m., S4CNA indicated she was unaware Resident #15 was an unsafe smoker and should not have smoking material in his possession. Resident #53 Review of Resident #53's smoking assessment dated [DATE], revealed, in part, Resident #53 was an unsafe smoker. Review of Resident #53's annual MDS with an ARD date of 05/28/2024, revealed, in part, Resident #53 had a BIMS of 15 which indicated Resident #53 was cognitively intact and was identified as a tobacco user. Review of Resident #53's care plan, dated 10/24/2024, revealed, in part, Resident #53 should be supervised while smoking and should use a smoker's apron. In an interview on 12/16/2024 at 12:45 p.m., Resident #53 indicated he kept his cigarettes in his personal locked box and a lighter in his shirt pocket and he does not have to be supervised while smoking. Observation on 12/16/2024 at 12:45 p.m., revealed Resident #53 took a lighter out of his shirt pocket. In an interview on 12/16/2024 at 12:46 p.m., S8CNA indicated Resident #53 should not have smoking material in his room. In an interview on 12/16/2024 at 12:47 p.m., S4CNA indicated Resident #53 should not have smoking material in his room. In an interview on 12/16/2024 at 12:48 p.m., S11LPN, indicated Resident #53 should not have any smoking paraphernalia in his room. In an interview on 12/16/2024 at 12:50 p.m., S2Director of Nursing (DON) indicated she was aware Resident #53 was identified as an unsafe smoker, Resident #53 had to be supervised while smoking, and Resident #53 had smoking material in his possession. In an interview on 12/17/2024 at 8:55 a.m., S1Administrator confirmed the administrative personnel is responsible for ensuring the facility's designated smoking areas are enforced, Residents who are identified as unsafe smokers do not have smoking paraphernalia available in their rooms or on their person, and there was a current list of identified unsafe smokers at the nursing station In an interview on 12/17/2024 at 9:45 a.m., S1Administrator indicated Resident #15 was an unsafe smoker and should not have had smoking material in his possession. The Immediate Jeopardy was removed on 12/17/2024 at 6:50 p.m., after it was verified through observations, interviews, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit. A Plan of Removal was accepted on 12/17/2024 at 6:50 p.m., which included the following actions to correct the deficient practice: 1.) On 12/16/2024, S2DON and S1Administrator inspected other identified unsafe smokers from a review of an updated smokers list in order to collect and store items on the nursing cart and to prevent other potential harm that could occur. 2.) On 12/16/2024, a review of the current smoker's policy was conducted by S1Admnistrator and S2DON immediately with no immediate changes made. 3.) On 12/16/2024, S2DON and S1Administerator inspected personal belongings of all unsafe smokers and any smoking material found in possession of residents and was confiscated to given to the assigned nurse on the medication cart. All materials collected by S1Administrator and S2DON were placed in a zip locked bag and labeled with the resident's name. 4.) On 12/16/2024, direct care staff were immediately in-serviced on the facility smoker's policy by S2DON, and made aware of who was currently deemed as an unsafe smoker and each resident's level of safety to smoke. 5.) Beginning on 12/16/2024, all direct care staff, CNAs and nurses, were notified and in-serviced by S2DON. All staff would assist with supervising smoking for unsafe smokers as well as ensuring smoker's aprons were worn. This was initiated with the staff who were present and would continue with each shift, prior to the provision of care. 6.) On 12/16/2024, nurses were told by S2DON that they would secure smoking items and would locate a smoking attendant that could assist with smoking activity each time a resident requested to go out and smoke. In-services would be ongoing. 7.) On 12/16/2024, an updated smoking list was provided by S2DON to the Minimum Data Set (MDS) nurses and placed at the desk for all staff to reference. 8.) On 12/16/2024, MDS nurses reviewed care plans to ensure all unsafe smokers' care plans were up to date with appropriate interventions as well as verifying a smoking assessment was on file to correlate to the person centered care plan. 9.) On 12/16/2024, the S2DON and S1Administrator ensured all unsafe smokers did not have any smoking materials on their person and made a final round prior to exit. There were no smoking materials identified on any resident. The likelihood of serious harm no longer existed for residents related to unsafe smoker supervision on 12/17/2024 at 6:50 p.m.

Based on interviews, observations, and policy review the administrative staff failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents by overseeing the effective implementation of the facility's smoking policy and procedure for monitoring and supervision for 3 (Resident #15, Resident #31, and Resident #53) of 3 (Resident #15, Resident #31, and Resident #53) residents identified as unsafe smokers. This lack of administrative oversight resulted in Immediate Jeopardy situation on 12/16/2024 at 9:50 a.m., when facility staff failed to ensure implementation of their smoking policy when an unsafe smoker (Resident #31) was observed smoking on the smoking patio, in possession of a cigarette and a lighter, alone, and without supervision. S1Administrator was notified of the Immediate Jeopardy on 12/17/2024 at 3:58 p.m. This deficient practice had the likelihood to cause more than minimal harm to the 3 residents (Resident #15, Resident #31, and Resident #53) identified as unsafe smokers. Findings: Cross-Reference Findings at F-689 Review of the facility's policy titled Smoking Policy, last updated 07/04/2024 revealed, in part, residents who continue to smoke will be assessed for the safety of smoking unattended. Further review revealed the administrator is responsible for seeing that the smoking designated areas are enforced. The nursing staff are responsible for keeping and distributing smoking paraphernalia for residents, and the ward clerk was responsible to monitor the active smoker list. In an interview on 12/16/2024 at 12:29 p.m., S1Administrator confirmed Resident #31 was on the unsafe smoker list. S1Administrator further indicated he observed Resident #31 smoking on the smoking patio, without a smoker's apron on, in possession of a cigarette and a lighter, alone, and without supervision. In an interview on 12/16/2024 at 3:58 p.m., S1Administrator indicated he is ultimately responsible to ensure the facility's smokers are safe and that the facility's policy and procedures for smoking is adhered to. In an interview on 12/17/2024 at 9:03 a.m., S2Director of Nursing (DON) indicated prior to the observation of Resident #31 smoking on the facility's smoking patio unsupervised, without a smoker's apron on, and in possession of smoking paraphernalia on 12/16/2024 at 12:24 p.m., the facility's staff was not educated on the facility's smoking policy. In an interview on 12/17/2024 at 3:30 p.m., S22Regional Administrator (RA) indicated he would provide in person oversight to S1Administrator and the administrative staff weekly beginning 12/17/2024. Further, S22RA would monitor the safe smoking areas of the facility on a weekly basis. In an interview on 12/17/2024 at 4:15 p.m., S22RA indicated in his absence, daily monitoring of the safe smoking areas of the facility will be done by S1Admininstrator. Further, S22RA indicated in the absence of S1Admininistrator, the daily monitoring of the safe smoking areas of the facility will be done by S2DON. In the absence of S2DON, the daily monitoring of safe smoking areas of the facility will be done by S6ADON. In the absence of S6ADON, the daily monitoring of the safe smoking areas of the facility will be done by the charge nurse on duty for that shift. The Immediate Jeopardy was removed on 12/18/2024 at 3:36 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. A Plan of Removal was accepted on 12/18/2024 at 3:36 p.m., which included the following actions to correct the deficient practice: S22Regional Administrator will provider oversight as follows: in part; 1.) On 12/17/2024, S22Regional Administrator (RA) provided in-person oversight to S1Admininistrator and administrative staff in the monitoring of unsafe smokers and the smoking areas on a weekly basis. 2.) On 12/17/2024, S22RA reviewed the Smoking Policy to ensure compliance with safe smoking 3.) On 12/17/2024, S22RA monitored unsafe smoking to ensure residents do not have smoking material on their person, are wearing smoker's aprons and are supervised. 4.) On 12/17/2024, S22RA quizzed direct care staff about the smoking policy and their role within. 5.) On 12/17/2024, S22RA reviewed the current smoking list to ensure it was updated. 6.) On 12/17/2024, S22RA reviewed all unsafe resident assessments and care plans to ensure all assessments and care plans were updated. The likelihood of serious harm no longer existed for residents related to unsafe smoking on 12/18/2024 at 3:36 p.m.