**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). On 05-22-19 record review for resident #21 revealed smoking evaluations that were done on 12-09-18 and on 03-22-19. The evaluations determined that the resident was an independent smoker and required no supervision to smoke. It also revealed that resident #21 understood smoking materials were for use only in the designated smoking area and smoking materials were to be kept locked at the nurses' station or other secure location On 05-24-19 further review of the clinical record revealed a secure smoking materials acknowledgement form signed by Resident #21 on 05-01-19 that stated, facility will store all smoking materials in a secure location for residents who smoke. In addition, social worker documented on 05-02-19 that Resident #21 was known to go out and buy cigarettes for residents so he/she was educated on smoking policies. The social worker educated resident #21 that he/she must give smoking materials that he/she purchased on behalf of other residents to the receptionist so that they could be kept secured for the safety of all residents. Resident #21 agreed to sign the acknowledgement form and was informed of consequences (not specified) should he/she violate the safe smoking policy. On 05-24-19 review of a physician progress note dated 04-24-19 revealed resident #21 was giving cigarettes to other residents. The note also revealed the attending physician's awareness that the resident was going out and buying cigarettes for other residents as well. However, although Resident #21 continued to violate the safe smoking policy, there was no evidence that any further actions were taken to address the risk the resident's actions posed to the safety of others. On 05-21-19 at 11:56 AM, surveyor interview with resident #21 revealed that he/she smoked outside the facility (not in the designated smoking area) and kept cigarettes and lighter on his/her person. The resident then showed surveyor a pack of cigarettes and a lighter in his/her pocket at the time of the interview. Review of the plan of care for resident #21 revealed No smoking materials will be kept by the resident if deemed unsafe. On 05-22-19 at 10:00 AM, interview with staff #4 (who accompanies residents out to smoke and monitors the secured smoking container) confirmed that resident #21 bought and kept smoking materials on his/her person as stated during the resident interview. Staff #4 also confirmed that resident #21 bought cigarettes for other residents as well. On 05-23-19 at 11:07 AM surveyor interview with the administrator revealed that resident #21 was noncompliant with facility smoking policy. He/she kept smoking materials on person as well. The administrator stated she/he talked to the resident multiple times about the smoking policy including safety hazards for other residents, but the resident was noncompliant. On 05-24-19 at 3:51 PM, DON interview revealed Resident #21 was a safe and independent smoker but he/she was not allowed to keep smoking materials. On 05-28-19 at 11:52 AM, Resident #21 again showed the surveyor that he/she had a pack of cigarettes and a lighter in his/her pocket. In addition, on 05-22-19 at 10:00 AM, interview with Staff #4 confirmed that Resident #21 bought and kept smoking materials on his/her person as stated during the resident interview. Staff #4 also confirmed that Resident #21 bought cigarettes for other residents as well. Interview with Staff #2 on 05-28-19 at 1:20 PM revealed that neither safe or unsafe smokers were allowed to keep smoking materials on their person but were required to keep them secured with facility staff in one central location. According to Staff #2, Resident #21 was noncompliant with facility smoking policy. Although Resident #21 continued to violate the safe smoking policy, there was no evidence that any further actions were taken to address the risk the resident's actions posed to the safety of others. On 05-29-19 Resident #21 signed a behavior contract that stated, holding on to smoking materials is a violation of facility's guidelines for resident behavior and failure to comply with the guidelines may result in administration actions. 4.) On 05-24-19 surveyor review of the social worker's notes revealed that, on 10-30-18, resident #57 was assessed by the social worker as a dependent smoker due to body stance and inability to wheel himself/herself around. Further review of the social worker's notes revealed that, on 10-30-18, Resident #57 signed a Secure Smoking Materials Acknowledgement acknowledging that the facility staff were to store all smoking materials in a secure location, catalog them, and upon request, during scheduled smoking times, make these materials available to residents who signed the agreement. On 11-06-18, Resident #57 was re-assessed by the social worker for smoking and was determined to be a dependent smoker, (requiring supervision) with a need to wear a smoking apron. On 11-10-18, a nurse's note revealed that Resident #57's room had the smell of cigarette smoke coming from the room. The nurse and the supervisor recovered a pack of cigarettes from the resident's room at that time. On 03-20-19, a nurse's note revealed that Resident #57 was observed with an unlit cigarette in his/her mouth. The resident removed the cigarette from his/her mouth but refused to give it to the nursing staff. The note also revealed that the geriatric nursing assistant (GNA) who observed the resident with the cigarette in between his/her lips notified the nurse, who then notified the shift supervisor. The shift supervisor asked the resident for the cigarette and the resident refused to comply. The shift supervisor informed Resident #57 local law enforcement would be contacted if the resident lit the cigarette. The resident did not light the cigarette; however he/she was permitted by facility staff to return the unlit cigarette to his/her bag. There was no further documentation or evidence of follow up related to the cigarette known to be in the possession of this resident with unsafe smoking practices. On 04-13-19, a nurse's note for Resident #57 revealed that the unit hallway was filled with the smell of burning grass, but no cigarette was found on the resident. The resident was again educated not to smoke in their room. On 04-14-19, a nurse's note for Resident #57 revealed that, patient's room smelled like cigarettes. Writer did not see resident smoking. Writer and oncoming nurse asked resident to give up the cigarettes. Resident gave up the cigarettes and was reminded smoking was not allowed in resident rooms. On 04-15-19 a nurse's note for Resident #57 revealed resident room smelled of cigarette smoke. Writer did not see resident smoking. Writer tried to educate resident of the danger of smoking in the room. On 04-16-19, a nurse's note for Resident #57 at 07:54 AM revealed, resident room smells like weed/cigarette smoke. No cigarette noted in hand. Writer educated resident regarding the facility smoking rules and dangers of smoking in their room. On 04-16-19,a nurses note at 09:06 AM revealed, Resident #57 was noted smoking in his/her room approximately 07:30 AM. DON was made aware and tried to explain about not smoking in the room On 04-19-19, a nurse's note for Resident #57 revealed, writer smelled smoke in front of resident's room. Writer re-educated resident that it is not safe to smoke in their room as resident was found smoking in their room in the morning. On 04-19-19, resident was seen by the psychologist for aggressive behavior related to cigarette use in room on 04-16-19. Resident denied smoking in his/her room. Resident was explained that his/her actions were unacceptable and could have resulted in being discharged from the facility, as will acts of aggression. On 04-22-19, an attending physician's order was written to, check resident for smoking materials every shift. However, 04-22-19, a nurse's note for Resident #57 revealed, resident was noted smoking in their room at approximately 10:30 PM with half of the cigarette and ashes on the floor. Teaching was done and explained no smoking in room again about the smoking policy. Although Resident #57 continued to violate the safe smoking policy, there is no evidence that any further actions were taken to address the risk that the resident's actions posed to the safety of others. Despite a month of incidents involving unsafe smoking by Resident #57, the clinical record review revealed that the facility demonstrated no aggressive measures to ensure the safety of other residents jeopardized by this resident's continued non-compliance with safe smoking practice. There was only documented evidence of verbal counseling of the resident, and an order for a psychologist consult on 04-19-19. On 04-25-19, a social worker's note revealed that facility would revoke smoking privileges if the resident was caught smoking in their room. On 05-01-19, a second Secure Smoking Materials Acknowledgement form was signed by the resident. On 05-02-19, the social worker documented a re-education of Resident #57 related to the facility smoking policy. However, on 05-05-19, a nurse's note for Resident #57 revealed that a cigarette was also found in resident's bed; teaching was done. On 05-06-19, an administrative note revealed that the administrator spoke with Resident #57 regarding the smoking policy. The administrator explained to the resident that smoking was allowed only in the designated smoking area and that no cigarettes or lighting materials will be kept by residents, but rather in the reception area, in a lock box. The administrator stated that the resident verbalized understanding. Although facility staff spoke to, and reeducated Resident #57 multiple times about the smoking policy, the resident continued to violate the safe smoking policy and there was no evidence that any further actions were taken to address the risk that the resident's actions posed to the safety of others. On 05-29-19 at 10:40 AM, surveyor interview with the administrator revealed that Resident #57 was in possession of two cigarettes which were allegedly obtained from a visitor and the resident voluntarily gave them to the Administrator to be saved for some other time. On 05-29-19 at 11:15 AM, during surveyor interview with Resident #57, the resident admitted having cigarettes in his/her possession earlier that morning, however, the resident informed the surveyor that the cigarettes were obtained from another resident who smokes, not a visitor. On 05-29-19 at 11:30 AM, surveyor observed resident smoking tobacco in the designated smoking area during the designated smoking time. On 05-29-19 at 1:00 PM, surveyor interview with the DON revealed that the resident had been unsuccessfully educated and re-directed several times. The DON stated the facility staff's issuing Resident #57 with a 30-day notice of discharge because of danger to self and others would be of no use as there is no safe discharge available for the resident to another facility or the community. However, there was no evidence in the clinical or administrative records to demonstrate the facility staff had made an effort to find placement for the resident elsewhere. On 05-29-19 at 1:15 PM, surveyor review of the form Notice of Violation of Guidelines or Resident Behavior revealed that the resident was issued this violation for holding on to his/her smoking materials and that the facility was taking the following administrative action: smoking privilege revoked. This form was signed by the administrator, the social worker, and the resident. On 05-29-19 at 1:30 PM, surveyor interview with the Administrator provided no additional information. Based on surveyor observation(s), review of clinical records, facility policies and procedures, and resident and staff interview(s), it was determined that facility staff failed at the time of admission to accurately assess a cognitively impaired resident's risk for elopement, and failed to assess the cognitively impaired resident's safe smoking risk (Resident #102). The facility staff also failed to prevent repeated episodes of unsafe resident smoking within the facility when identified, and failed to maintain smoking materials in a secured environment. These failures resulted in 6 of 6 residents being at risk for accidents/hazards. (#102, #100, #21, #57, #86, and #113). These failures resulted in an immediate jeopardy (IJ) being identified on 05-24-19 at 9:40 AM related to a resident's risk for elopement (Resident #102). On 05-24-19 at 5:36 PM, the facility staff submitted an IJ removal plan related to the elopement to the Office of Health Care Quality (OHCQ) which was accepted. On 05-29-19 at 1:00 PM a second IJ was determined related to the omission of a smoking risk assessment, and unsafe resident smoking practices (Residents #102, #57, #21, #100, #86, and #113). On 05-29-19 at 11:51 PM, the facility staff submitted an IJ removal plan for safe smoking evaluations and safe resident smoking practices to the OHCQ which was accepted. Both immediate jeopardies were removed on 5/31/19 at 12:15 PM after confirmation that the accepted plans had been fully executed. After removal of the immediacy, the deficient practice remained at a scope and severity of E. The findings include: 1. During investigation of facility reported incident #MD00139450, on 05-24-19, review of the clinical record for Resident #102 revealed that the resident was admitted on [DATE] with a diagnosis of cognitive impairment. An elopement assessment was completed at the time of admission to determine the resident's risk for wandering away from the facility. However, review of the elopement assessment tool revealed that the admitting nurse (Nurse #6) failed to accurately assess the resident's cognitive status which resulted in a lower risk score which indicated the resident was not at risk for elopement. In addition, Nurse #6 documented, on 04-18-19 at 7:59 PM, that Resident #102 was not oriented to time, not oriented to place, had short and long-term memory problems, and was unable to recall after 5 minutes. Nurse #6 did not incorporate the pertinent observations made while completing the nursing admission assessment into the elopement evaluation. As a result, the resident was not identified as being at risk for elopement, and Resident #102 eloped from the facility the following morning (04-19-19.) This cognitively impaired resident was located by facility staff in the company of a police officer blocks away from the facility. Review of the facility investigation revealed a written statement by a geriatric nursing assistant (GNA) #11. In the statement, GNA #11 wrote that, on 04-19-19 between 7:45 AM and 8:15AM, Resident #102 informed the staff member twice that he/she was going out to smoke. Surveyor also reviewed a written statement by Nurse #7 which stated on 04-19-19 at 9:20 AM, he/she had a conversation with Resident #102 in the resident's room. The resident also expressed intent to go out to smoke to Nurse #7. A written statement, dated 04-19-19, by the facility's admission concierge stated that family members were leaving the building from visiting. Resident #102 walked out when visitors were exiting the building. A nurse's note, dated 04-19-19 at 3:51 PM, written by Nurse #7 read, patient is status post new admission day one. Patient received in bed in stable condition. Had breakfast served, after which he/she verbalized that he/she wanted to go out and smoke in the smoking area. The nurse's note went on to state that, at approximately 10:00 AM, Nurse #7 went to administer medication to Resident #102 and was unable to locate the resident on the nursing unit. Facility staff then began a search on and off facility property to locate the resident. Resident #102 had wandered away from the facility after expressing an intent to go out to smoke to both GNA #11, and Nurse #7. On 05-22-19 at 1:33 PM, interview with Nurse #6 revealed he/she had completed an elopement risk assessment, based solely on a conversation held with the resident. Nurse #6 did not utilize the information provided to the facility in the hospital discharge summary which diagnosed the resident with cognitive impairment. That diagnosis of cognitive impairment would have increased the elopement risk score resulting in Resident #102 being identified as being at risk for elopement. Although there was evidence in the clinical record that the facility staff used pertinent information that had been provided in the hospital discharge summary to complete admission documentation for Resident #102, Nurse #6, upon interview, did not explain why some of the discharge summary information was used during the admission process (i.e. list of medication) for Resident #102 and some of the discharge summary information was omitted (i.e. diagnosis of cognitive impairment). On 05-23-19 at 5:45 PM, interview with the 3-11 shift supervisor (Nurse #10) revealed that he/she reviewed the information in the admission packet both prior to, and at the time of Resident #102's admission to obtain admitting orders from the attending physician. Nurse #10 also informed the surveyor that the admission packet was uploaded into the computer prior to resident #102's arrival by the facility admissions department staff to allow the physician and facility staff to review pertinent medical information about the resident before the resident arrived at the facility. Nurse #10 stated that the discharge summary was received electronically immediately prior to the resident's arrival, and a paper copy of the discharge summary arrived with the resident. Nurse #10 stated that the discharge summary was used by the attending physician to provide admission orders to the facility staff to ensure continuity of care. Staff #10 also informed the surveyor that Nurse #6 was responsible for the head to toe assessment on Resident #102, and that he/she (staff #10) was present during the assessment to determine the need to obtain further orders from the attending physician. However, there was no discussion between the two nurses about the diagnosis of cognitive impairment on the discharge summary which would have given Resident #102 a score of 10 on the elopement risk evaluation tool. A score of 10 on the elopement risk evaluation would have identified the resident as being at risk for elopement. Staff #10 stated that residents identified as being at risk for elopement would have interventions implemented to keep them safe to include a wanderguard bracelet which would alert staff of the residents attempt to exit the building. Because Resident #102 was not identified as being at risk for elopement, those interventions were not implemented, and the resident wandered out of the building without staff awareness. On 05-28-19 at 9:00 AM, surveyor interviewed the admissions concierge who wrote the statement dated 04-19-19 to determine who the family members were that Resident #102 exited the building with. The admissions concierge at that time informed the surveyor that he/she did not witness Resident #102 leaving the facility with family members as the written statement indicated, and in actuality did not witness Resident #102 exiting the building on the morning of 04-19-19 at all. In the presence of a second surveyor, the admissions concierge was again asked if he/she had witnessed Resident #102 leaving the building as the written statement indicated. The admission concierge hesitated in responding, so surveyor repeated the question, did you see Resident #102 leaving the building. The admission concierge then responded, No, I did not see him/her leave the building. Surveyor then asked the admission concierge, why did you provide this statement? (allowing the admissions concierge to see the written statement titled employee/witness interview listing the admissions concierge as the person providing the statement). The admissions concierge responded, The director of nursing told me to write it. On 05-28-19 at 10:00 AM, the director of nursing and the corporate consultant were informed of the admission concierge's allegation that he/she was instructed to write the statement which indicated that Resident #102 was witnessed exiting the building with family members. The director of nursing neither confirmed nor denied the admission concierge's allegation that he/she was directed by the DON to write the statement and provided no additional information. On 05-24-19 at 9:40 AM, an immediate jeopardy (IJ) was determined for resident's safety related to the facility staff's failure to accurately assess Resident #102's elopement risk, resulting in the resident's elopement from the facility. On 05-24-19 at 3:22 PM, the facility staff submitted the IJ removal plan which included the following measures taken: -on 04-19-19 resident #102's elopement risk assessment was revised to reflect cognitive impairment and implemented interventions (wanderguard bracelet, photo of the resident at the front reception area, and psychological physician evaluation) to prevent further elopement; -Nurse #6 was in-serviced 04-22-19 on elopement assessment accuracy and the importance of reviewing hospital medical records; -The elopement assessment tool was revised to include the words cognitive impairment next to Alzheimer's/Dementia on the tool; -100% of active licensed nurses were in-serviced between 04-19-19 and 04-24-19 on the accurate method of elopement assessment utilizing the tool and reviewing the hospital medical records; -On 04-22-19, the administrator audited all active residents to verify the accuracy of the existing elopement assessments. Any discrepancies were corrected immediately by the assistant director of nursing. -The removal plan also stated to ensure compliance, the supervisor/manager on duty, audits all new admissions and readmissions from 04-19-19 forward to ensure accurate elopement assessments were done by the charge nurse and reflective of the hospital medical records. Audits consist of checking the elopement risk assessment, checking the hospital records and assessing the resident. This audit was completed on 04-24-19. -Finally, the removal plan addressed Quality Assurance Performance Improvement by stating that the director of nursing or the assistant director of nursing will audit all new admissions for the accuracy of elopement risk assessment on a weekly basis. The results of the audits will be submitted to the QAPI committee monthly. The QAPI committee will determine if any additional interventions are needed at the end of the three-month period. On 05-31-19 at 12:15 PM, the administrator and director of nursing were notified that the surveyors had verified that the removal plan had been fully implemented, and the immediacy was removed. Additionally, during review of facility reported incident #MD00139450, and further review of the clinical record for Resident #102 on 05-29-19, revealed that the facility staff did not complete a smoking assessment on the newly admitted Resident #102 prior to the resident leaving to smoke unsupervised. Surveyor review of the clinical notes, written on 04-19-19, revealed that Resident #102 informed the charge nurse (Nurse #7) that he/she was going out to smoke after breakfast. At the time of the resident's expressed intent to go smoke, no safe smoking evaluation had been completed to determine if the resident was safe to smoke independently or required staff to be in attendance to ensure safety. Resident #102, with a diagnosis of cognitive impairment, left the nursing unit to smoke (as he/she had informed Nurse #7 and geriatric nursing assistant (GNA) #11 he/she was going to do) unattended. The resident eloped during that smoke break. A smoking evaluation was completed on 04-19-19, after the resident's return, which determined Resident #102 was a dependent smoker (requiring supervision to smoke). A policy, titled Safe Smoking Policy for Cadia Maryland Facilities Where Smoking is Permitted with a revision date of 01-22-19 included the following statements: The facility shall designate a specific area or areas where residents may smoke. Smoking shall not be permitted on facility property outside of designated smoking areas. The facility shall make reasonable efforts to secure resident smoking materials such as: cigarettes, cigars, lighters, lighter fluids, pipes etc. it shall be the facility's responsibility to secure these materials when they are not in use and make them accessible to residents who wish to smoke during appropriate/designated times. Residents who smoke and/or their responsible parties shall be presented with a form advising them of the facility's policy with respect to securing smoking materials. Signed copies of these forms shall be maintained in the residents ' medical record. Review of the facility's safe smoking policy on 05-24-19 revealed no reference to when safe smoking evaluations would be completed, or who would be responsible for completing safe smoking evaluations in a timely manner. (prior to allowing residents to smoke independently) As a result, on 05-24-19 at 1:20 PM, interview with Nurse #7 revealed that he/she did not know who completed safe smoking evaluations upon admission and was not sure where resident #102's safe smoking evaluation could be located in the clinical record. On 05-24-19 at 1:40 PM, interview with the social worker revealed that he/she was solely responsible for doing safe smoking evaluations in the facility. The social worker also stated that, if residents were admitted when the social worker was not in the building, the safe smoking evaluation(s) would not be completed until his/her return. On 05-24-19 at 2:30 PM, interview with the director of nursing provided no additional information. 2) On 05-23-19, review of the clinical record for resident #100 revealed a physician's progress note, dated 04-29-19. The attending physician documented the patient was found smoking in the room. The clinical record also revealed psychologist progress notes, dated 05-01-19, which documented, addressed resident regarding reported smoking in the building On 05-24-19 at 11:00 AM, interview with the attending physician revealed that he/she did not observe resident #100 smoking in the room, but facility staff had reported the resident's smoking in the room on two separate occasions, which prompted the entry in the physician's progress note. A safe smoking evaluation for resident #100 conducted on 04-17-19 determined that the resident was a dependent smoker who requires supervision to smoke. A physician's order for resident #100, dated 04-22-19, instructed facility staff to check resident room for any smoking materials every shift, confiscate and notify MD, however, the attending physician's progress note, dated 04-29-19, stated that the resident was found smoking in the room. A psychologist progress note, dated 05-01-19, documented that he/she addressed smoking in the building with resident #100, with the resident being defensive during the discussion, at first denying his actions though he had been observed by staff. Both physician notes documented that unsafe resident smoking occurred after the initial order instructing facility staff to check the resident's room for any smoking materials on 04-22-19. On 05-29-19 at 4:00 PM, interview with the facility social worker who completes all resident safe smoking evaluations in the facility revealed no additional information as to how resident #100 obtained the smoking materials when found smoking, despite staff checking the room each shift for the presence of smoking materials. 5) On 05-22-19 at 11:00 AM, surveyor interview with resident #86 revealed that he/she kept his own cigarettes and lighter since admission on [DATE]. Resident #86 then proceeded to pull out a pack of cigarettes and a lighter from his/her pocket and showed it to the surveyor. Further review of the clinical record revealed that, on 12-18-18 and 5-02-19, Resident #86 signed a Secure Smoking Materials Acknowledgement that stated that the facility staff were to store all smoking materials in a secure location and give them to the resident during scheduled smoking times. Despite the signed agreement, there was no evidence that facility staff were monitoring for resident #86's compliance with the secure smoking materials acknowledgement forms that he/she previously signed. On 05-28-19 at 11:10 AM, surveyor interview with the administrator revealed that resident was a safe smoker and the facility keeps all his/her cigarettes and lighter. The administrator was unable to explain how resident #86 was in possession of the pack of cigarettes in his/her pocket on 05-22-19. The administrator reported that resident #86 subsequently turned in his/her cigarettes and lighter to facility staff on 05-22-19 after surveyor observation/intervention. The administrator stated that Resident #86 had never been observed smoking in his room or in an undesignated smoking area. f. On 05-22-19 at 11:00 AM surveyor observation in facility's therapy department revealed resident #113 was observed in therapy with a pack of cigarettes and a lighter on his/her person. Interview with the resident at that time revealed that the resident smoked in the facility's designated smoking area but keeps all smoking materials. Review of the clinical record for Resident #113 revealed that the resident was alert and oriented and able to verbalize his/her own needs. On 05-01-19 at 5:40 PM, documentation by the SW (Social Worker) #2 revealed a smoking assessment was completed that the resident could make their own decisions and was able to demonstrate safe smoking techniques through a smoking observation. The facility's determination, that was based on the 05-01-19 assessment, revealed that the resident was an independent smoker, who required no supervision to smoke. On 05-28-19 at 11:00 AM, interview with SW #2 revealed that residents' smoking assessments are completed by SW #2 usually within 48-72 hours at the time of the resident's admission/readmission. When the smoking assessment is completed, a determination of whether the resident is a dependent or independent smoker is indicated. When asked, SW #2 revealed that no other staff members conducted the smoking assessment at the time of resident's admission to the facility. On 05-28-19, further record review revealed that, on 05-01-19, Resident #113 signed a smoking contract (as indicated in the facility's smoking policy) that all smoking materials (lighters, matches, cigarettes, etc.) for residents who smoke, will be secured by the facility. This included that smoking materials are to remain in a secured location and catalog by the facility. On 05-29-19, review of the facility's 05-28-19 Smoking Material Check Log revealed that staff found Resident #113's smoking materials on his/her person. Further review of the 05-28-19 Check Log revealed that staff updated the resident's smoking plan of care to address the resident's non-compliance with the facility smoking policy to reflect having smoking materials in the room unsecured. The facility staff also obtained a physician's order for a psychiatric consult from the attending physician, implemented a behavior contract for the resident and re-educated Resident #113 on the facility's smoking policy. On 05-29-19 at 12:30 PM, surveyor interview with the facility's administrator and the Director of Nursing (DON) revealed that on , 05-28-19, the resident's smoking materials were removed immediately by the facility[TRUNCATED]