**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure 3 of 6 residents (R1, R2, R3) were appropriately re-assessed to safely smoke independently at the facility and failed to ensure implementation of smoking interventions. This resulted in an Immediate Jeopardy when R1 sustained fourth degree burns to the left side of face, left side of neck, left shoulder, left arm, left chest, left abdomen, and left upper leg when she was left outside to smoke with out a smoking apron on, dropped a spark from her cigarette on her left side which set fire to her clothing. The immediate jeopardy began on 6/10/23, at approximately 7:55 p.m. when R1 was found by staff outside the facility, under a covered patio, on fire resulting in hospitalization and fourth degree burns. The immediate jeopardy was identified on 6/15/23, and the administrator was notified of the immediate jeopardy on 6/15/23, at 4:10 p.m. The immediate jeopardy was removed on 6/12/23, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. The admission Record identified diagnosis that included hemiplegia (one-sided paralysis), hemiparesis (partial weakness or inability to move on one side of the body) and nicotine dependence. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she required limited assistance from staff for locomotion on and off the unit. R1's MDS indicated she had impairments of her upper and lower extremities on one side. R1's Smoking Evaluation Tool dated 2/24/23, identified the following question: Resident smokes safely (Does not allow ashes or lit material to fall while smoking, inhaling or holding smoking item. Remains alert and aware while smoking. Does not forget he/she is smoking or falls asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). The question was answered no, however the assessment indicated R1 was a safe smoker who could smoke independently and unsupervised and required a smoking apron. R1's Smoking Evaluation Tool dated 5/23/23, identified a question: Resident smokes safely (Does not allow ashes or lit material to fall while smoking, inhaling or holding smoking item. Remains alert and aware while smoking. Does not forget he/she is smoking or falls asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). The assessment indicated R1 could smoke independently or with set-up and indicated she must wear a smoking apron at all times. R1's care plan dated 10/4/22, indicated she had a tendency to be non-compliant with the facility smoking policy and procedure. The care plan directed staff to remind R1 of the potential negative outcomes related to her choice of not smoking in the dedicated area and wearing a smoking apron. The care plan further directed staff to provide reminders to wear the smoking apron. R1's care plan was revised 6/11/23, and identified a critical injury from smoking. The care plan indicated per assessment R1 was unable to smoke per facility policy. R1's Progress Notes identified the following: 2/13/23, Per nursing assistant (NA) on 2/11/23, R1 refused lunch so she could smoke. The NA went to follow up with R1 and noted R1 must have flicked an ash into her purse because it (purse) was smoking. The NA dumped out R1's purse and a few tissues were smoldering along with the purse. 2/15/23, Staff had a discussion with R1 about not being able to go outside to smoke until an assessment could be done. R1 voiced that she was safe to smoke and the previous incident had been an accident. Staff voiced concern that although it had been an accident, the outcome could have been much worse so for now R1 was unable to smoke. 2/24/23, Smoking evaluation was completed per R1's request so she could smoke again. The results were as follows: R1 could not bring a purse out to smoke. R1 would have smoking materials on the nurses cart at all times and could have one cigarette and lighter when she went out then had to return the lighter after. R1 was to dress warmly and could put phone for emergency in her right coat pocket. R1 must wear smoking apron. Will wear doorbell to alert staff when she needed assistance getting over the threshold outside and would not bring smoked cigarettes or butts back into the facility. R1 was directed to put the cigarettes out in the snow on the ledge and throw onto the snowy ground. 4/19/23, NA reported R1 was asking staff and other residents to pick up cigarette butts for her to smoke. 6/2/23, Staff discussed smoking privileges at the facility and concerns from family member that R1 could only have two cigarettes at a time when she went outside. 6/10/23, Trained medication aide (TMA) went outside to administer medications to R1. As the TMA got to the outside door he noted fire under the covered patio and when he got outside realized it was R1 who was on fire and ran toward her and attempted to pat the fire out on the left side of her neck. The TMA then began removing clothing that was on fire. The TMA used R1's soda to dump on her and the clothes to extinguish the fire. The TMA called for assistance and emergency services were called. R1 was flown to Hennepin County Medical Center. Per staff, R1 was last seen at about 6:00 p.m. coming inside the facility wearing a smoking apron. 6/12/23, R1's family member reported R1 had been switched to comfort focused care with a goal to return to facility. Staff was able to get information from the hospital nurse who reported R1 sustained 4th degree burns and required dressing changes multiple times per day. During observation on 6/16/23, at 8:07 a.m. R1 was lying in bed with her eyes closed. R1 had a blanket covering the lower half of her body. R1 had no hair, had multiple bandages covering part of her face and neck and bandages covering her entire left arm and hand. R2's admission Record indicated an admission date of 3/27/20. The admission Record identified diagnosis that included Hemiplegia, hemiparesis and tobacco use. R2's annual MDS dated [DATE], indicated he had intact cognition, required extensive assistance with transfers and supervision with locomotion. R2's MDS indicated he had impairments to both his upper and lower extremities on one side of his body. R2's Smoking Evaluation Tool dated 3/30/23, identified the following question: Resident utilizes ashtray safely and properly (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into the ashtray). The box was checked no however, the evaluation indicated R2 was a safe smoker and could smoke unsupervised. The use of a smoking apron was not indicated. R2's care plan dated 5/16/23, identified a risk for injury related to smoking. The care plan directed nursing to store smoking materials and indicated R2 required a smoking apron. The care plan was updated 6/11/23, and indicated all residents who smoke must be supervised. R2's Progress Notes identified the following: 4/7/23, Staff provided R2 with education about the facility smoking area and that he could not be smoking outside other residents windows. Staff reminded R2 that if he chose not to use the designated smoking area his privileges could be revoked. 5/5/23, R2 was seen outside tipped over in his wheel chair. R2 said his wheel went off the sidewalk onto the grass and caused his chair to tip over backwards. 5/15/23, NA reported R2 had gone out to smoke without a smoking apron which resulted in burn holes in the the mechanical lift sling and R2's pants. Staff had an in-depth conversation with R2 who stated, I am too lazy to put it on, but I will wear it if someone helps me put it on. Decision made to have R2's smoking materials placed in the medication cart so he would have to have a smoking apron put on. R3's admission Record indicated she admitted to the facility on [DATE], with diagnosis that included muscle weakness. R3's significant change MDS dated [DATE], identified intact cognition. The MDS indicated R3 required supervision with locomotion on and off the unit and indicated she had lower extremity impairment on one side. R3's Smoking Evaluation Tool dated 5/15/23, indicated she could safely smoke independently but must request smoking materials from staff. R3's care plan dated 3/16/22, identified a risk for injuries related to smoking. The care plan directed staff to assess for safe smoking practices on admission, quarterly and as needed. R3's care plan was revised 6/12/23, to include all residents required to be supervised and have dedicated smoking times. R3's Progress Notes identified the following: 3/8/23, Staff found cigarette ashes in R3's bed, cigarettes on the floor in her room and it appeared R3 had put a cigarette out on the plastic part of her cigarette pack. R3 stated she did not remember lighting a cigarette in bed after being shown the ashes on her sheets. Staff reviewed the smoking policy with R3 and completed a smoking assessment. R3 continued to be a safe smoker but her cigarettes would be stored in the medication cart. 5/16/23, R3 fell out of her wheelchair outside while smoking . R3 stated she had been reaching down to get her cigarettes that she dropped. A NA found R3 face first on the ground. During interview on 6/15/23, at 1:45 p.m. the director of nursing (DON) stated smoking assessments were completed on admission, quarterly and if a policy change occurred. The DON said staff watched the resident while smoking to see how they did. The DON stated after R1 had the incident when she dropped the spark in her purse, she felt the interventions put in place at that time made R1 safe to continue smoking independently. The DON stated after R2 burned holes in his clothing he was assessed to need a smoking apron and felt that would make R2 safe to smoke independently also. When asked who monitored the residents to ensure the interventions were implemented the DON said she felt like the staff and the residents themselves were responsible. In regard to R3 falling out of her wheel chair while outside smoking and finding ashes in her bed along with burned plastic on her cigarette pack, The DON said staff removed R3's smoking materials and placed them in the medication cart. The DON was unable to articulate why supervision of smoking was not implemented following R1, R2 and R3's demonstrations of unsafe smoking. On 6/15/23, at 2:09 p.m. NA-A stated she remembered bringing R1 outside to smoke about 2:30 p.m. on 6/10/23, and she put a smoking apron on her. NA-A said she saw R1 at about 4:30 p.m. before dinner but did not recall seeing her after that time. NA-A said R1 could get herself out the door and said at that time there had been no restrictions on her smoking but said R1 needed to wear a smoking apron because she was one of the two residents that would burn themselves. On 6/15/23, at 2:14 p.m. NA-B stated she did not know how R1 had gotten outside and said R1 usually sat outside most of the day. NA-B said when she saw R1 just before 6:00 p.m. she had a smoking apron on and said when R1 went back outside she was not wearing one. NA-B said R1 had trouble getting over the threshold to get outside. NA-B said the only person staff worried about when smoking was R2 because he had burned a couple holes in the mechanical lift sling. NA-B said R1 and R2 were the only residents that needed a smoking apron. NA-B stated the incident with R1's purse was the reason she got the smoking apron. During interview on 6/15/23, at 2:22 p.m. TMA-A stated on the evening of 6/10/23, he went outside to bring R1 her medications. TMA-A stated when he got outside he saw a fire and initially thought it was the picnic table. He said when he got closer he realized R1 was on fire. TMA-A stated he tried to put the fire out and ended up ripping off R1's clothing, dumped her pop on her and radioed for help. TMA-A said he thought R1 had been outside for about an hour and had not been wearing a smoking apron when the fire started. TMA-A said R1 had been wearing a shirt, sweatshirt and a blue nylon scarf. Facility policy [NAME] Care Center Complex Resident Smoking Policy dated 5/5/21, indicated all residents who want to smoke or use tobacco products at the facility will be assessed by a nurse for safety and appropriateness upon admission to the facility, quarterly and as needed. Each resident will be assessed for physical, cognitive, mood and behavior factors that may affect a resident's ability to independently and safely smoke while at the facility. The policy identified the designated smoking area and indicated from 6:00 a.m. to 10:00 p.m. was open smoking. The past noncompliance immediate jeopardy began on 6/10/23. The immediate jeopardy was removed, and the deficient practice corrected on 6/12/23, after the facility implemented a systemic plan that included the following actions: - All residents in the facility who smoked were re-assessed for safety. - The facility implemented designated smoking times with staff supervision for all residents and implemented smoking audits. - The door leading out to the smoking area was equipped with a fire extinguisher, a fire blanket and additional smoking aprons. - The facility's smoking policy was updated to include: All residents will be supervised while smoking and taken outside at the designated times. - Staff education was implemented and ongoing and was verified through observation, interview and document review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the residents' current wishes which affected 1 of 17 residents (R20) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R20 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R20's electronic health record (EHR) main screen and orders identified R20 was to have CPR however, R20's updated POLST signed on [DATE], identified R20's wishes of do not resuscitate (DNR). The administrator, assistant administrator and director of nursing (DON) were notified of the IJ on [DATE], at 5:39 p.m. The IJ was removed on [DATE], at 1:55 p.m. when the facility had implemented corrective action, however non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R20's annual Minimum Data Set (MDS) dated [DATE], identified R20 had mild cognitive impairment and diagnoses which included: hypertension, emphysema (lung condition that causes shortness of breath) and Alzheimer's disease. R20's care plan revised [DATE], identified R20's advanced directives to be followed per medical provider (MD) orders. The care plan indicated the POLST would be reviewed as needed and placed in the front of R20's paper chart. R20's POLST signed by the medical provider on [DATE], identified DNR, scanned into R20's EHR. R20's POLST signed by the medical provider on [DATE], identified CPR, which was located in R20's paper medical record and in addition was scanned into R20's EHR. The paper chart lacked the most current updated POLST from [DATE]. Review of R20's EHR orders on [DATE], at 5:16 p.m. identified the order for CPR which had a revision date of [DATE]. The EHR lacked an order for DNR. Review of R20's progress notes from [DATE], to [DATE], identified the following: -[DATE], at 12:50 p.m. discussion with R20's guardian regarding R20's POLST and goals of care, provider felt R20 was more appropriate for DNR status as R20 did not desire any further medical interventions for care and did not wish to leave the facility. R20's guardian agreed and R20's POLST was changed to DNR. During an interview on [DATE], at 12:07 p.m. registered nurse (RN)-B indicated in the event a resident did not have a pulse or respirations, RN-B would refer to the resident's paper chart for code status. RN-B reviewed R20's paper chart and confirmed R20's POLST identified CPR was to be administered. RN-B stated the facility had instructed staff to follow the POLST in the paper chart. During an interview on [DATE], at 12:19 p.m. RN-A stated in the event of a resident experiencing cardiac arrest, staff were instructed to refer to POLST in the resident's paper chart. RN-A confirmed R20's POLST identified CPR and RN-A stated she would call 911 and begin CPR on R20 in the event of cardiac arrest. During an interview on [DATE], at 1:38 p.m. RN-C stated in the event a resident was not breathing or unresponsive, she would review the POLST in the resident's paper chart to determine code status. RN-C indicated the facility had provided education to staff to review the residents' paper charts to determine their code status. During an interview on [DATE], at 1:43 p.m. DON stated residents' POLST were completed with residents and/or their representative and their provider when they were admitted to the facility. DON stated the facility process involved completing the POLST with the resident or representative upon admission, make a copy of the POLST and placing in the resident's paper chart until it was reviewed and signed by the provider. Once the POLST was signed by the provider, staff were expected to place a gold copy of the form in the front of the resident's paper chart and scan it into the resident's EHR. DON identified if a resident was CPR, those wishes would also be identified in the resident's orders and would show up on their EHR. Further, if the resident's POLST identified DNR, the order would read see POLST. DON stated the facility recently completed education to the nursing staff on advanced directives which directed the staff to always look in the front of the paper chart in the event of cardiac arrest to assure the resident's wishes were followed. During a follow-up interview at 2:01 p.m. DON reviewed R20's POLST in R20's paper chart, confirmed the POLST identified CPR and verified it was inaccurate. DON reviewed R20's EHR and confirmed R20's main screen and orders identified CPR and again verified it was inaccurate. DON reviewed R20's current POLST signed [DATE], located in R20's EHR scanned forms which identified DNR and verified it reflected R20's current wishes. During a follow up interview at 2:26 p.m. DON stated POLST orders were completed by nurse manager (NM)-A, MDS coordinator (MDSC)-A, RN-B, or herself. DON indicated she had completed R20's POLST signed on [DATE], with the guardian and had placed it in the provider's file for review and signature. DON verified she was not certain where the paper copy of the POLST was currently located. At 4:00 p.m. DON confirmed R20's current POLST signed [DATE], had been found in the providers folder at the nurses station. DON confirmed R20's POLST orders and paper chart had not been updated after R20's provider had reviewed and signed R20's updated POLST. The facility policy titled Advanced Directives and Rights Regarding Treatment revised 10/22, identified the resident had the right to refuse treatment and to formulate an advanced directive. Identified if a resident had an advance directive or completed an advanced directive upon admission copies would be obtained and the documents would be consistently maintained in the same section of the resident's medical record and readily retrievable by any facility staff. Indicated the community would periodically review the existing care instructions and whether the resident wishes would change or continue with these instructions. Identified the resident's choices would be documented and communicated to the interdisciplinary team. The IJ was removed on [DATE], at 1:55 p.m. when the facility developed and implemented a systemic removal plan which was verified by interview and document review: -All residents' records were reviewed to ensure the POLST form and electronic medical record were updated to ensure resident's wishes for advance directive and care plan interventions were accurate on [DATE]. -The Advanced Directive policy was reviewed on [DATE]. -Nine RNs and two licensed practical nurses (LPNs) were educated on the policy for advanced directives, obtaining and documenting the POLST to reflect the resident's wishes, on [DATE], to [DATE], as evidenced by the Education Sign in Sheet. -A process was implemented to assure all other nurses completed mandatory education prior the start of their next shift on [DATE], by notification of required mandatory education via phone/text. -During interviews on [DATE], RN-D, NM-A, RN-A, RN-C, and DON, verified they received education regarding policies for advance directives, obtaining and documenting the POLST to reflect the resident's wishes.