**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure the resident safety from accident and hazards for 1 of 1 resident (R149) who smoked unsupervised while using oxygen via nasal cannula that was connected to a compressed oxygen (O2) canister. This resulted in an immediate risk of serious harm, injury, or death, from thermal burns to R149. In addition, the facility failed to follow facility policy and secure smoking materials (cigarettes and lighter) away from R149. The IJ began on 2/19/24 when R149 was admitted to the facility (a non-smoking facility) and with facility knowledge, smoked unsupervised while wearing oxygen upon her admission. On 2/26/24 at 3:32 p.m., R149 was observed to be smoking a cigarette unsupervised, while receiving oxygen from a portable oxygen tank. It was determined the facility failed to ensure the safety of R149 from this highly flammable and potentially deadly situation and had her sign a waiver to hold the facility harmless if she were to become injured because of her choice to continue smoking while she required oxygen. The administrator and director of nursing (DON) were informed of the IJ on 2/26/24 at 6:03 p.m. The IJ was removed on 2/27/24 at 12:37 p.m., when the facility took steps to remove the immediate situation, however non-compliance remained at the lower scope and severity level of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy: Findings include: Observation on 2/26/24 at 3:32 p.m., of R149 and an unknown person smoking within a couple feet of R149 in front of the HUD apartment entrance connected to the facility. R149 was smoking while wearing an oxygen nasal cannula tubing in her nose that was connected to a portable oxygen tank that was sitting on her electric scooter between her legs unsecured. The oxygen flow rate was on and flowing at 7 liters per nasal cannula. Interview on 2/26/24 at 3:33 p.m., R149 confirmed her oxygen was on and identified that she comes out to smoke several times a day. She identified she often forgets to turn her oxygen off before lighting her cigarette. The administrator was immediately notified by surveyor. Interview on 2/26/24 at 3:36 p.m., with administrator identified they are aware R149 smoked with her oxygen on and noted We had her sign an 'Assumption of Risk' because she sometimes forgets to remove her oxygen. Interview on 2/26/24 at 3:42 p.m., with the DON identified she educated R149 of the risks related to smoking with her oxygen on and they were aware that she sometimes forgot to take it off, but they do not supervise R149 while smoking. Facility staff do not ensure her oxygen is removed before she leaves the building to smoke. The DON stated the facility did not have the staff to go out with R149 to ensure she was not using oxygen while she smoked. R149's 2/26/24, admission Minimum Data Set (MDS) assessment identified a brief interview of mental status (BIMS) score of 12 out of 15 indicating her cognition was moderately impaired, she used a wheelchair for mobility, and she had diagnosis of chronic obstructive pulmonary disease (COPD), and tobacco use. R149's 2/19/24, admission orders identified R149 received continuous oxygen via nasal cannula administered at 6 liters (L) per minute via nasal cannula. R149's progress notes identified on: 1) 2/19/24, the social worker (SW) reviewed the facility's smoking policy with the resident and advised the resident if she was going to smoke while she was a resident at the facility, the nurse had to perform a smoking assessment. R149 was notified she would have to go across the street and asked about [senior living facility where she lived prior to her admission], which was located next door to the facility. The SW advised R149 she did not think she could smoke there unless visiting a friend. 2) 2/20/24, the SW noted they met with R149 about smoking in the parking lot. The SW told R149 she needed to make sure she is across the street before lighting up. R149 apologized and told the SW It wont happen again. She told the SW she was sitting in her brothers truck (an enclosed space) so she did not think it was a big deal. The SW noted she again told R149 smoking was prohobited at the facility. R149 apologized and said it wont happen again. 3) 2/20/24, a note was made that Resident is aware she is to exit from [NAME] door due to allowing herself to self-exit to smoke. R149 had requested a water based lubricant to be applied to both her nostrils. Provider [physician] to be notified that due to nasal dryness and congestion, request for saline sinus spray to reduce difficulty breahing. 4) 4) 4) 2/21/24, a nurse noted that they, along with R149's physician met with R149 and her family present to discuss R149's smoking status. R149 was noted to have verbalized understanding of appropriate, designated smoking areas. R149 was agreeable to have occupational therapy assess her to determine safety of operating scooter [electric wheelchair device used for mobility] off grounds. R149 signed Assumption of Risk for if she forgets/chooses not to remove oxygen while smoking, despite extensive education. Will place sign on scooter to remind resident. Resident also verbalized understanding of signing in/out of the facility so staff are aware of resident's whereabouts. 4) 2/23/24, staff made a late entry noting a sign placed on resident's scooter to remind her to remove oxygen prior to smoking. 6) 2/26/24, staff noted the licensed nurse (LPN) went to a registered nurse (RN) with concerns of R149's hypoximia (low oxygen levels) and non-compliance with oxygen. Both staff met with R149 and discussed the reasoning for her being on hosppice statting to turn O2 [oxygen] down to 3 L/min, not monitoring O2 sats. R149 verbalized understanding. Also educated resident on smoking cessation and encouraged resident to find alternative activities, resident laughed. The RN then reminded R149 to sign out when leaving the facility and remove O2 prior to smoking to which R149 stated well i know all that. R149's 2/20/24, Smoking Assessment identified her cognition was intact. She smoked 2-5 times each day. She could light her own cigarettes, and required no supervision or other safety measures. The assessment identified the facility did not lock up or store R149's smoking materials to secure them. The Smoking assessment identified Her care plan was to be used to assure R149 was safe while smoking. The assessment made no mention of R149's use of oxygen or that staff were aware of the fire or potential explosion hazard that may incur from smoking to R149 or others around her. Review of the 2/21/24, Assumption of Risk Agreement Policy and Procedure signed by R149 identified R149 was at risk for injury because she chose to smoke cigarettes and sometimes forgets to or chooses not to remove oxygen prior to smoking. The facility noted they had offered smoking cessation and identified the Assumption of Risk Agreement was added to R149's care plan. R149's current, undated care plan related to smoking only identified she had signed an Assumption of Risk waiver stating she chose to smoke and had not always removed her oxygen. The goal was for R149 was to remain free from complications or harm. Staff were to monitor her safety and intervene when necessary. Observation and interview on 2/27/24 at 5:00 p.m., R149 was on her scooter, she identified that staff had placed a sign in her basket to remind her to take off her oxygen before she smoked, she looked for the sign but it had been burried in her basket and was no longer visible. R149 moved several items and the sign was laying at the bottom of her basket. Review of the [NAME] R. Hall, Jr., The Smoking Material Fire Problem, NFPA [National Fire Protection Association] Fire Analysis and Research Division, July 2013 article indicated: 7% of fatal victims of smoking-material fires who were themselves the smokers whose smoking materials started the fires were under treatment with medical oxygen. The combination of smoking and use of medical oxygen is so dangerous that it became the subject of one of the seven recommended educational messages from the project. The article states In an NFPA analysis of fires and burns involving home medical oxygen, smoking materials were involved in 73% of 2003-2006 thermal burns reported to hospital emergency rooms and involving home medical oxygen. Interview on 2/28/24 at 2:34 p.m., with the medical director identified he was unaware R149 was smoking with her oxygen on, and unaware the facility had her sign an Assumption of Risk waiver. He confirmed the facility was responsible for her safety. He agreed R149 was not able to sign away her right to be safe. If the facility had knowledge that R149 forgot to remove her oxygen or chose not to remove her oxygen prior to smoking, the facility should be supervising her while she smoked. Review of the facility November 2023, Smoking policy identified the facility would determine resident smoking status upon admission. If a resident smokes, they would educate them on the facility policy of no smoking on the property and they would keep all smoking material locked in the medication room. The effectiveness of the individualized care plan would be reviewed and/or revised quarterly and as needed. The immediate jeopardy that began on 2/26/24 at 3:32 p.m. was removed on 2/27/24, at 12:37 p.m., when the facility took steps to ensure R149's safety including requiring staff to provide 1:1 supervision while smoking to ensure oxygen was removed and placed at least 15 feet away, and the oxygen was allowed to dissipate off clothing for a minimum of 5 minutes before lighting her cigarette. The facility also acquired an physician order to allow R149 to have her oxygen removed while smoking. R149's smoking materials were locked up to ensure she would have to ask staff prior to leaving the facility to smoke. A care conference was scheduled for 2/27/24 to inform family of the changes made to R149's care plan related to smoking and to present smoking cessation options. The smoking policy had been reviewed and revised to include all residents who smoke were to be supervised. Facility staff were educated on the updated smoking policy to include having a safety plan for R149 and all other residents who smoke to ensure safety to R149 and others within her vicinity from fire, injury, or explosion. All staff were educated prior to their next shift.