**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/26/2025 at 3:50 PM, there were greater than 30 cigarette butts observed scattered across the ground of the outdoor patio by the 100-dining room. There were two trash cans, one of which was without a plastic bag and was observed to have water at the bottom mixed with a dark matter. The contents of the trash can smelled strongly of cigarette ashes. No fire safety items were found in the area, including fire extinguishers and smoking protection gear such as aprons and gloves. On 02/26/2025 at 4:07 PM, a Receptionist reported residents that smoked went out the front entrance towards front of the building and also to the left of the entrance to smoke. Residents did not have to sign out on the facility log at the reception desk. The Receptionist explained there were no specific times designated for smoking; residents smoked anytime throughout the day. The Receptionist reported residents did not wear any protection such as smoking aprons and gloves, some wore regular street clothes. The receptionist indicated residents that needed assistance were accompanied by staff, however, could not confirm if staff remained with the residents to supervise them while smoking and residents that were physically able to go out on their own were not accompanied by staff. On 02/26/2025 at 4:10 PM, in the patio outside the 300-hall dining room, there were approximately more than 10 cigarette butts observed scattered on the floor of the patio. There was one large plastic trash can in the area, 3/4 full of dark ashes and a sand or dirt like material mixed with the ashes. On the side of the trash can there was a hole approximately the width of a finger that appeared to be burned out of the plastic which was melted, the melted and burned plastic had a strong scent of burned ashes. No fire safety items were found in the area including a fire extinguisher and no protection gear such as aprons and gloves. On 02/26/2025 at 4:16 PM, a Housekeeper reported Housekeeping routinely emptied ashtrays in the smoking area of the patio outside of the 300 hall. The Housekeeper reported the morning Housekeeping team emptied ash trays when they arrived at work, and would be emptied by the night Housekeeping team as well when they came to work. The Housekeeper explained some residents smoke in the patio outside the 300-hall dining area, however, the resident smoking area was actually by the patio outside the 100-hall dining room. The facility provided the Smoking Policy (undated) which documented the facility had been designated a smoke-free facility. Smoking by residents was not permitted anywhere on facility's property. All staff would be responsible for courteously informing any resident of violation of the facility's smoke-free policy. No lighting materials (matches, lighters), tobacco products, or smoking devices would be allowed to remain in the possession of the resident, either on their person or in the facility. The facility might check periodically to determine if residents had any smoking articles in violation of the smoking policies. Staff should confiscate any such articles and should notify the Charge Nurse/Unit Manager that they had done so. Non-compliance of the smoke-free policy included, but not limited to: - Giving cigarettes or lighters to residents; - Unsafe use of lighters, matches, or cigarettes; - Possession of lighting materials or smoking paraphernalia; and - Smoking in or on facility property including patios, resident rooms, and parking lot. Based on interview, record review, and observation, the facility failed to ensure three of three residents sampled for accidents (Resident 14, 34, and 116) had interventions implemented to identify hazards and risks associated with smoking. The facility failed to ensure: 1) Resident 14 with a lighter and cigarettes did not attempt to put a used cigarette in a trash can within the resident's room, 2) Resident 34 was a documented smoker with an Oxygen Concentrator (a device delivering up to 95 percent Oxygen, Oxygen when in contact with flammable materials through heat can cause severe burns) in the resident's room, and 3) a non-smoking policy and procedure was enforced when Resident 116 (R116) took out a black lighter from the left chest pocket. The deficient practice had the potential to result in fire hazards and compromise the safety of all residents and staff in the facility. During the extended survey, the sample was expanded to include an additional four smoking residents (Resident 188, 189, 190 and 320). Findings include: Resident 14 On 02/26/2025 at 12:15 PM, the door to Resident 14's (R14) room was closed. Upon entering R14's room, a distinct odor of cigarette smoke was observed. R14 was lying in bed in the room, alert and oriented. A used cigarette, along with ash and tobacco leaves, was found on the floor next to a trash bin containing combustible materials, approximately five feet from the bed. The discarded cigarette appeared extinguished with the presence of ash and tobacco leaves. R14 stated they attempted to toss the end of the cigarette into the trash can from the bed but missed. R14 explained being permitted to smoke on facility premises until two days ago, when the survey team arrived, and indicated smoking in the courtyard with Resident 34 (R34), Resident 116 (R116), and a third resident R14 could not identify. R14 also stated having cigarettes and a lighter in the room at the time of the observation. On 02/26/2025 at 12:21 PM, two surveyors exited R14's room, one surveyor remained in the hallway directly outside R14's room to continuously observe to ensure R14 did not light another cigarette and attempt to put it in the trash can. The other surveyor went to the nurse's station in 200-hall and informed a Licensed Practical Nurse (LPN) R14 had stated to the survey team R14 was in possession of a lighter and cigarettes. The LPN revealed the facility was a non-smoking facility and followed the surveyor back to R14's room. The survey team remained in front of the door while the LPN entered R14's room. LPN was observed asking R14 if R14 was in possession of a lighter and cigarettes. R14 confirmed being in possession of a lighter and cigarettes. When LPN requested R14 to relinquish the lighter and cigarettes, R14 refused. LPN exited R14's room and stated the room smelled of cigarette smoke, and the resident was in possession of a lighter and cigarettes. At end of interview, LPN was observed returning to the nurse's station. Review of the admission revealed R14 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a serious mental condition affecting thought, resulting in a mix of disorganized thinking and behavior), depression (a mental disorder resulting in loss of pleasure or interest in activities, hopelessness about the future, or thoughts of dying or suicide), and suicidal ideations (thoughts or ideas centered around death or suicide). Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/2025, indicated R14 was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 12. The Assessment under J1300 Current Tobacco Use indicated Yes, R14 was a tobacco user. Review of the Progress Notes revealed a History and Physical from R14's Physician dated 02/13/2025 documented R14 smoked 2 packs of cigarettes per day for the last 34 years. Review of the Comprehensive Care Plan initiated on 02/12/2025, did not include documented evidence of a smoking care plan which would include a focus, goals, and interventions for smoking for R14. On 02/26/2025 at 3:55 PM, three hours and 40 minutes after the initial observation of R14 attempting to throw a used cigarette in a trash can in the resident's room, R14's door was closed. Upon entering R14's room, a distinct odor of smoking materials was observed coming from R14. R14 verbalized going out to smoke at the main entrance over 30 minutes ago with Resident 116 (R116). R14 stated being in possession of lighter and cigarettes at the time of observation. On 02/26/2025 at 4:04 PM, an LPN stated R14, and another smoking resident, exited through the main entrance of the facility together around 3:00 PM. LPN identified the other smoking resident as a resident from 300-hall. On 02/26/2025 at 4:09 PM, an LPN in the 300-hall identified a smoking resident in the 300-hall as Resident 34 (R34). Resident 34 On 02/26/2025 at 4:16 PM, upon entering Resident 34's (R34) room, the resident was observed sitting on the bed in the room, alert and oriented. When asked if R34 had gone out to smoke, R34 explained how the resident used to smoke in the courtyard to the dining hall or the main entrance with other residents. R34 identified another smoking resident as Resident 116 (R116). An Oxygen concentrator was observed next to the bedside, two feet to the right of the resident's bed. When asked if R34 was in possession of a lighter or cigarettes, R34 stated I do not want to answer that. Review of the admission record revealed R34 was initially admitted on [DATE] with diagnoses including psychoactive substance dependence (a dependence on substances affecting the perception, consciousness and cognition, which include alcohol and nicotine), alcohol dependence with intoxication (a pattern of drinking which involves loss of control), and nicotine dependence (the need to use nicotine and being unable to stop). Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/2024, indicated R34 was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 12. The Assessment under J1300 Current Tobacco Use indicated Yes, R34 was a tobacco user. Review of the Comprehensive Care Plan initiated on 12/25/2024 did not include documented evidence of a smoking care plan which would include a focus, goals, and interventions for smoking for R34. Resident 116 On 02/26/2025 at 4:23 PM, upon entering Resident 116's (R116) room, R116 was observed lying in bed, alert and oriented. The resident had a distinct odor of cigarette smoke. When R116 was asked if they had recently smoked with R14, the resident said Yes. The resident stated two days ago, the facility put up non-smoking signs in the facility and no longer permitted residents to smoke in facility courtyards, urging residents to go across the street and off facility property to smoke. The resident indicated not being told upon admission the facility was non-smoking. When asked if R116 was in possession of smoking materials, R116 pulled out a black lighter from the left chest pocket of the jacket the resident was wearing. Review of the admission record revealed R116 was initially admitted on [DATE] with diagnoses including depression, abnormalities of gait and mobility (changes in walking or balance), and opioid dependence (a chronic disease which involved compulsive opioid use and an inability to control it) . Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/2025, indicated R116 was cognitive intact with a Brief Interview for Mental Status (BIMS) score of 14. The Assessment under J1300 Current Tobacco Use indicated Yes, R116 was a tobacco user. The Assessment under GG0115 Functional Limitation in Range of Motion indicated an impairment on one side of the upper extremity (shoulder, elbow, wrist, hand). Based on observation, facility map, and interview, a total of 4 facility courtyards were identified. On 02/27/2025 at 10:18 AM, in the 100-hall courtyard, eight extinguished cigarette butts were observed approximately two feet away from the entrance of the courtyard leading into the facility. On 02/28/22025 at 9:30 AM, LPN confirmed notifying the Director of Nursing and members of management within one hour of identification of R14 being in possession of a lighter and cigarettes, but R14 refused to give the smoking materials up. When asked what the response of the DON and members of management, the LPN did not respond except to shrug their shoulders. On 02/28/2025 at 10:14 AM, the DON stated not being informed of R14 being in possession of a lighter and cigarettes until 02/26/2025 at 6:25 PM when the Immediate Jeopardy (IJ) was presented to the DON and members of management. The DON verbalized not being aware of any actively smoking residents until the following day on 02/27/2025. The DON explained the facility was a non-smoking facility due to having residents on oxygen, and the danger of having smoking material could cause a fire within the facility and everyone would be affected. There is no evidence the staff removed the lighter and cigarettes from R14 from 02/26/2025 at 12:21 PM to 02/26/2025 at 6:25 PM. On 02/28/2025 at 10:21 AM, the Assistant Director of Nursing (ADON) stated not being aware R14 was in possession of a lighter and cigarettes until 02/26/2025 at 6:25 PM when the Immediate Jeopardy (IJ) was presented to the ADON and members of management. On 02/28/2025 at 11:21 AM, the Administrator stated the facility is a non-smoking facility for residents. The Administrator verbalized all staff are responsible to confiscate any smoking articles, if identified. When asked if the Administrator was aware the facility had smoking resident's, the Administrator confirmed receiving reports of residents smoking all the time and smoking paraphernalia being taken away from residents. Cross Reference to K741. The facility failed to enforce elements of their adopted smoking policy as it relates to employees, patients, and visitors while also ensuring the employee smoking area was properly designated and equipped with a metal can with a self-closing lid and extinguished smoking materials facility wide were disposed of within non-combustible ashtrays.