**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part B Refer to F610 On 01/21/25 at 10:00 AM, the surveyor reviewed the closed electronic medical record for Resident #264. According to the admission Record face sheet, Resident #264 was admitted to the facility with diagnoses which included but were not limited to; acute and chronic respiratory failure, hypoxia, epilepsy, tracheostomy status and dependence on respiratory ventilators. A review of Resident #264's quarterly MDS dated [DATE], reflected that the resident was coded as being comatose and yes to being in a persistent vegetative state/no discernible consciousness. Resident #264 was totally dependent on staff for all care. A review of Resident #264's ICCP included a focus area initiated on 02/27/24, for being at risk for falls related to poor safety awareness, impaired balance and poor trunk control, side effects of medications, non-verbal, and required mechanical lift transfers. Interventions included to use mechanical lift for transfers with two persons assisting with the transfer. A review of the Progress Notes revealed an Interdisciplinary Team (IDT) Note dated 11/06/24 at 10:20 PM, which included the IDT was made aware by CNA that Resident #264 was noted with discoloration and swelling of the right eye. The Nurse Practitioner (NP) was notified and ordered the resident to be sent to the hospital for further evaluation and treatment. A report was given to the nurse, and Resident's Representative (RP) was at bedside. A review of the IDT Note dated 11/06/22 at 10:22 PM, revealed that transportation was arranged with the [hospital name redacted] Emergency Services. A review of the IDT Note dated 11/07/24 at 8:05 PM, revealed a follow-up to the emergency room. The resident was admitted with diagnoses traumatic hematoma to right orbit (eye socket). On 1/16/25 at 10:30 AM, the surveyor reviewed the investigation and the Reportable Event Record completed by the facility dated 11/06/24. There was no causal factor identified for the injury. A review of a statement for CNA #1's, who cared for the resident revealed the following: On 11/06/24, CNA #1 documented that on 11/06/24, that she went in the afternoon to put Resident #264 in bed, and I found right face with a black eye and I reported to the nurse. The statement was signed CNA 3:00 PM-11:00 PM shift. (This note was documented before the mechanical lift transfer) On 11/06/24, CNA #1 documented that on 11/06/24, in the evening I put resident back in bed with a mechanical lift. The resident was sitting in the recliner chair and we assisted the resident back to bed lying on their left side. Once back in bed, I noticed resident had redness to face by eye. I reported discoloration to the nurse. (This note was documented after the mechanical lift transfer) The surveyor reviewed the statement provided by CNA #2, who also worked on the unit with CNA #1. CNA #2 documented that on 11/06/24, in the evening I assisted my co-worker to place resident back in bed with mechanical lift. The resident was sitting in the recliner chair and we assisted the resident back to bed lying on their left side. Once back in bed, I noticed the resident had redness to face by eye. The assigned CNA reported the discoloration to the nurse. A review of RN #2's statement dated 11/6/24 at 9:15 PM, indicated that they worked the 3:00 PM to 11:00 PM shift on the 2nd floor ventilator unit and was assigned to Resident #264. At 3:00 PM, I made rounds and the resident was sitting in a recliner chair along the bedside and I did not notice any changes to Resident #264. At 5:00 PM, the resident was provided care and placed back to bed by the CNA. At approximately 8:30 PM, the Resident Representative (RR) came to the unit to provide care for the resident. At 9:15 PM, the RR informed her that the resident was noted with a hematoma and swelling of the right eye. On 1/17/25 at 8:15 AM, the surveyor interviewed a staff CNA regarding the protocol to transfer residents with the mechanical lift. The CNA stated that two staff members had to be in the room for the transfer. On 1/17/25 at 8:52 AM, the surveyor interviewed the Respiratory Therapist (RT), and he confirmed that two staff had to be in the room to transfer a ventilator dependent resident from the bed to the recliner chair. When inquired regarding Resident #264, he confirmed that on 11/06/24, he had assisted CNA #3 with the transfer from the bed to the recliner chair in the morning, and there was no injury observed. The RT informed the surveyor that on 11/06/24 at 4:53 PM, he observed Resident #264 in bed and he did not assist with the transfer back to bed, nor was he made aware of the injury. On 01/17/25 at 11:59 AM, the surveyor reviewed the facility provided incident report and the statements attached with the DON. The DON stated that she was aware of the discrepancies in CNA #1's statements and could not provide any rationale for not clarifying the discrepancies prior to the submission of the investigation to the Department of Health (DOH). The DON stated there was a misunderstanding and miscommunication about the investigation. The DON stated she had understood Resident #264 sustained the injury during the transfer and stated that Resident #264 possibly hit the right eye on the mechanical lift. On 01/17/25 at 12:05 PM, the surveyor conducted a second interview with the RT. The RTF on duty that day revealed that one nurse and one CNA were to transfer any resident out of the bed and back to bed if the resident was on a mechanical ventilator (machine that acts as bellows to move air in and out of the lungs). The RT stated that some CNAs worked as floaters to the unit and they were not trained to transfer residents with the ventilator attached. The RT stated for safety reasons, a nurse had to be in the room to assist or if the nurse could not assist, the nurse delegated the task to the RT who supervised the transfer. When asked if there was a policy for transferring a resident with a ventilator, he stated, this is the [normal], not too sure if there is a policy. A review of the documents provided revealed that the RN nor the Respiratory Therapist assisted CNA #1 with the transfer. On 01/21/25 at 11:47 AM, the surveyor interviewed the Medical Director (MD) regarding the injury sustained by Resident #264 during the transfer. The MD stated that he was told by the DON the injury was caused by the hook from the mechanical lift and was not provided with any additional information. On 1/21/25 at 1:45 PM, the surveyor interviewed the NP, who ordered Resident #264 to be transferred to the hospital for a computed tomography scan ( CT Scan; a noninvasive medical procedure that uses X-Rays to create detailed cross-sectional images of the body). The NP stated that since the bruise was significant and since no one knew the source of the injury, she ordered the CT scan to ensure there were no fractures. A review of the summary provided to DOH on 11/08/2024, the DON indicated the following: Resident #264 has periods of involuntary movements related to hypoxia and seizure disorder as well as cough spasms. The Interdisciplinary Team concludes that resident during transfer may have coughed or had involuntary movement and may have leaned into [Resident #264] mechanical lift cross- bar. Interviews with staff familiar with the resident routine revealed that the resident was immobile. Actions included to: .4. Transfer to Hospital for Evaluation; 5. Mechanical lift Competencies with CNAs; 6. Maintain 2 person assist with mechanical lift transfer and care; CNA #1 had Resident #264 on the mechanical lift alone in the room. CNA #2 was not in the room when CNA #1 initiated the transfer and placed Resident #264 on the mechanical lift. Utilize soft padding on the mechanical lift crossbar during resident transfers. On 1/22/24 at 10:15 AM, two surveyors conducted an in person interview with CNA #1, who stated that she recalled the incident. CNA #1 stated that the evening shift was very chaotic, and that she observed the injury after transferring Resident #264 in bed. CNA #1 stated that Resident #264 always scratched their face, and the injury could be self-inflicted. When asked if she remained in the room with the resident and waited for the nurse to come and assess the injury, CNA #1 stated she had too much to do that day; she moved on and attended to other residents. The surveyor then inquired about the 2nd statement, and CNA #1 read the statement and stated, another co-worker coached her to write the second statement, but she did not observe any injury to the resident face and right eye while the resident was sitting in the chair. On 1/22/24 at 12:00 PM, the surveyor conducted a telephone interview with CNA #2, whom CNA #1 claimed assisted her with the transfer. CNA #2 stated that when she entered the room, [Resident #264] was in the room and on the mechanical lift alone with CNA#1. CNA #2 observed the bruise and advised CNA #1 to report the injury to the nurse. When asked if she assisted CNA #1 with care, CNA #2 stated, No, I left the room and continued with my assignment. On 1/22/25 at 1:15 PM, the surveyor interviewed CNA #3, who was assigned to the 7:00 AM-3:00 PM shift regarding Resident #264's care. CNA #3 stated that she cared for Resident #264 daily; that Resident #264 was immobile, had poor trunk control, and required a two-persons assist with transfers. CNA #3 further stated that on 11/06/24, she transferred Resident #264 to the recliner chair with the Respiratory Therapist. During the day she periodically checked Resident #264, and no injury was noted to the right eye. On 1/23/25 at 10:56 AM, the surveyor reviewed the investigation with the LNHA in the presence of the survey team. The LNHA stated that in reviewing RN #2's statement and the investigation, he could see there were some discrepancies. The LNHA added the investigation was not concise and thorough, and that his expectation was that the facility would thoroughly investigate injuries of unknown origin. On 1/23/25 at 1:30 PM, during the exit conference no additional information was provided. A review of the facility's Incident/Accidents policy dated 05/01/14, and last revised 1/2024, included Policies and Procedures are guidelines. They are intended to communicate information that generally applies to facility operations. Current rules, regulations and laws take precedence over guidelines. Policy: Each resident receives adequate supervision and assistive devices to prevent accidents; Purpose: A system to prevent and/or minimize further incidents and accidents; All interventions should be placed in treatment record and signed by nurses. A review of the facility's Abuse Prevention Program dated last revised 1/2025, under identification indicated the following: All residents sustaining bruises, skin tears, any marks of the skin, and any fractures or injuries, which are of unknown origin, shall be identified as potential abuse incidents and investigated as such . The policy for Hoyer lift transfer was not provided. Part C On 01/17/25 at 8:46 AM, Surveyor #2 reviewed the closed electronic medical record (EMR) for Resident #34. A review of the admission Record face sheet revealed Resident #34 had diagnoses including, but not limited to; sepsis, chronic viral hepatitis C, and opioid dependence. A review of an IDT Progress Notes (PN) dated effective 07/14/24 10:50 AM, and created on 07/15/24, by the nursing department included that on 7/14/24, the primary nurse called the supervisor for the Resident #34, and upon the supervisor's arrival, the supervisor found the resident on the bed with erratic behavior and uncontrolled movement. The room was fully searched, and drug related equipment was found on the resident's bed. The supervisor immediately confiscated the equipment. Education was given to the resident about the risks of substance abuse, and that these actions violate the policies of the hospital (the facility). The MD was made aware, and ordered the resident to be transferred to the hospital for evaluation, and ordered a toxicology screen. A review of the Laboratory (Lab) Results Report with a collection date of 07/16/24, revealed Resident #34 tested positive for cocaine metabolite. A review of the IDT PN dated late entry effective 08/08/24 at 1:26 PM, created on 11/24/24 at 1:27 PM, by the DON, included the resident was noted with restless behavior; talking very animated and excited; slurring speech; at time making incoherent statements. The resident declined to be transferred to the emergency room (ER) for evaluation. The resident was educated on risk versus benefit of using illicit substances, and urine toxicology obtained per physician order. A review of the Lab Results Report with a collection date of 08/08/24, revealed Resident #34 tested positive for cocaine metabolite, opiates, morphine, and methadone. A review of a IDT Note dated 08/15/25 at 10:12 AM, included urine drug screen results received. The resident was positive for opiates, positive for cocaine, and positive for morphine. The resident was positive for methadone which was prescribed. The DON and physician were notified. A review of the IDT PN dated late entry effective 12/19/24 at 11:56 AM, included at 10:39 AM, the resident was noted in the wheelchair in room lethargic with pupils dilated and not responding to commands. The NP ordered the resident be sent to the ER, and 911 was called. A STAT (immediate) drug screen ordered per physician and resident refused. The resident was noted with a vape pen and lighter in possession which were confiscated. The NP was made aware of the resident's refusal to go to ER. A review of the Order Summary Report for the admission date of 07/15/24, for Resident #39, revealed an physicians order (PO) to maintain one-to-one (1:1) supervision every shift ordered on 11/27/24. A PO that may have visitors under supervision as needed ordered 12/02/24, and an order for methadone HCL oral concentrate 10 (milligram/milliliter) (mg/ml); give 50 mg by mouth once a day for opioid dependence. A review of Resident #34's ICCP included the following focus areas: A focus area initiated on 07/15/24, for the resident having a past history of drug abuse and was a risk for relapse. The goal was to keep Resident #34 safe with the interventions including daily room searches initiated on 07/15/24. A focus area initiated 10/25/24, that the resident was a smoker with a goal to be a safe smoker. An Intervention included the Smoking Contract was reviewed and signed on 10/25/24. A focus area for the resident being on methadone for substance abuse, and on 07/14/24, the resident was noted with erratic behavior and uncontrolled movements, room check was done and suspected drug related items found on resident bed . A focus area for Resident #34 noted on 12/20/24, with erratic behaviors and uncontrolled movements and a room check was done and suspected drug related items found on the bed. A lighter and vape was confiscated. A focus area that Resident #34 will be free of illicit substances was initiated on 12/20/24. On 01/22/25 at 9:02 AM, Surveyor #2 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who was familiar with Resident #34. The LPN/UM stated she used to be on Resident #34's floor, and she stated that Resident #34 was alert and oriented and had an issue with addiction. Surveyor #2 asked about the methadone clinic process and when Resident #34 was found with drug paraphernalia. The LPN/UM stated Resident #34 smoked and went outside and was observed going to the fence and someone came and handed the resident something and quickly ran off. Resident #34 was asked what was given and stated to the LPN/UM it was nothing, and the LPN/UM then found Resident #34 not responding properly and they lifted the bed and found a home-made type twisted-up metal object under the resident's bed that was some sort of item used with drugs. Surveyor #2 asked about what was done to prevent Resident #34 from obtaining illegal drugs again, and the LPN/UM stated Resident #34 had 1:1 monitoring for a few weeks and then, got off of 1:1. On 01/22/25 at 9:45 AM, Surveyor #2 asked the DON for all incidents, grievances, investigations related to Resident #34 and they were provided them at 11:30 AM the same day. An Investigative Summary for the Concern on 07/14/24 at 8:55 PM, when Resident #34 was acting erratic and drug related paraphernalia was found on the bed. The undated Investigative Findings included that Resident #34's roommate observed the resident going to the fence in the smoking courtyard, but could not see what was happening. The resident (Resident #34) was found with a glass pipe on the resident's bed shortly after, and the drug panel was positive for cocaine metabolites. The conclusion revealed that the DON told the resident that illicit substances will not be tolerated due to risk of harm to self. Actions included: 1. Resident placed on every thirty-minute checks for 3 days . A statement signed by an unidentified person on 07/14/24, revealed Resident #34 was observed going to the gate continuously during the smoking time. Three Thirty-Minute Monitoring Sheets dated 07/15/24, 07/16/24, and 07/17/24, had a time and space next to the time for the 11:00 PM-7:00 AM (11-7) shift, 7:00 AM-3:00 PM (7-3) and 3:00 PM-11:00 PM (3-11) shift. The handwritten documents did not identify who filled them out each shift, and did not represent all meals, or smoking times. An Incident Report dated 08/08/24, and completed by the DON, revealed Resident #34 was noted with restless behavior . slurring speech .making incoherent statements. Immediate Action Taken was the resident was educated on the risk versus benefit of using illicit substances. There was no Investigative Summary Attached with additional actions to prevent recurrence. An Incident Report dated 12/19/24, completed by the LPN/UM, revealed the resident was noted with a vape pen and lighter in their position; pupils were dilated and resident was not responding to commands. 911 was called and the resident refused to go .There was no Investigative Summary with additional actions to prevent recurrence. On 01/22/25 at 1:46 PM, Surveyor #2 interviewed the DON in the presence of the survey team, and the DON was asked to explain what the drug paraphernalia found in Resident #34's room was. The DON stated there was a spoon with black residue on it, and another incident when a wire was found. The DON stated the resident was placed on 1:1 monitoring and room checks. Surveyor #2 asked if the police were contacted and the DON stated, we wouldn't do that, we did an investigation. Surveyor #2 asked if other residents obtained the drugs from Resident #34, and the DON stated no other residents appeared to be under the influence. The DON was asked who was to monitor the smoking area to see if items were passed through the fence, and she stated it would be seen on the security camera. Surveyor #2 asked what was done to prevent the recurrence, and the DON stated we asked Resident #34 initially about the drugs and Resident #34 denied it, and we did 1:1 observation for three days. The DON stated they could not prove where the drugs came from, and they must do the least restrictive intervention. The surveyor asked the DON why the 08/08/24, incident note was written in November 2024, and the DON stated she could not recall why and stated that the facility did not report any of the instances. Surveyor #2 asked where the resident received the cocaine that was identified on the drug screen. The DON stated the facility did not know, and stated maybe when the resident went to the methadone clinic as the residents were very sneaky at times and we can't always pin down where the drugs come from. Surveyor #2 asked the DON what the facility's responsibility was to protect all the residents in the facility from the drugs and for safety when the resident was found with a vape and lighter in the room. The DON stated Resident #34 was placed on 1:1 supervision for a while, and Surveyor #2 stated that the resident then was found having drugs, a vape, and a lighter while on 1:1 monitoring. The DON stated we confiscated the paraphernalia the first time. Surveyor #2 asked what about when it happened a second time in August. The DON stated it was discussed as a team and the DON stated it was her responsibility to protect the other residents, and she did not think Resident #34 was giving drugs to other residents, and stated, I think we would have known. On 01/23/25 at 8:53 AM, Surveyor #2 interviewed the Medical Director (MD) in the presence of the survey team, and asked if he was made aware of Resident #34's incidents with drug paraphernalia and was found in the facility in their room not responding, and found with a vape and a lighter and drugs were found in the resident's system. The MD stated he was not aware, and then stated, no, not at all was I aware of this. Surveyor #2 asked what should have been done after that occurred. The MD stated, that is concerning, the resident should get a warning discharge as could cause a huge fire, of course. On 01/23/25 at 11:32 AM, the survey team reviewed the above concerns with the LNHA, DON, [NAME] President of Clinical Services, and Quality Assurance Nurse. On 01/23/25 at 2:15 PM, during the exit conference, the facility administration had no further information to provide. NJAC 8:39 31.6(e); 4.1 (a)(5); 27.1(a)(b) Complaint NJ # 180392 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) ensure effective interventions were implemented and monitored for a resident (Resident #143) who resided in a piped-in oxygen room and was identified as a smoker and was observed smoking inside their room on 10/19/24. This deficient practice occurred for 1 of 1 residents reviewed for safe smoking. Observations on 1/15/25, 1/16/25, and 1/17/25, confirmed Resident #143 who resided in a piped-in oxygen room, kept their smoking materials in their room. The facility's failure to ensure all residents were protected from serious injury, harm or death from explosion or fire, from smoking inside of a room that had oxygen piped in through the walls resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/19/24, when Resident #143 was found by a Registered Nurse (RN #1) to be smoking in their room. From 1/15/25 through 1/17/25, the surveyor observed smoking materials inside of the resident's room and within arm's reach of Resident #143 and inside of an oxygen rich environment due to the facility utilizing oxygen that was piped in through the walls. The facility was notified of the IJ on 1/17/25 at 2:26 PM. The facility provided an acceptable Removal Plan (RP) which was verified on-site by the survey team on 1/21/25. The facility further failed to b.) ensure that two staff members were present to safely transfer a resident who was dependent on a ventilator for breathing and utilized a mechanical lift, who sustained a 16-centimeter (cm) x 10 cm traumatic hematoma to the right orbit (eye socket) and required hospitalization on 11/06/24. This deficient practice was identified for 1 of 1 residents (Resident #264) reviewed for accidents; the facility also failed to c.) ensure effective interventions and adequate supervision was provided to a resident (Resident #34) with a history of substance abuse who was found on 07/14/24, with erratic behavior and drug paraphernalia observed on the bed and on 08/08/24, with slurred speech making incoherent statements that tested positive for cocaine, opiates, and morphine; and d.) protect all residents from potential fire or gaining access to illicit drugs by ensuring effective interventions for the same resident (Resident #34) who on 12/19/24 was found lethargic, not responding to commands, and had a lighter and a vape (electronic cigarette) pen in their room. This deficient practice was identified for 1 of 2 closed records reviewed for accidents (Resident #34). The evidence was as follows: Part A A review of the facility's Smoking Safety policy revised/reviewed 1/2025, revealed Policy: It is the purpose of this facility to ensure smoking safety at all times while resident in the facility. Procedure: 1. All smoking residents will receive and sign the Smoking Agreement Contract. If the resident refuses to sign the contract, the resident will lose the privilege of smoking. 2. Upon admission, smokers will be assessed for smoking safety. 3. The Social Worker will review the Smoking Assessment Contract with the resident and answer any questions if needed. The Social Worker will have the resident sign the contract at this time. 4. Cigarettes and lighting materials are held in the security office. The resident will not keep lighters, matches and/or lighting materials with them while not actively smoking or in a smoking area. On 1/15/25 at 9:39 AM, during the initial tour, Surveyor #1 observed a sign posted on the wall outside of Resident #143's room which indicated, No Smoking (in red), Piped-In Oxygen In Use. Upon entering Resident #143's room, Surveyor #1 observed the resident in bed watching television. At that same time, Surveyor #1 observed a pack of cigars on the table next to the resident and the surveyor asked the resident what they were. The resident took a cigar out of the case and stated it's a cigar while holding it and showing it to the surveyor. On 1/16/25 at 8:50 AM, Surveyor #1 reviewed the electronic medical record for Resident #143. According to the admission Record face sheet (an admission summary) Resident #143 was admitted to the facility with diagnoses which included but were not limited to; hypertension (high blood pressure), heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), hyperlipidemia (abnormally high levels of fats in the blood), and diabetes mellitus (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of Resident #143's most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/28/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident had a moderately impaired cognition. A review of a nursing Progress Notes (PN), created on 10/19/24 at 7:18 PM, indicated [resident] was seen in room smoking cigarette; educated [resident] not to smoke in room. The [resident] shown area designated for smoking, states okay . A review of Resident #143's individualized comprehensive care plan (ICCP) initiated on 7/09/24, reflected that Resident #143 was a smoker. Interventions included: Smoking contract reviewed with [Resident #143]. Resident signed updated smoking agreement on 07/09/24, and understands smoking safety procedures and hours of operation 10:00 AM, 12:30 PM, 4:00 PM, and 7:00 PM. A further review of the resident's ICCP revealed a smoking focus area created on 10/19/24 at 7:18 PM, which revealed Resident #143 was seen smoking a cigarette in their room. The goal was for the resident to not smoke in their room. Interventions initiated on 10/22/24, included: cigarettes and lighter given to security; cigarettes and lighter were taken from resident's room; educated on risk of smoking in room; encouraged to ask for assistance if needs help; Medical Doctor and family made aware; Resident #143 will be monitored for smoking every shift for smoking; the resident was shown designated smoking area; smoke detector was immediately placed in room. On 1/16/25 at 11:44 AM, Surveyor #1 observed Resident #143 sitting in a wheelchair in their room with two loose cigars adjacent to the resident's meal tray and within the resident's reach. On 1/17/25 at 8:19 AM, Surveyor #2 interviewed the Security Guard (SG) who stated he was responsible to distribute the smoking materials and lighters for resident use. The SG Stated there was a Smoking Times list and a list of residents who smoked affixed to the wall and Resident #143's name was not listed. The SG stated for each smoking time, there would be a staff member assigned at 10:00 AM, 1:00 PM, 4:00 PM and 7:00 PM. Surveyor #2 asked if Resident #143 smoked since their name was not on the list of residents who smoked, and the SG removed a plastic bag labeled with Resident #143's name out of the desk drawer and the bag contained two packages of cigars and a lighter. Surveyor #2 asked if the residents could smoke in their rooms and the SG stated, no, we have oxygen on the floor. Surveyor #2 asked why Resident #143 was not on the list of smokers, and the SG stated Social Services needed to update the list. Surveyor #2 asked if a resident smoked in their room would it be a problem, and the SG stated, yes, because I would need to know, the resident's room would have to be checked, and the resident would have to be closely monitored. The SG stated, anything tobacco would have to come through me. Surveyor #2 asked if residents were allowed to keep the cigarettes in their room, and the SG stated, no, they cannot keep cigarettes in their room. Surveyor #2 then asked what should happen if staff found a resident with cigarettes in their room, and the SG stated he should be notified because the residents were not allowed to have them on the floors at all, there is oxygen on the floors. Surveyor #2 then asked if Resident #143 had been found smoking in their room, and the SG stated, he heard nothing about that, and that he should be immediately notified if any cigarettes were found in the room. The SG stated Resident #143 usually smoked once a day or less; usually at 1:00 PM. On 01/17/25 at 8:20 AM, Surveyor #1 observed Resident #143 sitting in a wheelchair in their room with two loose cigars on the tray table within reach of the resident and a cigar box was on top of the nightstand. The resident stated, I buy my own cigars; I walk to the store. Surveyor #1 asked Resident #143 if they had a lighter and the resident then gestured with both hands waving towards the nightstand, and stated, I put it up. Surveyor #1 asked the resident if they could show their lighter to the surveyor, and Resident #143 then began rummaging through their nightstand and stated, I can't find it. On 1/17/25 at 8:45 AM, Surveyor #1 interviewed RN #1, who stated that the residents smoked in the designated area as per the smoking schedule. RN #1 stated all residents were assessed for smoking upon admission, and staff let Security know if the resident was a smoker. RN #1 stated the residents were not allowed to smoke in their rooms and if they were caught smoking in their rooms, their smoking supplies were removed from their room and stored either with Security or inside the medication cart. RN #1 stated Resident #143 had smoked in their room before, and all the smoking supplies were taken away from the resident. RN #1 further stated smoking was not allowed in the rooms due to residents using oxygen and the risk of fire. On 01/17/25 at 9:16 AM, Surveyor #1 accompanied RN #1 to Resident #143's room, and the RN observed two packs of sealed cigars inside the resident's nightstand drawer. RN #1 stated Resident #143 was not allowed to have smoking supplies in their room and immediately removed the cigar packs from the resident's room. On 1/17/25 at 9:21 AM, Surveyor #1 interviewed the Assistant Director of Nursing (ADON), who stated residents were not allowed to smoke