**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #13 had diagnoses which included dementia and altered mental status. A care plan, dated 03/08/22, read in part, .staff will encourage .to smoke with supervision .keeps .cigarettes and lighter in the top dresser drawer . A smoking safety screen, dated 02/15/22, read in parts, .Does resident have cognitive loss .Yes . On 05/05/22 at 3:02 p.m., the DON stated resident #13 was safe to smoke and store their cigarettes according to the smoking assessment dated [DATE]. The DON stated resident #13 now needed supervision to smoke due to falls and medication changes. The DON stated they did not think resident #13 kept their cigarettes and lighter in the room. The DON stated the smoking assessment had not been updated with the change. 4. Resident #35 had diagnoses which included extrapyramidal and movement disorder. A smoking safety screen, dated 03/16/22, read in parts, .Does the resident have any dexterity problem(s) .Yes .Does resident need facility to store lighter and cigarettes .Yes . Physician orders, dated May 2022, documented the resident was to receive oxygen at 3 LPM via nasal cannula as needed for shortness of breath and to maintain oxygen saturation above 90%. On 05/4/22 at approximately 3:20 p.m., during an interview with resident #35 cigarettes and a lighter were observed on the resident's bedside table. On 05/05/22 at 5:17 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy related to smoking in the building while wearing oxygen. The facility did not have policies and procedures in place to address smoking material storage for residents who were on oxygen and/or who required supervision to smoke, and failed to assess/reassess residents for smoking safety. On 05/05/22 at 1:10 p.m., a resident who was blind was observed in their room wearing oxygen while smoking a cigarette. At 5:30 p.m., the administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. On 05/06/22 at 10:00 a.m., the plan of removal was accepted by the OSDH. The plan of removal was as follows: 5.5.2022 7:30 PM Proposed IJ Plan of Removal Immediate action: Approximately 1:30 PM May 5, 2022, All residents were asked to produce all cigarette lighters until smoking assessments are completed and it is determined that the resident is safe to maintain their cigarette lighter in their possession. Staff education started at 2:22 PM, May 5, 2022 with the last employee being educated at 6:35 PM May 5, 2022, regarding the storage of cigarette lighters until individual residents were assessed and deemed safe to maintain their lighters. Staff were educated by the Administrator and Director of Nursing. In their absence, the Certified Assistant Administrator or Charge Nurse. All staff will monitor and ensure all smoking residents do not have cigarette lighters on their person or in their room. All cigarette lighters will be maintained in a secure area and staff will access lighters upon request of the resident and retrieve lighters when residents return inside from smoking. Any staff member who observes a resident with a lighter will ask the resident for the lighter and give a reminder that they can obtain the lighter at any time they wish to go outside to smoke. Staff will supervise residents who are deemed unsafe to smoke independently. Residents will have a smoking assessment completed upon admission, on a quarterly basis, or if their condition changes. Staff will report any unsafe behavior or changes to the charge nurse immediately. Staff will observe to ensure that no one is smoking or introducing an open flame near oxygen. We will complete evaluations for each resident and return lighters to those residents who are capable of safely smoking in designated areas without assistance. Residents requiring assistance will have lighters maintained in a secure area. A policy revision was made, please see attached document. All Direct Care staff, Administrative staff, Social, and Activity staff, will be educated no later than 11:59 PM Thursday May 5, 2022. In the event a staff member is not available due to being out of town, on medical leave, etc., they shall be educated prior to being allowed to work their next shift. An alert message has been included in the Electronic Medical Record (EMR) to identify individual residents who are smokers and at what level they have been assessed for smoking. The medical record alert will identify smoking status and the level in which they are deemed to be supervised or unsupervised. Residents who do not require supervision will be provided a lock box to maintain their smoking materials. Residents who require extensive supervision will be identified and their cigarettes and lighting device will be maintained in a secure area and made available upon request. Residents who are utilizing oxygen will be allowed to keep their cigarettes without a lighting device if they meet the criteria for unsupervised smoking they will not be allowed to maintain their lighting device due to oxygen use. On 05/06/22 from 10:59 a.m. to 12:32 p.m., interviews were conducted with staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Residents were interviewed and stated they did not have their lighters in their room. Residents were observed obtaining their lighters from the nurses prior to going to smoke and were observed returning their lighters to the nurses after smoking. No lighters were found in the resident rooms. At 12:35 p.m., the administrator was notified the IJ was lifted effective 05/05/22 at 11:59 p.m. and the deficiency remained at a level of harm with a limited number of residents affected. Based on record review, observation, and interview, the facility failed to ensure: a. Residents who utilized oxygen were supervised to ensure they smoked without wearing oxygen, in a designated smoking area, and were assessed for smoking safety for one (#22) and; b. Residents who utilized oxygen and/or required smoking supervision were not allowed to keep their smoking materials in their room for four (#6, 13, 22, and #35) of five sampled residents who were reviewed for smoking safety. The administrator identified nine residents who smoked and three residents who smoked and utilized oxygen. Findings: The facility's smoking policy, dated 04/11/17, read in parts, .No resident .shall smoke on the property of this facility unless the following regulations are followed .Not inside of any building .Each resident who chooses to smoke will be assessed on their ability to smoke safely . The administrator reviewed the list of residents who smoked and identified the following residents who required supervision while smoking: Resident #6, #13, and #22. The administrator also identified the facility stored resident #6's smoking material and resident #13's lighter. The administrator stated they were unsure of the status of smoking supervision required for two other residents. 1. Resident #22 had diagnoses which included cortical blindness (loss of vision without any ophthalmological causes). A care plan, dated 12/30/20, read in part, .[name withheld] chooses to smoke tobacco products .vision is severely impaired .requires staff supervision .staff will hold the lighter to light the cigarette . A care plan revision, dated 4/7/21, read in part, .[name withheld] keeps one pack of cigarettes or less and a lighter in her room . Physician orders, dated May 2022, documented the resident was to receive oxygen at 2 LPM via nasal cannula as needed for shortness of breath and to maintain oxygen saturation above 90%. On 05/05/22 at 1:10 p.m., cigarette smoke was smelled in the hallway of the long hall. Housekeeper #1 was in the hall and stated they also smelled the cigarette smoke. Housekeeper #1 yelled down the hall for the DON and stated She is smoking. Resident #22 was in their room with the oxygen concentrator on with a lit cigarette. The DON was observed leaving the resident's room with a folded plastic lid containing the cigarette. At 1:12 p.m., resident #22 was observed sitting in their wheelchair in their room with oxygen on via nasal cannula. Resident #22 stated It's my fault, I thought I was outside. Resident #22 stated the cigarettes and lighter were in the pocket on the wheelchair. At 1:16 p.m., the administrator stated resident #22 kept cigarettes and lighter in their room. The administrator stated resident #22 would usually ask if they wanted to go out to smoke. The administrator stated resident #22 required supervision to smoke due to blindness. At 1:35 p.m., the administrator identified two other residents who smoked and utilized oxygen. The two residents who utilized oxygen were both observed to have cigarettes and lighter in their room. At 1:45 p.m., CNA #2 stated resident #22 usually smoked outside with supervision. At 2:05 p.m., resident #22's family member was asked about the resident smoking in the room. Resident #22's family member stated the resident was not usually like this. Resident #22 stated, I thought I was on the patio smoking. At 3:04 p.m., the DON stated they were unsure which residents, who required supervision while smoking, and/or had smoking materials stored in their room. The DON stated the facility determined residents were safe to keep smoking materials in their room by assessing their cognition. The DON stated residents who needed supervision to smoke should not keep their smoking materials in their room. A review of resident #22's electronic clinical record did not reveal a smoking assessment had been completed prior to 05/05/22 at 1:16 p.m. 2. Resident #6 had diagnoses which included hemiplegia and hemiparesis (Muscle weakness or partial paralysis of one side of the body.) following a cerebral infarction (stroke) affecting the left non-dominant side. A smoking safety screen, dated 04/07/22, read in parts, .Does resident need facility to store .cigarette .Yes .Safe to smoke with supervision .resident is in geri chair and cannot extinguish smoking materials without assistance . On 05/05/22 at 1:28 p.m., resident had two packs of cigarettes located in the top drawer of the dresser in the resident's room. At 3:04 p.m., the DON stated resident #6's smoking assessment, dated 04/7/22, documented the facility stored the resident's cigarettes and the resident required supervision to smoke.