On 07/08/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a system in place to ensure residents were monitored for the safe use of electronic vaping devices.Resident #1, 6, and Resident #11 were observed to use supplemental oxygen. The latest cognition assessments showed all three residents were intact in their cognition. Their care plans showed the three residents smoked, vaped, or both. The care plan showed the residents were not to use smoking or vaping materials while in the possession of or near any type of oxygen.On 07/08/25 at 3:43 p.m., Resident #11 was observed sitting in their motorized wheelchair in their room, vaping. The two O2 concentrators present in their room were running for the resident and their roommate. Resident #11's oxygen concentrator was approximately six inches from Resident #11 as they vaped.On 07/08/25 at 3:50 p.m., Resident #1 was observed lying in bed and vaping. The resident was observed to wear oxygen at 2 liters per nasal cannula.On 07/08/25 at 4:35 p.m., Resident #6 was observed vaping in their room while lying in bed with oxygen on per nasal cannula.On 07/08/25 at 4:52 p.m., Resident #6 was observed sitting in their motorized scooter in the dining room, at the dining table, vaping with Resident #12 at the head of the table. Resident #12 was observed to wear oxygen at 2 liters per minute via nasal cannula. The residents were observed to be less than five feet apart from each other.Interviews with direct care staff showed they were unaware or uncertain of the use of oxygen while vaping.On 07/08/25 at 6:25 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On 07/08/25 at 6:57 p.m., the administrator, DON, and regional administrator were notified of the IJ situation and was provided a copy of the template.On 07/09/25 at 9:20 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Ambassador Skilled Nursing and Therapy Plan of Removal 7/8/25 1. Inservice on facility smoking procedures/designated locations. What to do if someone is smoking outside of those areas or in the presence of oxygen. 2. Re-assess all residents who vape for safety and understanding of the agreement and policy. 3. Re-issue the smoking agreement to these residents. 4. Any of the residents who have been reported to smoke freely around o2, be it theirs or their roommates, must have privileges revoked and put on supervised vaping. 5. Initiate a supervised smoking schedule and ensure each resident who is supervised has this information. 6. All of this to be completed by midnight 7/8/25.The IJ was lifted, effective 07/08/25 at 10:46 p.m., when all components of the plan of removal had been verified as completed. Direct care staff from all three shifts were interviewed about inservice/education and showed the staff were knowledgeable of the facility's policy regarding vaping and the risks involved if residents vaped while utilizing supplemental oxygen. Review of clinical records showed residents who vaped had been assessed for safety related to vaping and had signed a smoking/vaping agreement. The supervised smoking schedule showed what type of supervision residents required for vaping. The deficient practice remained at a pattern level with the potential for more than minimal harm.Based on observation, record review, and interview, the facility failed to ensure residents were monitored for the safe use of electronic vaping devices for 6 (#1, 2, 6, 11, 12, and #13) of 6 sampled residents who were reviewed for the use of electronic vaping devices.The alphabetical room roster identified 131 residents resided in the facility.Findings:1. On 07/08/25 at 3:33 p.m., Resident #1 was observed in their motorized wheelchair wheeling down the 100 hall with an electronic vape in their lap.On 07/08/25 at 3:48 p.m., Resident #1 was observed laying in bed, vaping, and had oxygen on at 2.5L via nasal canula. Resident #1 and Resident #11 were observed to be roommates. A physician order, dated 12/03/24, showed Resident #1 was ordered oxygen at two to five liters per minute via nasal cannula as needed.A policy titled Smoking/Vaping, dated 02/24/20, read in part, Oxygen equipment is not permitted in smoking areas. Smoking is not permitted while in possession of or in the presence of oxygen equipment .To offer the resident the ability to smoke/vape free of danger to self or others. The term smoking/vaping referenced herein includes the use of any type of cigarette, pipe, electronic device, battery powered device or any other object/device that produces smoke/vape.A policy titled Smoking, signed by Resident #1 on 01/18/24, read in part, The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2, and in non-public areas to prevent offending others.An annual assessment, dated 04/28/25, showed Resident #1 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making and had a diagnosis of multiple sclerosis.A care plan, updated 05/22/25, showed Resident #1 was independent with vaping.A Smoking/Vaping Supervision Checklist, dated 06/10/25, showed Resident #1 utilized vaping products, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.On 07/08/25 at 3:50 p.m., Resident #1 stated they had quit smoking cigarettes and now utilized electronic vapes. Resident #1 stated they did not go outside, the staff allowed them to vape in their room and could vape with their oxygen on. Resident #1 stated they utilized oxygen most of the time.2. On 07/08/25 at 11:10 a.m., Resident #2 was observed vaping while sitting in their wheelchair in the dining room.On 07/08/25 at 3:32 p.m., Resident #2 was observed in their wheelchair on the 100 hall with an electronic vape in their lap. The resident seemed confused and was asking where their room was located. A Smoking and Behavior Agreement, signed by Resident #2 on 04/04/25, read in part, I [Resident #2] acknowledge the importance of the facility smoking policy to my own safety of others [sic] residents and agree to comply with the terms and conditions of that policy.A significant change assessment, dated 05/30/25, showed Resident #2 had a BIMS score of 05, which indicated the resident was severely impaired in cognition for daily decision making, and the resident utilized tobacco.A Smoking/Vaping Supervision Checklist, dated 05/30/25, showed Resident #2 utilized vaping products, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.A care plan, updated 07/03/25, showed Resident #2 was independent with smoking and mainly vaped. The care plan showed Resident #2 agreed to smoke/vape in designated smoking areas only and the residents would be monitored to ensure they were not vaping while in the vicinity of oxygen equipment.3. On 07/08/25 at 3:30 p.m., Resident #6 was observed in the therapy room vaping around other residents.On 07/08/25 at 4:02 p.m., Resident #6 was observed vaping in the back common area vaping.On 07/08/25 at 4:35 p.m., Resident #6 was observed vaping in their room while lying in bed with oxygen on per nasal cannula. A policy titled Smoking, signed by Resident #6 on 01/18/24, read in part, The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2, and in non-public areas to prevent offending others.A physician order, dated 10/10/24, showed Resident #6 was ordered oxygen at 2-4L per minute via nasal cannula every shift.An annual assessment, dated 06/02/25, showed Resident #6 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, utilized tobacco, and utilized supplemental oxygen.A Smoking/Vaping Supervision Checklist, dated 06/02/25, showed Resident #2 utilized tobacco and vaping products, received oxygen, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.A care plan, updated 07/03/25, showed Resident #6 smoked. The care plan did not show the resident utilized an electronic vape.4. On 07/08/25 at 3:38 p.m., Resident #11 was observed in their motorized wheelchair in their room, approximately 6 inches from their oxygen concentrator, vaping. The oxygen concentrator was observed to be on at 2L, water in the canister was observed to bubble, and the nasal canula was observed to lay over the top of the concentrator. On 07/08/25 at 3:43 p.m., Resident #11 was observed to have cigarettes and a lighter on the bedside table and two electronic vapes on their dresser.A Smoking/Vaping and Behavior Agreement, signed by Resident #11 on 11/29/22, read in part, Resident agrees to not smoke tobacco products or use vaping products, lighters or matches while in possession of oxygen equipment or while in the presence or vicinity of such equipment.A significant change assessment, dated 12/09/24, showed Resident #11 had a BIMS score of 14, which indicated the resident was cognitively intact for daily decision making, and utilized tobacco.A care plan, updated 01/27/25, showed Resident #11 was at risk for smoking related injuries, agreed to smoke/vape in smoking designated areas only, had signed and will abide by the smoking/vaping and behavior agreement, and the resident would be monitored to ensure they were not vaping in the vicinity of oxygen equipment.A physician order, dated 06/23/25, showed Resident #11 was ordered oxygen at 2-4L per minute via nasal cannula as needed.A Smoking/Vaping Supervision Checklist, dated 07/02/25, showed Resident #11 utilized vaping products, received oxygen, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.On 07/08/25 at 3:43 p.m., Resident #11 stated they were allowed to vape in their room.5. A policy titled Smoking, signed by Resident #12 on 04/03/24, read in part, The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2, and in non-public areas to prevent offending others. A significant change assessment, dated 01/27/25, showed Resident #12 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, utilized tobacco, and utilized supplemental oxygen.A care plan, updated 02/04/25, showed Resident #12 vaped, to remind them of designated smoking areas, and that they kept their vaping material in their room.A physician order, dated 02/25/25, showed Resident #12 was ordered oxygen at 2-4L per minute via nasal cannula every shift.A Smoking/Vaping Supervision Checklist, dated 06/04/25, showed Resident #12 utilized vaping products, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.6. On 07/08/25 at 3:57 p.m., CNA #1 was observed to make Resident #13's bed while the resident was observed to sit in their wheelchair beside the bed and vape. Resident #13's roommate, Resident #6, was not observed in the room but their oxygen concentrator was observed to be on. A policy titled Smoking, signed by Resident #13 on 08/08/24, read in part, The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2, and in non-public areas to prevent offending others.A care plan, updated 05/24/25, showed on 11/12/24 the administrator and the social services director met with the resident and discussed the resident smoked in their room earlier in the day, and they would now purchase them a vape.An annual assessment, dated 05/07/25, showed Resident #13 had a BIMS score of 02, which indicated the resident was severely impaired in cognition for daily decision making, and that the resident utilized tobacco.A Smoking/Vaping Supervision Checklist, dated 06/04/25, showed Resident #13 utilized vaping products, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.On 07/08/25 at 4:59 p.m., CNA #1 stated residents were allowed to vape in the facility. CNA #1 stated the residents could vape while oxygen was in use because there was not a flame.On 07/08/25 at 5:01 p.m., RN #1 stated a lot of residents used electronic vapes in their rooms. RN #1 stated if a resident utilized supplemental oxygen, they encouraged them to remove the oxygen while they vaped. RN #1 stated Resident #6 vaped everywhere in the facility, including the common areas, and utilized supplemental oxygen. RN #1 stated they just found out Resident #13 (Resident #11's roommate) vaped. RN #1 stated they had informed Resident #11 they should remove their oxygen if they were going to vape.On 07/08/25 at 5:08 p.m., CMA #1 stated residents were not allowed to vape inside the facility.On 07/08/25 at 5:13 p.m., CMA #2 stated residents were allowed to vape in the facility. CMA #2 stated they thought residents could vape in the common areas as well because residents did and no one had told them they could not vape there. CMA #2 stated residents could use electronic vapes and utilize supplemental oxygen because there was not a risk if residents vaped and utilized oxygen, only if they smoked cigarettes and utilized oxygen.On 07/08/25 at 5:15 p.m., CMA #3 stated residents were allowed to vape in the facility and they were not aware of any places they could not use electronic vapes. CMA #3 stated they do ask residents to be mindful and not vape while they were at the dining room tables. CMA #3 stated they did not think the use of supplemental oxygen while using an electronic vape had any potential negative effects, but they did not know for sure.On 07/08/25 at 5:23 p.m., CNA #2 stated they were not sure if residents were allowed to use electronic vapes while wearing supplemental oxygen or what the negative impact could be. On 07/08/25 at 5:25 p.m., LPN #1 stated residents were not allowed to vape inside the facility.On 07/08/25 at 5:55 p.m., CNA #1 stated they had observed Resident #6 use an electronic vape while wearing oxygen.On 07/08/25 at 5:57 p.m., CNA #3 stated Resident #1 and Resident #11 utilized oxygen regularly and knew both residents vaped. CNA #3 stated they had not observed either resident to wear supplemental oxygen and use an electronic vape.On 07/08/25 at 6:02 p.m., CMA #1 stated they had observed Resident #1 and Resident #11 both use electronic vapes while wearing supplemental oxygen.On 07/08/25 at 6:14 p.m., the DON stated they completed smoking/vaping assessments on residents on admission, quarterly, and as needed. The DON stated residents were allowed to vape in the facility, except in the dining room. The DON stated residents were not to wear supplemental oxygen or be in the vicinity of oxygen equipment while utilizing electronic vapes. The DON defined vicinity as approximately six feet. The DON stated themselves and the ADON monitored to ensure residents who utilized electronic vapes were safe by completing the smoking assessments, interviewing the residents who vaped, and speaking with staff. The DON stated utilizing an electronic vape while wearing supplemental oxygen could be risk to the residents because it could be flammable and the residents could get burned or injured. The DON stated they were aware Resident #1, 6, and Resident #11 utilized oxygen at times and vaped at times. The DON stated they had not observed the residents use their electronic vapes while wearing oxygen. The DON stated staff were made aware of the smoking/vaping policy through inservice. The DON stated the last inservice was conducted on 07/08/25 because staff had come to them with questions about residents who vaped and utilized supplemental oxygen after they had been interviewed by the survey team. They stated prior to 07/08/25 they had not been made aware residents vaped while utilizing supplemental oxygen.