**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and review of the facility policy, the facility neglected to identify and acknowledge that Resident (R)3 was missing from the facility. The facility further failed to implement emergency protocol in a timely manner in order to locate the missing resident. On 11/18/24 at 3:15 PM, the Administrator was notified that the facility neglected to acknowledge a resident was missing from the facility and implement emergency protocol timely for locating the missing resident, which constituted IJ at F600. On 11/18/24 at 3:15 PM, the survey team provided the Administrator with a copy of the CMS IJ Templates, informing the facility IJ existed as of 11/04/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 11/19/24 the facility provided an acceptable IJ Removal Plan for F600. On 11/19/24, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 11/07/24. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings Include: Review of the facility policy titled, Elopement, with a revision date of 11/1/17 states, to safely and timely redirect patients/residents to a safe environment. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: depression, cognitive communication deficit, acquired absence of left leg above knee, and unspecified psychosis not due to a substance or known physiological condition. Review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/24, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R3 had moderate cognitive impairment. Review of R3's Elopement Risk Observation dated 11/07/24 revealed, Resident is not oriented to person, place and time. Resident is confused. Does not have safe decision-making capabilities. Wanderguard placed on right ankle. Review of R3's Decisional Making Capacity Form located in his Electronic Medical Record revealed an undated document with R3's name on it. There was a slash across the form. Review of the Facility's 5 Day Reportable revealed R3 was taken from the facility on 11/04/24 between 1:00 PM - 2:00 PM. R3 was last seen sitting in his wheelchair on the front porch of the facility after lunch, which is his usual routine. On 11/04/24 at 5:30 PM, R3 was noted to not be available for his afternoon medications or dinner. Staff assumed R3 was visiting friends in the facility. R3 was not reported as potentially missing to the Administrator or the Police within 30 minutes as required by the facility's policy. An attempt was made to interview R3 on 11/18/24 at 11:38 AM with no success. A second attempt was made to interview R3 on 11/19/24 at 9:15 AM and 11:00 AM, with no success. Observations of R3 during these times revealed a wanderguard bracelet in place to R3's ankle. During an interview with the Medical Records Clerk on 11/18/24 at 11:57 AM, she stated she is responsible for setting up transport for appointments. She stated on the day of the appointment, she called the transport company to verify because she noted the original resident who was to be transported was still in the facility. She was told that the call had been completed, meaning transport had taken someone. She stated she notified transport that no one had been taken because the intended resident was still in the building. At that time, she was told that an investigation would be taking place. During an interview with the Central Supply Clerk on 11/18/24 at 12:09 PM, she stated, I was covering the Receptionist's lunch break at approximately 12:30 PM - 1:00 PM that day. I did notice 2 transport vans, 1 black and 1 gray, but did not see anyone get into the vans. She stated she was not made aware of R3 being missing until the next morning when she returned to work. She stated the process for residents leaving for appointments is typically a resident with a wheelchair will sit in the lobby and wait for transport. However, if they need a stretcher, transport comes to their room to get them. During an interview with Licensed Practical Nurse (LPN)1 on 11/18/24 at 12:13 PM, she stated, I got on the [med] cart around 1:00 PM. I did not receive a report, the keys to the cart were left in the book. I started giving medications so I could catchup on anything that may have been late. I believe it was around dinner time when a Certified Nursing Assistant (CNA) stated [R3's] tray was still in his room, untouched. I knew this was unusual because he goes to other units looking for food. She stated she then made the Director of Nursing (DON) and Unit Manager (UM) aware and went on about her night. LPN1 said, There was no code white or sense of urgency to look to see if anyone knew where [R3] was. During a telephone interview on 11/18/24 at 12:47 PM, the DON stated, [R3] left the facility with transport, instead of the resident that was intended to go. [R3] normally sits outside in the lobby but has never attempted to wander away from the facility. The Assistant DON (ADON) was supposed to go with the intended resident to the appointment, however, she left before him. Once it was noted that the intended resident was still in the building, transport was called and stated they had taken someone from the facility. Code White was not initiated because it was unknown that a resident was truly missing at that time. Later that day, the police notified the facility that [R3] was at a local Waffle House and a facility staff member went and picked him up. A telephone interview with the Lead Customer Service Supervisor of the Transport Driver on 11/18/24 at 1:24 PM, she stated, Driver asked and [R3] signed the letters BJ, so she took him. She stated that she is unaware of the drivers needing to go into the facility to verify who they are taking. She stated, I will reach out to our upper management to see if they will be putting a process in place so this doesn't happen again. During an interview on 11/18/24 at 1:30 PM, the ADON stated, I agreed to escort the original attendee to the appointment. She was sitting in the lobby of the facility with the original attendant and said she would meet him in there, so she left the facility to head to the doctor's office, which is approximately 18 minutes/13 miles away. The ADON stated she asked the Unit Manager (UM) to text or call when he (the intended resident) was picked up. The DON called and asked her to make a new appointment for him since there was an issue with transportation, but she was not made aware of what the issue was. When the ADON left the facility around 1:40 PM on 11/04/24, R3 was not outside of the facility at that time. She stated that when she was sitting at the doctor's office, there were no residents outside, nor was there a van. Since she was not made aware of the incident, she did not know to look for R3. During an interview with the Administrator on 11/18/24 at 2:07 PM, she stated, I was not made aware of the incident until Tuesday. I believe it was around 2:00 AM on 11/05/24 when [R3] returned to the facility with a staff member. [R3] told the workers at Waffle House that he was ready to go home. The workers then called the police and [R3] told the police his name and that he lived at Riverside. The police called the facility, and a staff member went and picked him up. When asked what her expectations were, the Administrator stated, If I had known he was missing or that transport had stated they had taken someone, I would have immediately locked the building down and completed a headcount, but unfortunately, that was not done. Multiple attempts were made to contact the staff member who returned R3 to the facility, for interview, with no success. During a telephone interview with R3's brother on 11/19/24 at 9:26 AM, he stated, The police called my mother stating my brother was at a Waffle House. My mother then told them to call me. When the police called, I told them that my brother is supposed to be at Riverside Nursing Home, so I don't know how he got to the Waffle House. The facility did not tell us all what happened, someone just called to say they were putting an ankle monitor on him. During an interview with the Administrator on 11/19/24 at 10:30 AM, she indicated that the form with the slash meant the resident has decisional making capabilities, but she would defer to the Social Services Director (SSD) for further clarification. During an interview with the SSD on 11/19/24 at 12:30 PM, he stated that the slash meant the resident does have decision making capacity, but there was not any documentation from a Physician to confirm it. He stated that he dropped the ball and R3's medical record is confusing because of conflicting information. During a follow-up interview with the Administrator and Administrator in Training on 11/19/24 at 1:15 PM, she stated that part of their audits was to ensure all residents were safely located in the building and residents who wish to be outside have now been provided with a courtyard that does not have access for them to be able to wander away from the facility unknown. On 11/19/24 the facility provided an acceptable IJ Removal Plan, which included the following: -What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice: Resident #1 left facility via transport van without staff knowledge. The resident was out of the facility without staff knowledge for more than two hours. Staff re-educated on physically checking on every resident at least every two hours on 11/7/24. Resident #1 is without injury and elopement risk assessment repeated on 11/7/24 with interventions in place per plan of care. A resident count was conducted for all residents when Resident #1 returned to the facility. All residents were accounted for. AOC date is 11/07/24. -How other residents who have the potential to be affected by the alleged deficient practice are identified: Residents who socialize on the front porch or along the walkway may be affected by this alleged deficient practice. -How the corrective action will be monitored to ensure the deficient practice will not recur: (include re-education) 1. Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch- 11/7/24 2. Re-education for staff on Abuse, Neglect, or Mistreatment starting 11/7/24. 3. Re-education for staff on physically checking on residents at least every two hours on 11/7/24. 4. Continue a midnight census every night as a daily audit. 5. Safe area (courtyard) provided for residents to socialize. Residents informed 11/7/24. 6. Adhoc QAPI- 11/7/24. 7. ADON/designee will audit midnight census five times weekly x4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved. -What quality assurance program will be put into place: Results of the monitoring will be presented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of the facility policy, the facility failed to provide adequate supervision for Resident (R)3, who successfully eloped from the facility. On 11/18/24 at 3:15 PM, the Administrator was notified that the failure to provide adequate supervision to prevent an elopement constituted Immediate Jeopardy (IJ) at F689. On 11/18/24 at 3:15 PM, the survey team provided the Administrator with a copy of the CMS IJ Templates, informing the facility IJ existed as of 11/04/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 11/19/24 the facility provided an acceptable IJ Removal Plan for F689. On 11/19/24, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 11/07/24. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of the facility's policy titled, Elopement, with a revision date of 11/01/17 states, to safely and timely redirect patients/residents to a safe environment. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: depression, cognitive communication deficit, acquired absence of left leg above knee, and unspecified psychosis not due to a substance or known physiological condition. Review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/24, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R3 had moderate cognitive impairment. Review of R3's Decisional Making Capacity Form located in his Electronic Medical Record revealed an undated document with R3's name on it. There was a slash across the form. Review of the Facility's 5 Day Reportable revealed R3 was taken from the facility on 11/04/24 between 1:00 PM - 2:00 PM. R3 was last seen sitting in his wheelchair on the front porch of the facility after lunch, which is his usual routine. On 11/04/24 at 5:30 PM, R3 was noted to not be available for his afternoon medications or dinner. Staff assumed R3 was visiting friends in the facility. R3 was not reported as potentially missing to the Administrator or the Police within 30 minutes as required by the facility's policy. An attempt was made to interview R3 on 11/18/24 at 11:38 AM with no success. A second attempt was made to interview R3 on 11/19/24 at 9:15 AM and 11:00 AM, with no success. Observations of R3 during these times revealed a wanderguard bracelet in place to R3's ankle. During an interview with the Medical Records Clerk on 11/18/24 at 11:57 AM, she stated she is responsible for setting up transport for appointments. She stated on the day of the appointment, she called the transport company to verify because she noted the original resident who was to be transported was still in the facility. She was told that the call had been completed, meaning transport had taken someone. She stated she notified transport that no one had been taken because the intended resident was still in the building. At that time, she was told that an investigation would be taking place. During an interview with the Central Supply Clerk on 11/18/24 at 12:09 PM, she stated, I was covering the Receptionist's lunch break at approximately 12:30 PM - 1:00 PM that day. I did notice 2 transport vans, 1 black and 1 gray, but did not see anyone get into the vans. She stated she was not made aware of R3 being missing until the next morning when she returned to work. She stated the process for residents leaving for appointments is typically a resident with a wheelchair will sit in the lobby and wait for transport. However, if they need a stretcher, transport comes to their room to get them. During an interview with Licensed Practical Nurse (LPN)1 on 11/18/24 at 12:13 PM, she stated, I got on the [med] cart around 1:00 PM. I did not receive a report, the keys to the cart were left in the book. I started giving medications so I could catchup on anything that may have been late. I believe it was around dinner time when a Certified Nursing Assistant (CNA) stated [R3's] tray was still in his room, untouched. I knew this was unusual because he goes to other units looking for food. She stated she then made the Director of Nursing (DON) and Unit Manager (UM) aware and went on about her night. LPN1 said, There was no code white or sense of urgency to look to see if anyone knew where [R3] was. During a telephone interview on 11/18/24 at 12:47 PM, the DON stated, [R3] left the facility with transport, instead of the resident that was intended to go. [R3] normally sits outside in the lobby but has never attempted to wander away from the facility. The Assistant DON (ADON) was supposed to go with the intended resident to the appointment, however, she left before him. Once it was noted that the intended resident was still in the building, transport was called and stated they had taken someone from the facility. Code White was not initiated because it was unknown that a resident was truly missing at that time. Later that day, the police notified the facility that [R3] was at a local Waffle House and a facility staff member went and picked him up. During an interview on 11/18/24 at 1:30 PM, the ADON stated, I agreed to escort the original attendee to the appointment. She was sitting in the lobby of the facility with the original attendant and said she would meet him in there, so she left the facility to head to the doctor's office, which is approximately 18 minutes/13 miles away. The ADON stated she asked the Unit Manager (UM) to text or call when he (the intended resident) was picked up. The DON called and asked her to make a new appointment for him since there was an issue with transportation, but she was not made aware of what the issue was. When the ADON left the facility around 1:40 PM on 11/04/24, R3 was not outside of the facility at that time. She stated that when she was sitting at the doctor's office, there were no residents outside, nor was there a van. Since she was not made aware of the incident, she did not know to look for R3. During an interview with the Administrator on 11/18/24 at 2:07 PM, she stated, I was not made aware of the incident until Tuesday. I believe it was around 2:00 AM on 11/05/24 when [R3] returned to the facility with a staff member. [R3] told the workers at Waffle House that he was ready to go home. The workers then called the police and [R3] told the police his name and that he lived at Riverside. The police called the facility, and a staff member went and picked him up. When asked what her expectations were, the Administrator stated, If I had known he was missing or that transport had stated they had taken someone, I would have immediately locked the building down and completed a headcount, but unfortunately, that was not done. During an interview with the Administrator on 11/19/24 at 10:30 AM, she indicated that the form with the slash meant the resident has decisional making capabilities, but she would defer to the Social Services Director (SSD) for further clarification. During an interview with the SSD on 11/19/24 at 12:30 PM, he stated that the slash meant the resident does have decision making capacity, but there was not any documentation from a Physician to confirm it. He stated that he dropped the ball and R3's medical record is confusing because of conflicting information. During a follow-up interview with the Administrator and Administrator in Training present on 11/19/24 at 1:15 PM, she stated that part of their audits was to ensure all residents were safely located in the building and residents who wish to be outside have now been provided with a courtyard that does not have access for them to be able to wander away from the facility unknown. On 11/19/24 the facility provided an acceptable IJ Removal Plan, which included the following: -What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice: Resident #1 left facility via transport van without staff knowledge. The resident was out of the facility without staff knowledge for more than two hours. Staff re-educated on physically checking on every resident at least every two hours on 11/7/24. Resident #1 is without injury and elopement risk assessment repeated on 11/7/24 with interventions in place per plan of care. A resident count was conducted for all residents when Resident #1 returned to the facility. All residents were accounted for. AOC date is 11/07/24. -How other residents who have the potential to be affected by the alleged deficient practice are identified: Residents who socialize on the front porch or along the walkway may be affected by this alleged deficient practice. -How the corrective action will be monitored to ensure the deficient practice will not recur: (include re-education) 1. Elopement drill conducted 11/7/24. 2. Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch- 11/7/24 3. Re-education for staff on Elopement Policy and Process and Abuse, Neglect, or Mistreatment starting 11/7/24. 4. Elopement risk assessments completed on residents who reside in the facility on 11/7/24. 5. A review of residents who are assessed as an elopement risk was completed on 11/7/24 and care plans updated as appropriate. 6. Safe area (courtyard) provided for residents to socialize. Residents informed 11/7/24. 7. Adhoc QAPI- 11/7/24. 8. Continue a midnight census every night as a daily audit. 9. ADON/designee will audit for elopement assessments completed and accurate within 24 hours or admission/readmission five times weekly for 4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved. 10. ADON/designee will audit 24-hour report and new nurses' notes (facility activity report) for documentation of elopement risks five times weekly x 4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved. -What quality assurance program will be put into place: Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, interviews, and observations, the facility failed to conduct smoking assessments for 4 out of 10 residents (Resident (R)84, R116, R133, and R75) who smoke. Additionally, the facility failed to provide proper safety protocols for 10 out of 10 residents (R80, R84, R116, R595, R60, R133, R75, R93, R37, and R103) who smoke. On 03/13/24 at 4:32 PM, the Administrator was notified that the failure to conduct assessments on residents who smoke and failing to provide proper safety protocols for residents who smoke constituted Immediate Jeopardy (IJ) at F689. On 03/13/24 at 4:32 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/10/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 03/13/24, the facility provided an acceptable IJ Removal Plan. On 03/14/24 the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F689 at a lower scope and severity of E. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of the facility's admission Handbook with a revision date of 05/22/20 revealed the following, Smoking Policy. Unless otherwise noted in a separate policy, this facility is a smoke-free environment . All residents are prohibited from keeping any type of smoking materials (lighter, matches, cigarettes, etc.) in their rooms or on their person. Violations of this policy endanger the health and safety of others at the facility . Review of the facility's policy titled Smoking Policy for Residents and Visitors with an effective date of 08/31/07, revealed, . our nursing facility discourages smoking due to complications that may arise due to medications, illnesses and smoking accidents. Further, we have the added responsibility of ensuring all residents, visitors and staff is free from all fire and smoking hazards . Accordingly, the following smoking policy has been implemented in our Facility and shall be enforced for ALL resident admitted after August 14, 2006 . This Facility is a smoke-free environment and, as such, there are NO designated smoking areas inside the building or on its premises for either residents or visitors. All residents are prohibited from keeping any type of smoking materials (lighter, matches, cigarettes, etc.) in their rooms or on their person. Residents' smoking materials will be kept in assigned lockers adjacent to the exit door to the garden area between Units 100 and 200. The keys for the lockers will be controlled by the medication nurse on the back hall of Unit 200 and kept in the medication cart. During an observation on 03/13/24 at approximately 9:45 AM, R80, R84, and R116 were across the street from the facility smoking. R80 was in a motorized wheelchair, R116 was in a manual wheelchair, and R84 did not have any assistive devices for ambulation. Further observation revealed no protective equipment and no staff were present to supervise and/or provide assistance. During an interview on 03/13/24 at approximately 10:00 AM, the Assistant Business Office Manager (ABOM), who was working the receptionist desk, stated, There were residents trying to smoke. But we put a stop to it. the residents that do smoke have to sign out on a leave of absence. They sign out at the nurses station. During an interview on 03/13/24 at 10:05 AM, with the group of residents smoking, revealed: R80 stated, We use to smoke on property, but they made it no smoking on property. So we come across the street. It's not really safe cause we have to cross the street and the cars zoom by like a bat out of hell. We have to watch out for the traffic. I haven't had any assessment and I keep my cigarettes and lighter on me all the time. There are about eight of us who come out here to smoke. They lock the front doors at seven, so we can't smoke after that. R84 stated, The cars come barreling through here and it is not safe. R116 stated, I keep my cigarettes and lighter on me all the time. During an interview on 03/13/24 at 10:40 AM, Licensed Practical Nurse (LPN)3 stated, I have one smoker [R84]. The resident keeps their own smoking supplies. They sign out and they can go on their own. The smoking situation is new and we are adjusting. [R84] doesn't usually sign out because she is independent. I don't know if they had assessments. During an interview on 03/13/24 at 10:43 AM, LPN12 stated, [R133] tries to buy cigarettes from other residents and sometimes his family brings him some. I am not sure if the residents have had assessments. LPN12 identified the following residents who smoke: R595, R60, and R133. During an interview on 03/13/24 at 10:50 AM, LPN13 stated, I got one smoker on my hall [R93]. He goes out at least four times on my shift. I don't know if he's had an assessment. I hope he had one done. I don't know what he does with his smoking supplies. I am from [another state] and when I worked there we kept it (smoking materials) in a lock box, I don't know what they do here. Investigation identified the following residents that smoke: 1. Review of R80's Face Sheet revealed, R80 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory disease, sepsis, paraplegia, chronic obstructive pulmonary disease with acute exacerbation, shortness of breath, morbid obesity, asthma, and cognitive communication deficit. Review of R80's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/23, revealed R80 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. Review of R80's Physician Orders dated 02/12/24 revealed an order for 2L oxygen PRN via NC. Review of R80's Electronic Medical Record (EMR) revealed, a Smoking Policy with an effective date of 08/31/07 signed by R80 on 01/31/24. Review of R80's Smoking Risk (Acuity) dated 03/01/24 revealed, R80 smokes cigarettes every few hours. Further review of the Smoking Risk revealed, R80 is a moderate problem for Inappropriately Provides Smoking Materials to Others and Mobility. The Smoking Risk evaluated R80 at a score of 4.0 indicating R80 was a safe smoker. Review of R80's Care Plan with a start date on 02/20/24 revealed the following problems: [R80] requires oxygen therapy PRN R/T COPD. Problem start date 09/05/23 [R80] is a former smoker, smoking cessation patch offered. Problem start date 01/27/22 [R80] is at risk for complications related to Asthma and COPD. Problem start date 01/27/22 [R80] at risk for falling R/T Paraplegia, lack of coordination, muscle wasting, and weakness. 2. Review of R84's Face Sheet revealed R84 was admitted to the facility on [DATE] (latest return on 12/19/23), with diagnoses including but not limited to: Type 2 diabetes, cognitive communication deficit, disorientation, acute respiratory disease, muscle weakness, abnormalities of gait and mobility, osteoarthritis, shortness of breath, major depressive disorder, lack of coordination, difficulty in walking, and cognitive social or emotional deficit. Review of R84's Quarterly MDS with an ARD of 03/02/24, revealed R84 had a BIMS score of 99 indicating the resident was unable to complete the interview. Review of R84's Physician Orders revealed the following orders: Seroquel (quetiapine) tablet; 50 mg; amt: 1.5 tablet; oral At Bedtime 09:00 PM 09/12/2023 and tramadol - Schedule IV tablet; 50 mg; amt: ONE TABLET; oral Special Instructions: ONE TAB TID PRN FOR KNEE PAIN As Needed PRN 1, PRN 2, PRN 3 03/05/2024 Review of R84's EMR revealed no Smoking Risk (Acuity) was completed. Review of R84's Care Plan with a start date of 09/11/23 revealed the following problems: [R84] has cognitive impairment and communication deficit, memory problems: Symbolic dysfunction, short/long term memory problems Impaired ability to make decisions R/T Following CVA. [R84] at risk for falling R/T R side weakness . 3. Review of R116's Face Sheet revealed R116 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic kidney disease, acute kidney failure, altered mental status, type 2 diabetes, nicotine dependence, cognitive communication deficit, unsteadiness on feet, lack of coordination, muscle wasting and atrophy, and muscle weakness. Review of R116's Quarterly MDS with and ARD of 01/11/24, revealed R116 had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. Review of R116's EMR revealed no Smoking Risk (Acuity) was completed. Review of R116's Care Plan revealed the following problems: Problem start date 07/25/22 [R116] has cognitive impairment AEB memory problems: short/long term memory problems. Impaired ability to make decisions. Impaired communication. Problem start date 07/07/22 [R116] is at risk for falling R/T orthostatic hypotension. 4. Review of R595's Face Sheet revealed R595 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 diabetes, panic disorder, heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Review of R595's admission MDS with an ARD of 02/29/24, revealed R595 had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. Review of R595's Smoking Risk (Acuity) dated 03/08/24, revealed R595 smokes cigarettes more than once per hour. Further review of the Smoking Risk revealed, R595 is a minimal problem for Smokes in Unauthorized Areas and Mobility. R595 is a moderate problem for General Awareness and Orientation-Including Ability to Understand the Facility Safe Smoking Policy, General Behavior and Interpersonal Interaction and Capability to Follow Facility Safe Smoking Policy. The Smoking Risk evaluated R595 with a score of 8.0, indicating R595 to be a safe smoker. Review of R595's Care Plan revealed the following problems: Problem start date 03/10/24 Resident at risk for falling R/T impaired mobility. Problem start date 03/10/24 Resident is limited in physical mobility R/T impaired mobility and weakness. 5. Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE] with diagnoses including but not limited to: undifferentiated schizophrenia, acute respiratory failure, muscle weakness, tremor, internuclear ophthalmoplegia bilateral, elevated blood-pressure reading, nicotine dependence, cognitive communication deficit, and convulsions. Review of R60's Quarterly MDS with an ARD of 12/15/23, revealed R60 had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. Review of R60's Smoking Risk (Acuity) dated 03/09/24, revealed R60 smokes cigarettes more than once per hour. R60 scored a 0.0 on indicating R60 is a safe smoker. Review of R60's EMR revealed a Smoking Policy with an effective date of 08/31/07, signed by the resident on 01/09/23 and 08/04/23. Review of R60's Care Plan revealed the following problems: problem start date 09/26/22 [R60] appears to have recall deficit related to: short term recall - long term recall - poor decision making. Problem start date 12/22/21 [R60] requires assistance with ADL's due to Anemia, weakness and TBI . Problem start date 10/11/18 [R60] has the dx of bipolar and schizophrenia and is at risk for behaviors including yelling out, seeing things that aren't there, insomnia, puts self on floor when angry bout going home, crying, and decline in mood. Combative at times with staff and aggressive with another resident . Non compliant with smoking policy. Problem start date 09/26/18 [R60] at risk for falling R/T left sided weakness, tremors and Psychotropic meds. 6. Review of R133's Face Sheet revealed R133 was admitted to the facility on [DATE], with diagnoses including but not limited to: schizophrenia, chronic bronchitis, wheezing, bipolar disorder, nicotine dependence, cough, mental disorder due to known physiological condition, lack of coordination, cognitive communication deficit, muscle wasting and atrophy, and muscle weakness. Review of R133's Quarterly MDS with an ARD of 02/14/24 revealed a BIMS score of 14 out of 15 indicating the resident was cognitively intact. Review of R133's Physician Orders revealed the following orders: albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 Puffs; inhalation Special Instructions: Inhale 2 puffs into the lungs every 4 hours as needed for shortness of breath/wheezing As Needed PRN 1, PRN 2, PRN 3 02/06/2024, ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg(2.5 mg base)/3 mL; amt: 3mL; inhalation Special Instructions: 3mL q4 PRN for SOB/wheezing As Needed PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6 01/26/2024, Ativan (lorazepam) - Schedule IV solution; 2 mg/mL; amt: 2mg; injection Special Instructions: 2mg BID PRN As Needed PRN 1, PRN 2 12/15/2023, Breo Ellipta (fluticasone furoate-vilanterol) blister with device; 100-25 mcg/dose; amt: 1 puff; inhalation Special Instructions: Rinse and spit after each use Once A Day 09:00 AM 02/07/2024, and Seroquel (quetiapine) tablet; 50 mg; amt: 1 tab; oral Three Times A Day 09:00 AM, 01:00 PM, 09:00 PM 01/18/2024. Review of R133's Smoking Risk (Acuity) dated 11/09/23 revealed, R133 scored a 12.0 indicating R133 was an unsafe smoker. Further review of the Smoking Risk revealed the following: Potentially Unsafe Smoker - Follow Facility Policy - Clinical Judgement - Resident is not capable of even supervised smoking. Smoking will result in danger to self or others. True - Withhold smoking materials. Review of R133's Care Plan revealed the following problems: problem start date 02/12/24 [R133] is at risk for respiratory distress R/T bronchitis. Problem start date 11/16/23 [R133] is at risk for falling R/T neyrocognitive disorder. Problem start date 11/16/23 [R133] is at risk for further cognitive impairment R/T Neurocognitive disorder. Problem start date 11/10/23 [R133] is at risk for having mood and behaviors changes R/T Schizophrenia. Problem start date 11/10/23 '[R133] wanders and/or is an elopement risk. Requites wander guard. 7. Review of R75's Face Sheet revealed R75 was admitted to the facility on [DATE] with diagnoses including but not limited to: Wernicke's encephalopathy, tremor, delirium, Type 2 diabetes, reduced mobility, delusional disorders, difficulty in walking, and major depressive disorder. Review of R75's Quarterly MDS with an ARD of 12/12/23 revealed a BIMS score of 12 out of 15, indicating R75 was moderately cognitively impaired. Review of R75's EMR revealed no Smoking Risk (Acuity) was completed. 8. Review of R93's Face Sheet revealed R93 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic osteomyelitis, cough, and sepsis Review of R93's Quarterly MDS with an ARD of 12/27/23, revealed a BIMS score of 14 out of 15 indicating the resident was cognitively intact. Review of R93's Smoking Risk (Acuity) dated 03/01/24, revealed R93 smokes cigarettes every few hours. Further review of the Smoking Acuity revealed R93 was a minimal problem for Inappropriately Provides Smoking Materials to Others and Mobility. R93 scored a 2.0 indicating R93 is a safe smoker. Review of R93's Care Plan revealed the following problems: problem start date 05/21/21 [R93] has behaviors which include cursing at staff, refusing to obtain weight, and makes false acquisitions regarding meal/portion preferences and medication administration. Problem start date 04/01/21 [R93] at risk for falling . 9. Review of R37's Face Sheet revealed R37 was admitted to the facility on [DATE] with diagnoses including: cerebral palsey, acute upper respiratory infection, acute bronchitis, pneumonia, contracture, cough, bipolar disorder, nicotine dependence, and acquired absence of right leg below knee. Review of R37's Quarterly MDS with an ARD of 12/13/23 revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. Review of R37's EMR revealed a Smoking Policy with an effective date of 08/31/17 signed by the resident on 01/29/24. Review of R37's Smoking Risk (Acuity) dated 03/01/24, revealed R37 smokes cigarettes and vape a couple times per day. Further review of the Smoking Risk revealed, R37 is minimal risk for Smokes in Unauthorized Areas, Inappropriately Provides Smoking Materials to Others, and Begs or Steals Smoking Materials From Others. R37 is a moderate problem for Mobility. R37 scored a 5.0 on the Smoking Risk indicating R37 is a safe smoker. Review of R37's Care Plan revealed the following problems: problem start date 09/27/23 [R37] is a risk for self harm related to: SUD, Poor support system, loneliness as evidence by: Statements of despair, helplessness, hopelessness, Suicide behavior (talk). Problem start date 09/19/23 [R37] is at risk for cognitive decline and behaviors R/T cerebral palsy, Bipolar with use of psychotropics. Problem start date 09/05/23 [R37] is a former smoker and occasionally staff has caught resident smoking despite encouragement and education. Problem start date 10/14/21 [R37] is unable to make daily decisions without cues/supervision R/T decreased safety awareness. Problem start date 09/27/21 [R37] chooses to smoke an e-cigarette. 10. Review of R103's Face Sheet revealed R103 was admitted to the facility on [DATE] with diagnoses including but not limited to: acute hematogenous osteomyelitis, difficulty walking, spastic hemiplegia, and cognitive communication deficit. Review of R103's Quarterly MDS with and ARD of 12/30/23 revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. Review of R103's EMR revealed a Smoking Policy with an effective date of 08/31/07 signed by R103 on 08/07/23. Review of R103's Smoking Risk (Acuity) dated 03/01/24 revealed R103 smokes cigarettes a couple times per day. Further review of the Smoking Risk revealed R103 is a moderate problem for Mobility. R103 scored a 2.0 indicating R103 is a safe smoker. Review of R103's Care Plan revealed the following problems: problem start date 03/07/24 Resident at risk for falling R/T unsteady gait. Problem start date 05/15/23 He is at risk of having mood and behavior needs as evidence by periods of (type of behavior, socially inappropriate, physically aggressive, verbally aggressive, refusing care). Problem start date 05/10/22 [R103] may have c/o pain r/t left arm and hand contracted. Problem start date 05/04/22 [R103] is at risk for falling R/T traumatic amputation of 2 or more toes, seizures, resident removes wheel chair arm rest per preference. During an interview on 03/13/24 at 2:13 PM, R75 states, I smoked about a month and a half ago. I kept my cigs in my room and I borrowed someone's lighter. During an interview and observation on 03/13/24 at 2:25 PM, R133 states, I smoked yesterday, across the street. I get lucky and get one every now and again. I buy cigarettes from other residents. Observation revealed an oxygen tank in R133's room. During an interview and observation on 03/13/24 at 2:31 PM, R103 states, I smoked yesterday and I had to cross the street. I don't like crossing that street. I went out to smoke on Sunday, when I was crossing the street to come back, someone almost hit me with their van. I get my cigarettes and lighter from who ever is out there smoking. I buy my own cigarettes whenever I get some money. Observation revealed R103 in a manual wheelchair and both of R103's hands were contracted. During an interview and observation on 03/13/24 at approximately 2:35 PM, three additional residents were observed smoking across the street. During an interview on 03/13/24 at 2:37 PM, while smoking, R60 states, It ain' t too safe crossing that street. I smoked yesterday. I keep my cigarettes and lighter in my room. During an interview and observation on 03/13/24 at 2:40 PM, while smoking, R93 states, I smoke three to four times a day. I don't like crossing the street because of traffic and the parking lot. It's hard to get out here because the wheels on my walker get stuck. I keep all my smoking supplies in my walker. Observation revealed R93 sitting on his walker smoking. R93 pulled up the seat on the walker, revealing a pack of cigarettes and a lighter. During an interview and observation on 03/13/24 at 2:44 PM, while smoking, R37 states, I smoke about three to four times a day. I don't like crossing the street cause I got hit by a car when I was younger. I keep my cigarettes and lighter in my dresser drawer. Observation revealed R37 smoking, in a mechanical wheelchair, R37's left hand was contracted. During an interview on 03/13/24 at 3:17 PM, the Administrator and Director of Nursing (DON) revealed, residents have to sign out and leave the building to smoke. The DON stated her expectation is that they do not smoke. When they leave here we don't know what they are doing. We were not aware that the residents were keeping smoking materials in their room. When we see them in the facility, we will take the smoking items. The Administrator revealed, the lighter goes to the nurses station and the cigarettes we throw away. It usually goes with the nurse in their cart. We do not know how many smokers are in the facility. We were not aware that residents were sharing and borrowing cigarettes from other residents. The DON concluded, if it is a resident that we know smokes, we will do an assessment. On 03/13/24 the facility provided a removal plan, which included the following: Residents currently residing in the facility were asked by facility leadership if they currently are smokers on 3/13/24. Those self-identified as smokers will have a smoking acuity (assessments) completed by a licensed nurse on 3/13/24. The Administrator will review on 3/13/24 with the residents, that have self-identified as smokers, the admission policy including the smoking policy which states the facility is a nonsmoking facility and any smoking materials must be turned into a nurse for secured storage. Residents who had smoking materials have turned in those smoking materials to the administrator for storage in a secured area on 3/13/24. Smoking Cessation products will be offered to any resident that has identified as a smoker. If they chose to utilize smoking cessation products, the physician will be notified and orders obtained on 3/13/24. A Review of the Release of Responsibility for leave of absence forms was completed by the Director of Nursing. resident who are currently signed out were located in the facility and reeducation was provided to residents who sign themselves out regarding signing back in upon return and notifying the nurse when leaving the facility and returning on 3/13/24. Facility Staff and residents who sign themselves out via leave of absence form will be reeducated by Director of Nursing/Designee on the following: - Residents who identify as smokers will have the Smoking Acuity (Assessment) completed upon admission by a licensed nurse. - Residents will sign in and sign out with the nurse or facility representative at the nurse's station when they leave the building. - Residents check in with charge nurse or facility representative upon return. - Residents are prohibited from keeping any type of smoking materials in their rooms or on their persons. If residents do not surrender smoking materials upon reentry, appropriate discharge planning by Social Services will occur if smoking materials are identified. Any staff not receiving this education on 3/13/24 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation and for agency staff. The Director of Nursing will validate in clinical morning meeting Monday-Friday that Smoking Acuity (assessment) has been completed for newly admitted residents identifying as a smoker. The Director of Nursing will randomly interview a minimum of 2 staff and 3 interviewable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with leave of absence sign in/out process. Director of Nursing/designee will review sign out logs twice a shift for 5 days then daily for 3 additional weeks, then monthly for 2 additional months to validate residents remain complaint with signing in and out of the facility. Administrator/designee will round in resident rooms 2 times per day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate there are no smoking materials in residents' rooms or on their persons. Any concerns will be addressed at time of discovery. The Medical Director was notified on 3/13/24 of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting was held on 3/13/24 to discuss contents of this plan. Administrator will oversee compliance of this plan for three months.