**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** (2.) Based on review of the facility policy, observations, record reviews and interviews, the facility failed to ensure R131 was free from potential accidents, related to smoking on facility grounds for 1 of 4 residents identified for smoking. R131 being observed smoking unsafely, on the property of a smoke-free facility on 06/13/2025. On 06/13/2025 at 1:31 PM, the SA presented the Administrator with an IJ template related to this incident. On 06/13/2025 at 5:00 PM, the facility presented an acceptable IJ removal plan. Verification of the plan revealed the facility implemented their removal plan as of 06/16/25 at 6:30 PM. The facility remained out of compliance at a lower scope/severity level of D. Findings include: A review of the facility policy titled, Smoking Policy, Guidelines with a revision date 11/01/2017 states: Policy:Facility's Leadership will establish and enforce a specific smoking policy for Facility patients/residents, visitors and employees, outlining the parameters, if any, under which patients/residents, visitors and employees may be permitted to smoke on Facility's property. Procedures 6. ALL patients/residents are prohibited from keeping any type of smoking materials (lighter, matches, cigarettes, etc.) in their rooms or on their person . 10. Smoking by any person, including, without limitation, patients/residents, employees or visitors, in non-designated areas of the building or on Facility property, is strictly prohibited. Review of R131's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to, chronic obstructive pulmonary disease, nicotine dependence, and cognitive communication deficit. Review of R131's admission MDS with an ARD of 06/04/2025 revealed R131 had a BIMS score of 15 out of 15, indicating intact cognitive function. During an observation on 06/13/2025 at 07:40 AM, R131 self-propelled in a wheelchair, behind a cement column, in the courtyard. R131 was observed smoking a cigarette. During an interview on 06/13/2025 at 07:42 AM, Registered Nurse (RN)2 was asked about R131 smoking in the courtyard. RN2 stated, We are a smoke-free facility. She is not supposed to be smoking. During an interview on 06/13/2025 at 08:58 AM, the Nurse Practitioner stated, She is currently on the Nicotine patch. I was not aware of her smoking. I was just informed. The patch is not holding her. I will place her on the lozenges today. During an interview on 06/13/2025 at 10:32 AM, Administrator stated, I have spoken with R131 and the resident voluntarily gave me her cigarettes and lighter. I did the education for smoking with her. She will get discharged on Monday. This is a previously planned discharge. During an interview on 06/13/2025 at 11:00 AM, Certified Nursing Assistant (CNA)5 stated, I did not know she was a smoker. During an interview on 06/13/2025 at 11:05 AM, RN4 stated, I knew she had a Nicotine patch, I didn't know she was a current smoker. During an interview on 06/13/2025 at 11:37 AM, R131 stated, I've been smoking for 41 years. I have been smoking since I got here on Wednesday. Alot of people here smoke, they just don't get caught. A pack would last me about a week. Someone would bring me cigarettes. I kept my cigarettes, lighter, and vape in my little bag, and my bag always stays with me. I go out to the courtyard to smoke. None of the staff ever came out there. A lot of people didn't know. During an interview on 06/13/2025 at 11:43 AM, the Social Worker (SW) stated, Apparently this morning she was smoking, and our Administrator went out and talked to her and took the cigarettes from her and re-educated her. About 20 mins ago, I saw her vaping and took that away from R131. I wasn't aware that she was smoking prior to today. During an interview on 06/13/2025 at 11:49 AM, the Director of Nursing (DON) stated, I was not aware of any smokers prior to today. I'm not sure if she was a tobacco user upon her admission. It is possible that residents smoke when they go out on a leave of absence. We don't routinely ask them upon return from a leave of absence if they have smoking supplies. During an observation on 06/13/2025 at 1:15 PM, R131 was observed in the entryway to her room, crying. She stated, I don't know how I am going to be able to go a few more days without smoking anything. I have been smoking for years. During a follow-up interview with the Administrator on 06/13/2025 at 1:45 PM, she was made aware of the interview with R131. The Administrator stated they had identified a total of 4 residents in the facility, who currently smoked, however, none had any smoking paraphernalia on their person or in their rooms. The facility's removal plan included: Resident (R)131 smoking materials were given to the administrator for storage in administrator's office. Residents currently residing in the facility were asked by facility leadership if they currently are smokers on 06/13/2025. Four residents identified as current smokers. Two of the four declined cessation products and stated that they sign out and leave the premises with their family and smoke off site. The other two residents requested smoking cessation products. One of these residents does not have order or smoking cessation products and will be referred to NP on 06/13/2025 from the provider for smoking cessation product change. The Administrator will review on 06/13/2025 with the residents, that have self-identified as smokers, the admission policy including the smoking policy which states the facility is a non-smoking the facility and any smoking materials must be turned into the administrator for storage in administrators' office. RP/family will be notified and requested to pick up. Residents who have smoking materials will be asked to turn in those smoking materials to the administrator for storage in administrator's office on 06/13/2025. No residents had smoking materials. 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 06/13/2025. Facility staff will be reeducated on 06/13/2025 regarding the Smoking Policy including that the facility is a nonsmoking facility and that smoking residents are prohibited from keeping any type of smoking materials in their rooms or on their persons. Any staff not receiving this education by 06/13/2025 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 randomly interview a minimum of 2 staff and 2 interviewable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with the admission and smoking policy. 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 thru observation and interview that there are no smoking materials in resident's rooms or on their persons. Administrator/designee will round in the courtyard 2 times a day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate no smoking is occurring in this area. Any concerns will be addressed at time of discovery. The Medical Director was notified on 06/13/2025 of the Immediate Jeopardy. Ad Hoc quality Assurance Performance Improvement Meeting was held on 06/13/2025 to discuss contents of this plan. Administrator will oversee compliance of this plan for three months. Based on review of the facility policy, record review, and interviews, the facility failed to ensure that Resident (R)78 was free from elopement from the facility on 03/23/25, at an unknown time. On 06/13/2025 at 1:20 PM the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm. On 06/13/2025 at 1:21 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicare Services (CMS) Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/23/2025, when Resident (R)78 eloped from the facility. The IJ was related to 42 CFR 483.25 -Quality of Care, related to F689- Free of Accident Hazards/Supervision/Devices. On 06/16/2025 at 3:56 PM, the facility provided an acceptable IJ Removal Plan related to R78's elopement. The survey team validated the facility's implementation of the removal plan related to the elopement on 06/16/2025. The IJ was removed and lowered to a scope/severity level of D. Findings include: Review of the facility's policy titled, Elopement revised 11/01/2017 revealed, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. Procedures: 1. Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead______ (insert code name). 2. The DON/designee completes a missing resident profile. 4. The entire search process of the facility and grounds, from the time the patient/resident is missing, will be completed within (30) thirty minutes. Review of the facility's policy titled, Against Medical Advice (AMA)- Day Outings/Therapeutic Leaves of Absence revised 6/9/2023 revealed Under Procedures: 3. C. If the resident/legal representative still wishes to leave, the facility designee will ask the resident/legal representative to sign the Against Medical Advice Waiver and Release for Day Outings/Therapeutic Leaves of Absence form (Waiver). 1. If the patient/resident can make his/her own healthcare decisions, as documented in the medical record by the treating physician, resident will sign the Waiver. Review of R78's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to; muscle wasting and atrophy, and abdominal aortic aneurysm, without rupture. Review of R78's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/25 revealed a Brief Interview for Mental Status (BIMS) score was not recorded. Further review of the MDS revealed R78 has impairment of the upper extremity on one side, is at risk for falls, and need partial/moderate assistance for sit to stand mobility, to walk 10 feet and walking 50 feet with two turns as not attempted due to medical condition or safety concerns. Review of R78's Electronic Medical Record (EMR) did not reveal any documentation reflecting R78 was capable of making her own healthcare decisions. Review of Accuweather.com revealed that on 03/23/25, the high was 57 degrees Fahrenheit and the low was 28 degrees Fahrenheit, in regards to the temperature. Review of the facility's document titled, Release of Responsibility for Leave of Absence did not include any completed documents for R78. Review of R78's Nursing- Elopement Risk Observation dated 03/22/25 indicated Does the patient/resident have safe decision-making capabilities?. This question is answered as No. During an interview on 06/12/25 at 3:51 PM, Licensed Practical Nurse (LPN)2, provided the following account regarding an incident on 03/23/25 involving R78, a newly admitted resident. She stated, At the start of her shift on 03/23/25, another nurse reported to LPN2 that R78 had received her medication and was outside on the front porch with family. The resident was expected to sign the leave of absence log if she left the facility. LPN2 stated that she did not personally see the resident during her shift. Around 7:30 PM to 8:00 PM, during routine rounds, LPN2 noticed that R78 was not in her room. A search was conducted in common areas including the activity rooms, dayroom, dining room, courtyard, and the front parking lot, but R78 was not found. LPN2 attempted to contact both the resident and the resident's representative by phone, but neither answered. LPN2 informed the Director of Nursing (DON) of the situation. The DON advised continuing attempts to contact the resident and representative, with a plan to call again the following day. LPN2 stated that, per her training, when a resident is missing, staff are instructed to contact the family. LPN2 reported that no follow-up was made with her about the incident. Upon reflection, she believed she should have checked for the resident earlier, confirmed who the resident was with, and contacted the police when the resident could not be located. During an interview on 06/12/25 at 6:02 PM, the Administrator stated, On the 21st of March, R78 left on Sunday. I believe she was a smoker and wanted to leave because she couldn't smoke. I do know we assessed everyone for smoking on admission. LPN2 did follow up to reach R78. She wasn't at risk for elopement or disappeared. She was at no risk for elopement. She was told she needed to sign herself out and she did not. Someone in the building knew she was going to leave. She said she was going to the store. Our door locks on an automatic lock at 9 PM. Those who are confused, they wear a wanderguard. We tell the residents they have to sign out, we can't make them. We tried to call and the next day the Social Worker attempted to call the family. The Speech Language Pathologist (SLP) saw her on Sunday. I am unsure if the Physician was notified. During an interview on 06/13/2025 at 09:08 AM, Medical Director stated, I can not confirm or deny my awareness R78 left against medical advice. During an interview on 06/13/2025 at 9:09 AM, Certified Nursing Assistant (CNA)1 revealed that she was assigned to work with R78 on 03/23/2025. CNA1 stated, I assisted R78 with personal care around 1:00 PM and no later than 2:15 PM. R78 was dressed in a short sleeve green shirt, black leggings and some non-skid yellow socks, with no shoes or undergarments and her legs were covered, with a sheet. CNA1 further explained, I last saw R78 sitting inside the building at the front door around 2:30 PM or 2:40 PM. CNA1 stated that the resident had an issue with her right arm, but was able to use a wheelchair, she never walked but was able to stand and pivot to a chair. CNA1 further revealed that she left for the day around 2:55 PM or 3:00 PM and the resident was no longer at the door, she was unaware where the resident was and that she did not know that the resident had left the facility until she returned to work on Monday, 03/24/2025. During an interview on 06/13/25 at approximately 01:15 PM, the Administrator revealed that upon admission to the facility, the resident was made aware of the facility's policy regarding leaving the facility and acknowledged understanding by signing the admission handbook. During the survey, the Administrator stated that R78 had a BIMS of 14, she was cognitive and she had told staff that she would be leaving to go to the store with family and that the resident had a right to leave. The Administrator acknowledged at the time of the incident and currently, the whereabouts of the resident remained unknown, the facility had not considered this an elopement, so they did not notify the local authorities and/or continue to look for R78. Facility provided the following removal plan: Resident 78 no longer resides at the facility. The Social Worker attempted to call the resident & her son on 3/24/25. Voice message was left for both contacts and no call back were received. Adult protective services were notified to do welfare check on 06/16/25. Police department was notified to do wellness check on 06/16/25. . Elopement Risk evaluations done in the past 90 days on current residents inhouse will be reviewed by Director of Nursing/Designee for accuracy by 6/13/25. Residents identified at risk will be reviewed for appropriate interventions including placement in the Elopement Binder and validated care plans have interventions listed. The Director of Nursing was reeducated by the Clinical Consultant on 6/13/25 on Accidents and Incidents and Resident Care including: o Elopement risk o validating that when a resident is leaving and or expressing the desire to leave the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence o elopement risk assessment process and putting interventions in place based on risks identified. Validation with in service attendance sheet signature. Facility Staff will be reeducated by 6/13/25 by the Director of Nursing/Designee on Accidents and Incidents including: o elopement risk o validating that when a resident is leaving the facility and or expressing the desire to leave the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence Any staff not receiving this education by 6/13/25 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation. Nursing Staff will be reeducated on 6/13/25 by the Director of Nursing/Designee on Accidents and Incidents and Resident Care Including: o Elopement Risk o Validating that when a resident is leaving the facility and or expressing the desire to leave the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absences o Elopement risk assessment process accuracy o Checking for residents needs approximately every 2 hours o Notifications to Charge Nurse or Director of Nursing as indicated when a resident is not located Any staff not receiving this education by 6/13/25 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation. An elopement drill will be completed on 6/13/25 that includes: o The Administrator will notify the Charge Nurse, Director of Nursing and Social Service Designee that a resident is missing. The Director of Nursing/designee will announce Code [NAME] to signal the Elopement Drill Procedure o The Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds. The entire search process will be completed within 30 minutes o If the search fails to locate the missing resident in the allotted time, the Administrator/designee will place a mock telephone call to the appropriate community agencies, resident's legal representative and attending physician. Staff will provide the mock police with all the physical identifying information o The Search will continue if resident not located to include 2 staff members searching the surrounding streets by care for a 2 mile radius o When the volunteer resident is located the Charge Nurse will complete a head to toe assessment. The Social Services Designee will assess the resident for emotional distress. The Director of Nursing will notify the appropriate community agencies, attending physician and the resident's legal representative. o The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences o When the missing resident is found, an announcement will be made, Code [NAME] all clear. The Director of Nursing will randomly interview a minimum of 2 staff daily to validate understanding of elopement risk and elopement binder for 5 days, then weekly for 3 weeks then monthly for 2 additional months. The Director of Nursing/Designee will validate elopement risk assessments for accuracy beginning 6/13/25 in clinical morning meeting. The Medical Director was notified on 6/13/25 of the Immediate Jeopardy. A review of the facilities policy and procedures on leave of absence, resident's signing out, and Elopement was conducted on 6/13/25. No loopholes or changes were identified or needed during the review. An Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 6/13/25 to discuss contents of this plan. Administrator will oversee compliance of this plan.