**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for 10 of 11 residents (Resident #11, Resident #15, Resident #24, Resident #27, Resident #34, Resident #36, Resident #50, Resident #53, Resident #55, and Resident #68) while smoking in designated smoking areas. The facility did not provide adequate supervision to 10 residents that smoke outside in the designated smoking area. The facility failed to ensure adequate supervision was provided to Resident #11, Resident #15, Resident #24, Resident #27, Resident #34, Resident #36, Resident #50, Resident #53, Resident #55, and Resident #68 to ensure safe smoking and smoking materials were maintained by facility staff for all 10 residents and while they smoked outside in the designated smoking area. The facility did not comply to their policy and resident's care plans of securing all the smoking materials in the designated area at the nursing station. All of the resident's care plans stated smoking materials would be kept at the nursing station. An Immediate Jeopardy (IJ) situation was identified on 10/19/22 at 4:30 PM. While the IJ was removed on 10/22/22 at 5:10 PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of widespread due to the facility continuing to monitor their implementation plan and need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents who smoke at risk of injury and/or all the residents in the facility at the risk of fire and safety hazard that could cause serious harm or death. Findings included: Review of Resident #11's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of seizures, unsteadiness on feet, neoplasm of meninges (abnormal growth of tissues on meninges), other lack of coordination, cataract (cloudy lens in the eyes), and anxiety disorder. Review of Resident #11's care plan last revised on 07/25/2022 stated he will be monitored for safety when outside smoking and he will keep all smoking materials at the nurses station. Review of Resident #11's MDS revealed he has a BIMS Score of 14 showing he was cognitively intact. Review of Resident #11's smoking safety evaluations dated 08/25/21, 11/29/21, 03/15/22, 06/7/22, and 09/13/22, listed him as demonstrating the ability to safely smoke without supervision. Review of Resident #15's undated face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease, Major Depressive Disorder, and anxiety disorder. Review of Resident #15's care plan last revised on 8/29/22 stated to keep all smoking materials in designated area at the nurses station and to monitor resident when smoking and ensure resident's safety. Review of Resident #15's MDS revealed a BIMS Score of 15 showing she was cognitively intact. Review of Resident #15's smoking safety evaluations dated 08/29/22 and 10/18/22 states, Resident is a safe smoker and can smoke without supervision. Review of Resident # 24's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Major Depressive disorder, Recurrent, in partial remission, Anxiety disorder, Dependence on wheelchair, Panic Disorder, Other lack of coordination, Bipolar II Disorder, Primary insomnia, Muscle weakness (generalized), Unsteadiness on feet, Other abnormalities of gait and mobility and Nicotine dependence. Review of Resident #24's smoking safety evaluations dated 04/05/22, 07/12/22, and 09/20/22, revealed no concerns. Review of Resident #27's undated face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Dementia, anxiety, insomnia, muscle weakness, unsteadiness on feet, chronic a fib, and TIA. Review of Resident #27's care plan last revised 08/24/22 stated she is sometimes noncompliant with returning smoking materials to nurses desk and to keep all smoking materials in designated area at the nurses station and to monitor resident when smoking and ensure resident's safety. Review of Resident #27's MDS revealed a BIMS Score of 12 showing she was cognitively intact. Review of Resident #27's smoking safety evaluations dated 12/21/21, 03/29/22, 06/27/22, and 08/24/22, stated, Resident is a safe smoker. Review of Resident #34's undated face sheet revealed an [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Dementia, Major Depressive Disorder, Unspecified Psychosis, Adjustment Disorder with Disturbance of Conduct, Other Psychoactive Substance use, unspecified with other Psychoactive Substance-Induced Disorders. Review of Resident #34's care plan last revised on 09/06/22 stated to keep all smoking materials in designated area at the nurses station and that supervision is needed while he is smoking and to ensure his safety. Review of Resident #34's MDS revealed a BIMS Score of 08 indicating he is moderately impaired. Review of Resident #34's smoking safety evaluation dated 11/29/21, stated, Resident has smoked in non-designated areas. Recommend supervision and for staff to store his lighter and cigarettes. Review of his smoking safety evaluations on 06/27/22 and 09/06/22 states, Resident needs to be supervised during smoking. Review of Resident #36's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Dementia, Bipolar, Anxiety, Major Depressive Disorder, other impulsive disorders, and delusional disorders. Review of Resident #36's care plan last revised 08/30/2022 stated to keep all smoking materials in designated area at the nurses station and to monitor him when smoking and to ensure his safety. Review of Resident #36's MDS revealed a BIMS Score of 06 which indicated severely impaired cognition. Review of Resident #36's smoking safety evaluations dated 04/12/22, 07/19/22, and 10/18/22 stated, Resident is safe when smoking with staff assistance and supervision. Review of Resident #50's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis, Cannabis abuse with Psychotic Disorder with Delusions, Lyme Disease, Unspecified, Major Depressive Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Attention-Deficit Disorder. Review of Resident #50's care plan last revised 09/14/2022 stated he is keeping a cigar cutter and scissors at bedside and has been found smoking inside his room and is noncompliant with keeping smoking products and materials at nurses desk. The interventions included to keep all smoking materials in designated are at the nurses station and to monitor him when smoking to ensure his safety. Review of Resident #50's MDS dated [DATE] revealed a BIMS Score of 15 showing he was cognitively intact. Review of Resident #50's smoking safety evaluations dated 08/23/21, 11/29/21, 02/15/22, 05/31/22, and 08/30/22 did not list any concerns for the resident. Review of Resident #53's undated face sheet revealed an [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Dementia, Bipolar Disorder, Major Depressive Disorder, Lack of Coordination, Essential Tremor, and anxiety disorder. Review of Resident #53's care plan last revised 09/20/22 stated she is noncompliant with keeping smoking products at nurses desk. Her interventions included keep all smoking materials in designated area at the nurses station. Review of Resident #53's MDS dated [DATE] revealed a BIMS Score of 12 which indicated moderately impaired cognition. Review of Resident #53's smoking safety evaluations dated 08/23/21, 11/29/21, 03/01/22, 06/07/22, and 09/20/22, did not list any concerns for the resident. Review of Resident #55's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of cognitive impairment, alcohol abuse, insomnia, anxiety disorder, hx of falls, muscle weakness, and CVA (cerebrovascular accident) (Stroke). Review of Resident #55's care plan last revised 09/20/22 stated he is periodically noncompliant with keeping smoking products at nurses desk. His interventions included to keep all smoking materials in designated area at the nurses station and to monitor while smoking to ensure resident's safety. Review of Resident #55's MDS dated [DATE] revealed a BIMS Score of 11 which indicated moderately impaired cognition. Review of Resident #55's smoking safety evaluations dated 04/19/22, 07/19/22, 09/20/22, stated, Resident smokes safely and does not require staff supervision. Review of Resident #68's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of 2x12 Low Vision Right Eye Category 1, Low Vision Left Eye Category 2, Bilateral Unspecified Hearing loss, Alcohol Dependence, Unspecified Speech Disturbances and Personal history of Nicotine Dependence. Review of Resident #68's smoking safety evaluation dated 08/17/22, states, Resident is able to smoke without supervision. In an observation on 10/18/22 at 8:07 AM, 8:52 AM, and 9:14 AM, Resident #55 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 9:12 AM, 10:46 AM, and 11:12 AM, Resident #11 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 9:52 AM, 10:44 AM, and 11:46 AM, Resident #50 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 11:45 AM, 1:452 and PM, 3 PM, Resident #68 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 9:34 AM, 10:26 AM, and 11:19 AM, Resident #50 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:05 AM, 1:05PM, 1:35PM, 2:02PM, 2:48PM, 3:42PM, and 4:12PM, Resident #55 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:25 AM, 1:32 PM, 2:42 PM, and 3:41 PM, Resident #11 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 10:30 AM, 1:20 PM and 2:30 PM Resident #24 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:20 AM, an overstock of smoking supplies was observed to be kept in an unsecured drawer at the nurses' station. Plastic trash cans and metal trash cans with cigarette butts mixed with trash was located in designated smoking areas outside of the 400 hall, the front of the building, and the therapy area. In an observation and interview on 10/18/22 at 2:53 PM, Resident #53 was observed smoking and she said she keeps her cigarettes and lighter with her. She uses oxygen at night and her room has a board posted that says, Do not smoke, oxygen in use. In an observation and interview on 10/19/22 at 08:50 AM Resident #50 was observed to be asleep in his room. There was a strong smell of smoke. Investigator A asked CNA #1 to step into the room to identify the smell and she said, It smelled like it could be coming from his body, his clothes, and/or definitely smoking in the room. At 9:30 AM Investigator B visited Resident #50's room with ADM. ADM confirmed the smell of smoke and stated that Resident #50 had the history of smoking in his room and noncompliance to facility staff directives regarding safe smoking practices. In an observation and interview on 10/19/22 at 11:25 AM, Resident #11 was observed with visible tremors to his bilateral upper extremities. He said he had a difficult time holding onto things at times. In an observation and interview on 10/19/22 at 10:05 AM in her room, Resident #15 said she kept her cigarettes and lighter in her walker and displayed the items. She was informed that there was a Smoking Policy about where you were allowed to smoke. In an interview on 10/19/22 at 10:25 AM Resident #36 said the nurse rolled him out to smoke and she stayed most of the time. In an interview on 10/19/22 at 10:42 AM Resident #50 said his cigarettes and lighter fluid for his cigars were kept at the nursing station. He kept his cigars in his room in the brown box above his safe. He kept his cigarette lighter in his jacket. He stated the nurses, the ADMIN, and the DON were aware that he kept the cigars in his room. In an interview on 10/19/22 at 10:50 AM Resident #55 said he smoked on his own and displayed his cigarettes and lighter. He said the facility did not keep any of his supplies. He stated he did not have to adhere to smoking times and he smoked whenever he wanted. He did not have issues with burns on him, or his clothing. In an interview on 10/18/22 at 11:15 AM Resident #68 said she kept her cigarettes and lighter with her and displayed the cigarette packet and lighter that was with her in her room. In an interview on 10/19/22 at 1:00 PM Resident #24 said she secured the cigarettes and lighter in her room. She said she never smoked in her room as it was not safe. In an interview on 10/19/22 at 11:20 AM, the ADON stated that 8 residents kept their cigarettes and lighters on them or in their room (Resident #11, Resident #15, Resident #24, Resident #27, Resident #50, Resident #53, Resident #55, and Resident #68) and one of these residents were not allowed to keep smoking supplies because of previously smoking in his room. Staff were aware he kept his own supplies. Two additional residents required supervision (Resident #36 and Resident #34, but they had not smoked for several months). If an aide or nurse were available, they would take these two residents outside to smoke or leave them with other residents to supervise them while they smoked. In an interview on 10/20/22 at 3:30 PM with the RNA, she said without a proper Smoking Assessment, placed residents in jeopardy of harm. They have to monitor their residents. In an interview on 10/20/22 at 3:40 PM the ADMIN stated noncompliance to smoking policies and procedures lead to the risk of fire hazards that could cause serious harm to the residents. He said they have changed their policy to include supervision for all residents and checking their rooms daily. He said they cannot search personal items but would search around to avoid injuries and unnecessary fires inside of trash bins. Record Review on 10/19/22 of policy titled [facility name] Smoking Policy (undated) stated: All smoking materials (lighters, matches, cigarettes, cigars, pipes, electronic cigarettes) are to be kept at the nurses' station in a secure container. Staff will be required to supervise/assist those residents identified as having risk factors that require supervision/assistance during smoking. Smoking assessments are to be done on admission, quarterly, annually, and as needed for changes Record Review of policy titled Smoking Policy - Residents [facility name] (dated: Revised July 2017) stated: 11. Any resident with restricted smoking restrictions requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. No resident is allowed to keep smoking materials, to include lighters in their possession at any time. 13. Residents will be provided their smoking materials at designated smoking times by the staff member supervising the smoke time. The ADM was notified on 10/19/22 at 04:30 PM an IJ situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/22/2022 at 5:10 PM and included: Revisions were made to the policy to include safe smoking assessments that will be done monthly and on an as need basis started on 10/19/22. These assessments will be completed by the social worker. In-services on the revised smoking policy were started on 10/19/22 at 5:45 PM and completed the following morning on 10/20/22 at 9:00 AM by the ADON for all facility staff, including direct nursing staff, charge nurses, dietary staff, SW, MDS nurses, maintenance, and the receptionist. No employee will be allowed to work until they have been in-serviced on the revised smoking policy. This will be monitored for compliance daily by the ADM and the ADON and was in compliance on 10/20/22. All new employees will be in serviced; on the smoking policy before they begin their employment. The SW and the ADON completed new smoking assessments on the 8 residents that choose to smoke, and no resident required supervision except for one resident due to noncompliance with the smoking policy. Revisions were made to the policy to include safe smoking assessments that will be done monthly by the social worker. This will be monitored for initial and continued compliance by the ADM and /ADON. All 8 residents were observed by the social worker when the smoking assessment were completed. There are 4 additional residents that have not smoked for the past 2 to 3 months that had the resident status portion of the smoking assessment completed with documentation that the resident no longer smokes. This was completed by the SW on 10/19/22. The SW observed each of the 8 smokers while they were smoking for a new baseline assessment on 10/19/22. All new residents will also be given smoking assessments on arrival, and as needed. The ADM met with each resident that smoke on 10/19/22 to review the smoking policy which include supervision of smoking for any residents requiring supervision per their care plan. If they are unable to appropriately answer smoking safety evaluation questions, and or exhibit unsafe physical ques that could lead to possible harm and require supervision to be noted in their care plan. Each resident verbalized understanding of the smoking policy as explained by the ADM. All residents that smoke signed the revised smoking policy on 10/19/22. This will be monitored for initial and continued compliance by the ADM and ADON for six weeks or until achieved compliance. After review of the new smoking assessments, all residents were cleared to smoke with exception of one resident. To achieve safety compliance, and ensure all fire and accidental hazards are removed, a tackle box with a lock was purchased on 10/19/22 and all smoking materials for one non-compliant resident were placed inside. This resident is non-compliant due to ordering and using lighters and potential hazardous materials via mail and using these items in an unsafe environment. This resident also has past and recent history of smoking in his room, which could lead to fire hazards. No smoking materials were visually observed in this resident's room on 10/19/22 at 7:00 PM, or on 10/20/22 at 7:00 AM. The ADM confirmed that this resident's lighters or any combustible items were collected on 10/20/22 at 7:00 AM. These items were placed in the lock box at that time on 10/20/22 at 7:00 AM and will remain until resident demonstrates compliancy. Nurses will keep a key to the lock box and provide access per the resident's request. All nursing staff were in-serviced on the items that are to be kept in the locked box belonging to this resident. This will be monitored for compliance by the ADM and ADON. Rounding on one will be done to ensure the resident remains compliant, and not in possession of lighters or any combustible items two times per day by the SW, ADM or ADON starting on 10/19/22 on an as need basis for six weeks or until achieved compliance. The resident agreed for the ADM to remove smoking materials from his room on 10/20/22. This resident has been put on 1 on 1 observation due to a history of non-compliance due to ordering and using lighters and potential hazardous materials via mail and using these items in an unsafe environment. Resident #50 has past and recent history of smoking in his room, which could lead to fire hazards. Resident #50 will continue 1 on 1 supervision until safety concerns are met (related to non-compliance due to purchasing and maintaining lighters via mail). A hospitality aide will provide 1 on 1 supervision to this one resident. Only one resident has been placed on one-on-one supervision and his care plan has been updated by the MDS nurse on 10/20/22. This will be monitored for compliance by the ADM and ADON until safety concerns are met via IDT meetings. The ADM and MDIR rounded all smoking areas on 10/19/22 at 7:00 PM and replaced all regular trash cans and replaced them with metal trash bins that are covered and non-flammable. All facility staff were in-serviced on the proper disposal of cigarette butts. In-service was completed on 10/19/22 and 10/20/22 by the ADON and the ADM 10/20/22. All new employees will be in-serviced on cigarette butts not being emptied into trash cans at orientation by human resources. Safety concerns will be monitored for compliance by the administrator and the ADON daily until compliance is attained or as needed to ensure all residents and resident environment is free from fire hazards and potential harm. Record Review on 10/21/22 at 5:20 PM of the new Smoking Safety Evaluations revealed assessments had been completed for all smokers. Record Review on 10/21/22 at 5:45 PM revealed in-services on the Smoking Policy had been completed for all staff. In an interview on 10/21/22 at 6:30 PM, Resident 11 stated his cigarettes and lighter were at the nurse's station. He stated he follows the smoke schedule and is supervised while smoking. He did not need help while smoking and his hands only shook when they were cold. He demonstrated with his hands on how he smoked a cigarette, and observation revealed his hands were not shaking. In an interview on 10/21/22 at 7:13 PM, OT #1 stated she had been in-serviced on the Smoking Policy and made aware of the supervised smoking times and that all smoking supplies were to remain at the nurse's station. In an interview on 10/21/22 at 7:24 PM, LVN #2 stated she had been in-serviced on the Smoking Policy and made aware there were now posted smoke times and a staff member must be present to observe the residents at all times. She understood it must be done for safety purposes. In an interview on 10/22/22 at 1:05 PM, CNA #2 stated she had been in-serviced on the Smoking Policy by the ADM. She understood the residents were to be taken outside every 2 hours to smoke and they must be monitored at all times. In an interview on 10/22/22 at 2:15 PM with Resident #15, she stated they were monitored, and her cigarettes and lighters were left at the nurse's station at all times. In an interview on 10/22/22 at 2:30 PM with Resident #50, he stated he was not allowed to keep smoking materials in his room. He stated he was supervised and was only allowed to smoke during the designated times. During an observation on 10/22/22 at 3:11 PM revealed CNA #2 outside with the smokers and monitoring them while they were smoking. On 10/22/22 at 5:10 PM the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of widespread due to the facility's need to complete in-service training and evaluate their corrective actions.