**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care consistent with professional standards of practices for 5 of 5 residents (CR # 1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for respiratory care related to tracheostomy care. The facility failed to train nurses on tracheostomy care, including LVN A. On 8/21/2025, LVN A noticed CR #1's trach appeared to be at an angle and when CR # 1 was repositioned, his entire tracheostomy was out and, on his chest below his chin. Attempts to reinsert the tracheostomy canula were unsuccessful as the stoma was closed. CR # 1 was admitted to the hospital with evidence of prolonged decannulation SNF stay. The facility failed to ensure licensed nursing staff were trained to provide tracheostomy care for CR # 1, Resident # 2, Resident # 3, Resident # 4 and Resident # 5 An Immediate Jeopardy (IJ) situation was identified on 8/27/2025. The IJ template was provided to the facility on 8/27/2025 at 1:15 p.m.,. While the IJ was removed on 8/28/2025 at 4:13 pm the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained and due to the facility's need to evaluate the effectiveness of thee corrective systems. This failure could place residents at risk for respiratory distress, serious injury harm, impairment or death. Record review of CR # 1's face sheet, dated 8/22/2025, revealed he was a [AGE] year-old male that had been admitted on [DATE] with diagnoses of Cerebral Infarction due to unspecified Occlusion and Stenosis of unspecified Cerebral Artery (a medical condition where a blood vessel in the brain becomes blocked or narrowed, leading to a loss of blood flow to the brain.), Type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), Hemiplegia-unspecified affecting right dominant side(a condition where there is paralysis or weakness on one side of the body (hemiplegia), and the affected side is the dominant (usually the right) side of the brain, Convulsions (uncontrolled and involuntary rapid tensing and relaxing of muscles, causing the body to shake) and Hypertension (a chronic condition characterized by persistently elevated blood pressure levels). Record review of CR # 1' s MDS, dated [DATE], indicated CR # 1 had a BIMS score of 6 (cognitive impairment). CR # 1 was total dependent and required assistance of two people for all ADLs. CR # 1 was always incontinent (unable to control) of bowel and bladder. CR #1 sometimes make was able to make self-understood ad understood other.Record review of CR #'1 care plan, dated 8/14/2025, revealed it did not address he had a tracheostomy (direct airway into the trachea (windpipe) through a surgical incision in the neck) or the care of the tracheostomy. Record review of CR # 1's physician order report start date 7/17/2025 and no end date revealed, CR # 1 trach care: HOB- elevate head of bed every shift, suctioning-every shift suction, trach tie-every day shift every 7 days, change tubing and mask-every shift every Sunday, 5L O2 via trach collar (to help patients breathe independently after a tracheostomy, to deliver humidified air or medications, and to facilitate weaning from mechanical ventilation)continuously. Titrate to keep O2>90% every shift, disposable inner cannula (is a single-use plastic tube that fits inside the main, or outer, tracheostomy tube) every day shift change, oral care-every shift provide oral care, site dressing-every shift trach site clean.Record review of CR # 1's progress notes documented by LVN A, dated 8/21/2025 at 9:25 pm read in part change of condition identified dislodged tracheostomy tube. [ What do you think is going on with the resident. Nurse in patient's room for medication administration nurse noticed patient's trach is tilted to the side upon assessment when the 4x 4 gauze is removed the trach is observed laying on the patient's chest. An attempt made to replace the trach unsuccessful. The step-down trach unable to enter as well. [ CR # 1] oxygen saturation fluctuating 88%-91% patient bagged. Oxygen saturation increased to 97 %. 911 called, patient transferred to a {local hospital emergency room} for trach replacement.Record review of CR #1's hospital records, dated 8/22/2025, revealed, No distal tracheostomy tract appreciated with tracheoscopy, trach has likely been out for extended period. Stoma (a surgically created opening on the abdomen to an internal organ) significantly stenosed to size barely larger than flexible laryngoscope. Evidence of prolonged decannulation during SNF stay.Record review of CR # 1's hospital progress notes, dated 8/27/2025, read in part [CR # 1] was recently admitted to a local hospital on 6/19/2024 altered mental status , acute metabolic encephalopathy complicated by aspiration pneumonia which required prolonged intubation and eventually trach placement on 7/3/2025. [CR#1] was administered for respiratory monitoring due to trach dislodgement after an unknown period.Record review of Resident # 2's face sheet dated 8/28/2025 revealed Resident # 2 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in low blood oxygen levels), diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), narcolepsy without cataplexy (a type of narcolepsy characterized by excessive daytime sleepiness (EDS) but without the sudden loss of muscle tone (cataplexy) that is typically associated with narcolepsy), and tracheostomy status ( refers to a patient having an existing tracheostomy, indicated by a stoma or opening in the neck to the windpipe (trachea), often using a tracheostomy tube).Record review of Resident # 2's MDS, dated [DATE], indicated Resident # 2 was unable to perform the BIMS. Resident # 2 was active diagnosis included Acute Respiratory Failure with Hypoxia (life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in low blood oxygen levels) Resident # 2 was total dependent and required assistance of two people for all ADLs. Resident # 2 was always incontinent (unable to control) of bowel and bladder. Resident # 2 was unable to communicate. Resident # 2 rarely self-understood and rarely understood other. Record review of Resident # 2's care plan dated, 8/26/2025, revealed: Focus-Resident # 2 had a tracheostomy and is at risk for changes in secretions, infection, and respiratory distress. Goal: Resident # 2 would not experience no adverse effects through the review date (target date 9/8/2025). Interventions: conduct routine equipment maintenance and changes as indicated, emergency equipment: ambu bag (a portable, handheld device used to provide positive pressure ventilation to patients who are not breathing or are not breathing adequately), and spare trach (a crucial piece of emergency equipment for individuals with a tracheostomy, in case the original tube becomes dislodged, blocked, or damaged), encourage resident to keep head of bed elevated, follow physicians orders: O2 administration, medication administration, labs and x-rays, notify the physician of any adverse findings/changes, and observe for needed suctioning of increased secretions/congestion suctioning-assess for relief, observe for signs and symptoms of infection (redness, swelling, warmth, pain, increased secretions, malodorous secretions, bleeding), and provide tracheostomy site care as ordered. Record review of Resident # 3's face sheet, dated 8/28/2025, revealed Resident # 3 was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (occur when there isn't enough oxygen in the blood), encephalopathy ( a general term for a condition that affects brain function), respiratory disorders in diseases classified elsewhere (lung or airway conditions caused by an underlying, systemic disease), and tracheostomy status (refers to a patient having an existing tracheostomy, indicated by a stoma or opening in the neck to the windpipe (trachea), often using a tracheostomy tube).Record review of Resident # 3's MDS, dated [DATE], re-entry from an acute hospital. Resident # 3 was unable to perform the BIMS. Resident # 3 was total dependent and required the assistance of two people for ADLs. Resident # 3 was always incontinent (unable to control) of bowel and bladder. Resident # 3 had a tracheostomy. Record review of Resident # 3's care plan, dated 8/26/2025, revealed it did not address he had a tracheostomy or the care of the tracheostomy.Record review of Resident # 4's face sheet, dated 8/28/2025, revealed Resident # 4 was a [AGE] year-old that admitted to the facility on [DATE] with diagnoses of cerebral infarction due to the thrombosis of right middle cerebral artery (an ischemic stroke where a clot blocks the right MCA (middle cerebral artery), starving a portion of the right brain of blood and oxygen) tracheostomy status, atrioventricular block (a condition where the electrical signals that control the heartbeat do not properly travel from the atria (upper chambers of the heart) to the ventricles (lower chambers)), and dependence on supplemental oxygen (the need for continuous or intermittent supplemental oxygen therapy to maintain adequate oxygen levels in the body).Record review of Resident # 4's MDS, dated [DATE], indicated Resident # 4 was unable to conduct BIMS. Resident # 4 was total dependent and required the assistance of two people for ADLs. Resident # 4 was always incontinent of bladder and bowel. Resident # 4 had a tracheostomy. Resident # 4 was unable to communicate with others. Record review of Resident # 4's care plan, dated 7/21/2025, revealed Focus: Resident# 4 had a tracheostomy related to chronic respiratory failure, and is at risk for increased secretion, congestion and infarctions; Goal: Resident # 4's secretions/congestion would be relived with suctioning or medications and will have no occurrence of infection over the next 90 days; Interventions: encourage Resident # 4 to keep head of bed elevated, ensure all equipment is in proper working order each shift, give medication per order-monitor labs/x-rays- report result to physician, keep extra same tracheostomy size equipment and /or next smaller size-down in room; observe for needed suctioning of increased secretions/congestion-provide suctioning -assess for relief, and observe for sign and symptoms of infection-report to physician. Record review of Resident # 5's face sheet dated, 8/28/2025, revealed Resident # 5 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of acute respiratory failure, unspecified whether with hypoxia or hypercapnia (a medical condition in which the lungs fail to adequately exchange oxygen and carbon dioxide gases in the blood), anoxic brain damage (a condition where the brain does not receive enough oxygen, leading to brain cell damage or death), and tracheostomy status. Record review of Resident # 5's MDS, dated [DATE] indicated Resident # 5 was unable to perform BIMS. Resident # 5 was total dependent and required the assistance of two people for all ADLs. Resident # 5 was always incontinent of bowel and had a foley catheter (tube into the bladder to drain urine). Resident # 5 had a tracheostomy. Resident # 5 was unable to communicate. Record review of Resident # 5's care plan, not dated, revealed: Focus: Resident # 5 had a tracheostomy and was at risk for changes in secretions, infection, and respiratory distress; Goal: Resident # 5's tracheostomy would experience no adverse effect through the review date (target date 8/31/2025); Interventions: conduct routine equipment maintenance and changes as indicated, emergency equipment: Ambu Bag and Spare Trach to bedside, encourage resident to keep head of bed elevated, follow Physicians orders: O2 administration, medication administration, labs and x-ray, notify the physician of any adverse findings and changes, observe for signs and symptoms of infection, and provide tracheostomy site care as ordered. Observation of Resident # 2 on 8/26/2025 at 11:06 am revealed he had an ambu bag and emergency tracheostomy supplies at the bedside as well as ample supplies of saline, suction tips and tubing including yankauer ( is a suctioning tool used in medical procedures) and was a 7 Shiley (type of breathing tube, specifically a tracheostomy tube) with adequate supplies of extra Shiley's at bedside. He had Jevity 1.5 hanging and infusing via pump at 85/hr. with water bolus infusing via pump as well at 40ml/hr. Both were dated and labeled 8/26/25. His tracheostomy tubing was connected via bedside concentrator at 4/L/min (refers to supplemental oxygen administered at a flow rate of 4 liters per minute) with humidified air water bottle dated 8/23/25 and trach tubing dated 8/26/25. O2 in use and EBP signs posted with EBP supplies readily available at bedside.Observation of Resident # 4 on 8/26/2025 at 11:37 a.m., revealed Resident # 4's O2 in use and EBP signs posted. Resident was resting in bed appropriately dressed and groomed. His call light was within reach and his facial beard was clean and trimmed as well as his fingernails. He had Jevity 1.5 infusing via pump at 65 ml/hr. with water bag flush connected and infusing via pump at 50 ml/hr. Both bags were dated 8/25/25. Resident was able to nod his head yes and no in response to questions, He nodded yes when asked if he was ok. His bedside concentrator was set at 5/L/min and infusing via trach tubing. Trach tubing was dated 8/25/25.Interview with the RT on 8/26/2025 at 11:28 a.m., she said that she provided facility nursing staff training at the facility yearly and prn. She said that training included return demonstrations and in-services on cleaning, maintenance and changing or trach as well as emergency care. Observation of CR # 1 on 8/27/2025 at 3:10 pm at a local hospital, revealed CR #1 was lying in bed asleep. CR # 1 did not have a tracheostomy at the time of this visit. Hospital Nurse A stated that CR# 1 was stable. Hospital Nurse A declined to provide any additional information regarding CR #1. Interview with the ADON on 8/26/2025 at 6:01 pm she stated that a Respiratory Therapist trained the nursing staff on Tracheostomy care. She stated she had not been trained on Tracheostomy care while working at this facility. Interview with the Administrator on 8/26/2025 at 6:15 pm, investigator inquired about tracheostomy training for nursing staff who were scheduled for 8/26/205 on the pm shift. (LVN A, LVN B, and LVN C). He stated that these nurses had not been trained by this facility on tracheostomy care. He stated he would conduct an Audit on Tracheostomy care training.Interview with LVN A on 8/26/2025 at 6:48 p.m., who said she was CR #1's charge nurse on the evening of 8/21/25. She said she did initial rounds at the beginning of her shift 6pm-6am which included checking CR #1 at the bedside, but only saying hello and CR #1 appeared to be breathing normally and in no apparent distress. LVN A said she did not notice any abnormalities with CR #1's tracheostomy at that time and continued her initial resident rounds. LVN A said she did not recall the time, but more than an hour later she returned to CR #1's bedside to provide medications and obtain vital signs and noticed CR #1's trach appeared to be at an angle, so she asked CNA A to assist her with repositioning the resident and when CR #1 was repositioned she noticed his entire tracheostomy was out and sitting on his chest below his chin. LVN A said she attempted to reinsert the tracheostomy canula but the surface of the stoma was closed. She grabbed the emergency kit at the bedside and attempted to utilize the step down (a downsized tube size) shiley (a type of tracheostomy tube) but that did not work either, so she initiated a code which included activation of 911. LVN A said they did not know how long CR #1's tracheostomy tube had been out. LVN A said she had not been trained at or by the facility to perform tracheostomy care. LVN A said she did not remember any competency or return demonstration trainings or assessments at this facility. Interview with LVN B on 8/26/2025 at 7:20pm revealed she worked at facility for 3 months and had not been trained or in-serviced on Trach care. She said she had worked with 1 current facility tracheostomy resident, CR # 1 and also worked the night CR #1 had his change in condition. LVN B said she did not attempt to reinsert CR #1's Tracheostomy tube on 8/21/25 because it did not look like it could be reinserted without causing additional trauma. LVN B explained that CR #'1 tracheostomy site appeared to have closed already. LVN B said she felt comfortable providing trach care to CR #1 even though she had not been trained by this facility on trach care. Interview with LVN C on 8/26/2025 at 7:37pm who said she had worked at facility for about 1 year and was trained tracheostomy care with a return demonstration about 3 weeks to a month ago. LVN C said the ADON did training with her early in the morning. LVN C said they had never done any training with an RT at this facility and never received trach training certificate at this facility. The surveyor notified the Administrator on 8/27/2025 at 1:15 pm., that they had a current Immediate Jeopardy related to respiratory/tracheostomy care. The IJ template was emailed to the to the Administrator on 8/27/2025 at 1:37 pm and a Plan of Removal was requested. The plan of removal was accepted on 8/27/2025 at 7:20 p.m. and included: Plan of Removal: Date: August 27, 2025 Immediate Action: According to the IJ Template, F695 Respiratory/Tracheostomy care and suctioning. The facility failed to ensure that CR # 1 who needed respiratory care, including tracheotomy care, circuit was attached appropriately causing it to become dislodged. The facility failed to ensure licensed nursing staff were trained to provide tracheostomy care. Resident #1 was transferred on 8/21/2025 to the ER and remains in the hospital.The four tracheostomy residents in house were assessed by the Respiratory Therapist and Director of Nursing on 8/27/25, residents were stable, and no signs of respiratory distress or complications were identified. The Respiratory Therapist validated that each resident had the correct tracheostomy supplies at bedside and the required emergency equipment readily available. On 8/27/25, the Respiratory Therapist provided tracheostomy care education and completed skill validation for the Director of Nursing. On 8/26/25, the Regional Nurse Consultant provided one-on-one training to the nurse on duty, covering tracheostomy care and suctioning procedures. A skills validation was completed during the session to ensure the nurse demonstrated competency with facility protocols. No issues were identified.Action: All licensed nursing staff will receive education and skills validation on tracheostomy care and suctioning, to be provided by a Respiratory Therapist and/or DON/ADON. The training will include: Routine tracheostomy care Suctioning of artificial airways Emergency response procedures, including accidental decannulation Signs and Symptoms of respiratory distress Oxygen TherapyA skills check-off will be completed to verify competency. Licensed nursing staff will not be allowed to work their next scheduled shift until both the education and competency validation have been completed. All newly hired licensed staff will receive this training as part of their orientation process. They will not be allowed to accept independent assignments until their skill check-off has been completed and approved by respiratory therapy or clinical leadership.Responsible: Director of Nursing Completion: August 28, 2025 Action: Ad Hoc QAPI conducted on 8/27/25 with Medical Director, Administrator, DON, & ADON regarding IJ F695.Responsible: Administrator/Director of NursingCompletion: August 27, 2025 Action: Administrator reviewed the facility policy for tracheostomy care and suctioning. No changes were made. Completion: August 27,2025 Monitoring: Observation of Resident #2 on 8/28/2025, revealed Resident # 2 was lying in bed and Resident # 2 did not display signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 3 on 8/28/2025 revealed Resident # 3 was lying in bed, and Resident # 3 did not display signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 4 on 8/28/2025 revealed Resident # 4 was lying in bed, and Resident # 4 did not display signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 5 on 8/28/2025 revealed Resident # 5 was lying in bed, and Resident # 5 did not display sign or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. In a telephone interview with LVN B on 8/28/2025 at 11:10 am she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent performing tracheostomy care. LVN B stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. In a telephone interview with LVN C on 8/28/2025 at 11:25 am she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent performing tracheostomy care. LVN C stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. In a telephone interview with LVN A on 8/28/2025 at 2:15 pm she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent in performing tracheostomy care. LVN A stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. On 8/28/2025 telephone interviews were conducted with LVN D, LVN, E, LVN F, LVN G, LVN H, LVN I, LVN J, AND RN A. All staff stated they were in-serviced on tracheostomy care and management. All staff reported the completed a returned demonstration and felt competent in performing tracheostomy care. These staff worked various shifts to include morning shift, night shift and weekend shifts. Record review of the facility policies and procedures for Tracheostomy Management, dated 5/2022, revealed Licensed Nurses providing care for residents with tracheostomies will be trained on tracheostomy care. Precautions/Side Effect: accidental decannulation Record review of the facility policies and procedures for Tracheostomy Care, dated 11/22, read in part Tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and soma site, to prevent plugging of the tracheostomy tube, to prevent airway obstruction, to prevent infection of trach site, and to maintain a patent airway for suctioning. Precaution /side effect(s): accidental decannulation. On 8/28/2025 at 4:13 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of potential more than minimal harm that is not immediate jeopardy because all staff had not been trained on 8/26/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking. 1. The facility failed to secure smoking paraphernalia and supervise smoking for Resident #1, who was paralyzed on one side and had a known history of dropping cigarettes which resulted in multiple burn holes in his clothing and the armrest of his wheelchair. 2. The facility failed to secure smoking paraphernalia and supervise smoking for Resident #2 and Resident #3, who were known to have unsafe smoking habits and were either prescribed oxygen or had a roommate who was prescribed oxygen. An Immediate Jeopardy (IJ) was identified on 02/03/2024 at 8:33 a.m. The IJ template was provided to the facility on [DATE] at 8:33 a.m. While the IJ was removed on 02/04/2024, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed smoking residents and their roommates at risk of serious harm/injury from possible accidental cigarette burns and fires from lighter/oxygen ignition. Findings included: Resident #1 Record review of Resident #1's face sheet dated 02/02/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with diabetes (a chronic health condition that affects how the body turns food into energy; too much sugar in the blood), acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), acute respiratory failure (when the blood does not have enough oxygen or has too much carbon dioxide), vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized muscle weakness (muscle weakness due to a chronic condition or infection), aphasia (a disorder that affects how you communicate/speak), seizures (a sudden, uncontrolled burst of electrical activity in the brain), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted flow to the brain; ischemic stroke) affecting left non-dominant side, and traumatic subdural hemorrhage (a pool of blood between the brain and the outermost covering) with loss of consciousness. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had unclear speech/slurred or mumbled words; he had impaired vision - saw large print, but not regular print in newspaper/books; he had a BIMS score of 4 (severe cognitive impairment); he had functional limitation in range of motion on one side (upper and lower extremity); he was wheelchair bound; he required setup or clean-up assistance with eating; he required supervision or touching assistance with oral hygiene; he required partial/moderate assistance with upper body dressing; he required substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, and personal hygiene; and he was always incontinent of bowel and bladder. Record review of Resident #1's care plan revised 12/12/2023 revealed the following care areas: * Smoking: Resident #1 had a potential for injury related to smoking. He was evaluated to be a safe smoker. His family preferred the facility to keep his cigarettes for him. Resident #1 had impaired cognition related to dementia and encephalopathy (a broad term for any brain disease that alters brain function or structure). Revised 12/01/2023. Goal included: Resident #1's risk for injury and danger to himself and the environment related to smoking in his room, will be minimized with interventions. Interventions included: Evaluation for assistive devices as indicated. Inform resident of facility's smoking policy and potential consequences of noncompliance. Orient to designated smoking area(s). Provide information and education in smoking cessation options as indicated. Reinforce to Resident #1 that smoking is not permitted in rooms, only in designated areas. Smoking apron if indicated. Smoking assessment upon admission, quarterly, annually, and significant change. Smoking material to be maintained by staff if indicated. Supervised Smoker (Date initiated 06/23/2023). * Resident #1 had difficulty with communication related to chronic aphasia, late effects of CVA (stroke). Goal included: Resident #1 will communicate basic needs over the next 90 days. Interventions included: Allow resident time to communicate needs. Approach in a calm manner. Praise resident for all efforts to communicate. Provide writing tablet for resident to communicate with staff. Speech Therapy referral as needed. * ADL self-care deficits: Resident #1 had ADL self-care deficits related to muscle weakness, deconditioning, and dementia. He was at risk for further decline in ADL functioning and injury. Goal included: will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide assistance for ambulation per therapy orders. Provide encouragement and cueing as needed to performed ADL cares. Provide extensive assist x1 for eating. Provide extensive assist x1 for personal hygiene/grooming. Provide extensive assist x1 for upper/lower body dressing. Provide extensive assist x2 for bed mobility. Provide extensive assist x2 for toileting/incontinent care. Provide privacy and maintain dignity. Provide total assist x1 for bathing. Provide total assist x1 for locomotion on/off unit. Provide total assist x2 for transfers. * Dementia: Resident #1 has a diagnosis of vascular dementia and metabolic encephalopathy, and is at risk for increased confusion and decline in ADLs as the diseases progress. Goal included: Resident #1's needs will be anticipated and met by staff. Interventions included: Administer medication(s) as ordered by MD. Assist resident with ADLs as needed. Re-assure resident when confusion has increased. Re-orient resident daily as needed. Verbal reminders and cues to assist resident with daily orientation. Record review of Resident #1's, Resident Smoking Behavior Contract dated and signed by Resident #1 on 08/01/2022 revealed, . I understand that I must follow each and every rule governing smoking and should I violate even one rule, even one time, I am aware that the facility may temporarily suspend, revoke, and/or initiate discharge proceedings and I will not be allowed to live in this building . I agree to only soke in the designated area. I agree that, if my assessment shows I need assistance, I will only smoke at the designated times, unless with my family. I agree that, if my assessment shows I need assistance, I am not allowed to have in my possession and must permit the facility to store smoking materials (cigarettes, tobacco, rolling papers, lighters, matches) . I will smoke carefully to minimize risk for burning my clothes or fingers (or any other person). I know that careless smoking will cause my privileges to be suspended. I agree to allow staff to check/search my room for contraband (such as hidden cigarettes, lighters, and matches) at staff discretion Record review of Resident #1's, Smoking Safety Screen dated 07/05/2023 (the name of the staff who completed the assessment was not listed on the document) revealed, 1. Does resident have cognitive loss? (Yes) 2. Does resident have any visual deficits? (Yes) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (No) 7. Resident Need for Adaptive Equipment - Supervision . 8. Resident Requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) . 8c. Resident is safe to smoke independently and to store own smoking materials? (No) . Resident #1 wants to smoke more than the designated smoking times. He can become very angry if not given the opportunity to smoke his cigarette. He has good ability to understand others however due to his dementia, his speech is not clear. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: Resident #1 is safe to smoke with supervision. Resident #1 does not like to be supervised and will go out on pass or go out in order to find cigarettes. This is another reason he is an unsafe smoker. Record review of Resident #1's, Smoking Safety Screen dated 12/01/2023, competed by the Activity Director revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (Yes) 7. Resident Need for Adaptive Equipment - (Nothing was checked) . 8. Resident Requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) . 8c. Resident is safe to smoke independently and to store own smoking materials? (No) . Resident can smoke safely without supervision but per the family request, they would like for the facility to store his cigarettes. 2. Team Decision: Safe to smoke without supervision. 3. Rationale/conditions: Resident #1 can smoke safely without supervision but per the family request, they would like for the facility to store his cigarettes. Observation of Resident #1 on 02/02/2024 at 10:00 a.m. revealed he was alert and self-ambulated via wheelchair. Resident #1's left arm and leg were immobile (due to cerebral infarction). Resident #1 was outside in the courtyard smoking a cigarette with Resident #2, Resident #3, and several other residents. No staff were observed outside with the residents for approximately eight minutes until the Activity Assistant went outside. Observation and interview with Resident #1 on 02/02/2024 at 11:30 a.m. revealed he was outside in the courtyard smoking a cigarette unsupervised. Resident #1's speech was slurred, and he also communicated by shaking his head and making other gestures. Resident #1's left arm/hand rested in his lap. The left armrest of his wheelchair was wide and was covered with a black, soft cushion. The cushion had 7-8 holes (the orange-colored foam of the cushion could be seen through the holes) of varied sizes with the largest approximately dime-sized. Resident #1 stated he was allowed to keep his own cigarettes and lighters in a small bag which was hanging from his neck. He stated the facility's staff allowed him to go outside to the smoking area alone as he pleased. He indicated, by holding up his lit cigarette when asked what caused the holes on his armrest, the holes in the cushion of his armrest were caused by cigarettes. Resident #1 demonstrated how he placed lit cigarettes on the cushioned armrest while he reached for his bottle of water which was located on the section of the cushioned armrest behind the lit cigarette, opened it, and drank from it all with his right hand. Resident #1 stretched out the left sleeve of his jacket with his right hand and pointed out 4-6 holes. He indicated the holes on his jacket were caused when the lit cigarettes fell from the cushioned armrest, onto his jacket. He indicated when the lit cigarettes fell from the armrest onto his jacket, he brushed the cigarettes down to the ground with his right hand. He stated that happened multiple times with at least one recent incident (he could not say when the incident occurred). He stated he sometimes burned himself when the cigarettes fell onto his clothes, but he did not have any visible skin injuries. Observation of Resident #1's arm at that time revealed no skin injuries. He stated his clothes never caught on fire and he got scared when the cigarettes fell onto his clothes, but he never reported the incidents to staff. Further review of Resident #1's care plan, revised 12/12/2023, revealed no plan or interventions regarding the burn holes in his clothes or the armrest of his wheelchair. Resident #2 Record review of Resident #2's face sheet dated 02/02/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with hypertensive heart disease (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), acute and chronic respiratory failure with hypoxia (sudden respiratory failure and over time; when you do not have enough oxygen in your blood), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease affecting right dominant side. Record review of Resident #2's admission MDS dated [DATE] revealed she had a BIMS score of 7 (severe cognitive impairment); she had upper extremity impairment on one side and bilateral (both sides) lower extremity impairments; she ambulated via wheelchair; she required partial/moderate assistance with toileting hygiene, bathing, upper body dressing, and lower body dressing; and she was frequently incontinent of bowel and bladder. Record review of Resident #2's care plan revised on 02/01/2024 revealed the following care areas: * Resident #2 has episodes of inappropriate behaviors and is at risk for further increased episodes and injury as evidenced by: 1) Refusal of Care. 2) Requesting to smoke outside of designated smoking times. 3) Agitation (yelling/hitting walls). Goal included: episodes of inappropriate behaviors will be reduced no more than 2 episodes weekly and will be free from injury. Interventions included: Encourage to attend social activities of preference. Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Provide psych consult as ordered. * SMOKING: Resident #2 has a potential for injury related to smoking. Goal included: Resident #2's risk for injury related to smoking will be minimized with interventions. Interventions included: Evaluation for assistive devices as indicated. Inform resident of facility's smoking policy and potential consequences of noncompliance. Orient to designated smoking area(s). Provide information and education in smoking cessation options as indicated. * COGNITIVE IMPAIRMENT: Resident #2 has impaired cognition and is at risk for further decline and injury. Goal included: Resident #2's needs will be met, and dignity maintained. Interventions included: Allow time for tasks and responses. Explain all procedures using terms gestures the resident can understand. Involve in care to maintain or increase level of independence. Praise for tasks the resident completes. Repeat information as needed. * SHORTNESS OF BREATH: Resident #2 is at risk for respiratory distress/failure and increased episodes of SOB related to COPD (disease that causes airflow blockage and breathing-related problems) and history of acute/chronic respiratory failure. Goal included: Resident #2 will be free from any respiratory distress/failure and will have minimal/no further episodes of shortness of breath. Interventions included: Allow breaks when performing tasks - do not rush. Apply O2 per order - encourage to take slow, deep breaths. Check pulse oximetry as ordered. Minimize stress/anxiety - allow to verbalize feelings when appropriate. Observe for s/sx of respiratory infection - report any noted to MD. Provide respiratory treatments as ordered - observe for signs of relief from SOB. * ADL SELF CARE DEFCITS: Resident #2 has ADL self-care deficits related to muscle weakness, history of CVA with right hemiplegia, and is at risk for further decline in ADL functioning and injury. Goal included: Resident #2 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Anticipate needs - provide prompt assistance. Encourage independent function as able. Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide encouragement and cueing as needed to performed ADL cares. Provide privacy and maintain dignity. Record review on 02/03/2024 at 10:35 a.m. of Resident #2's Clinical Physician Orders for February 2024 revealed the following order: * Oxygen @ 2-3 LPM via nasal cannula continuously while in room. Monitor O2 saturation. Every shift. Start Date: 02/02/2024. Revision Date: 02/02/2024 at 6:00 p.m. (while in room was added to the order) Record review on 02/02/2024 at 3:07 p.m. of Resident #2's MAR for February 2024 revealed: * Oxygen @ 2-3 LPM via nasal cannula continuously. Monitor O2 saturation every shift. Order Date: 01/24/2024. The order was followed on 02/01/2024 and 02/02/2024. Observation of Resident #2 on 02/02/2024 at 10:00 a.m. revealed she was outside in the courtyard smoking unsupervised with Resident #1, Resident #3, and several other residents without an apron on. Record review of Resident #2's Smoking Safety Screen dated 02/02/2024 at 10:30 a.m. revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (No) . Safety: 6. Can resident light own cigarette? (Yes) 6a. Does the resident or the resident's roommate use oxygen? (Yes) . 8. Resident requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) 8b. Resident is safe to smoke independently but resident/roommate uses oxygen and needs facility to store lighter and cigarettes? (No) . Resident #2 is safe to smoke without supervision however, she uses O2 and needs the facility to store smoking material. Team Decision: safe to smoke without supervision. Rationale/conditions: Resident #2 is safe to smoke without supervision however, she uses O2 and needs the facility to store smoking material. Observation and interview with Resident #2 on 02/02/2024 at 1:15 p.m. revealed she was outside smoking unsupervised with several other resident. Resident #2 was alert and self-ambulated via wheelchair. Resident #2 stated she kept her own cigarettes and lighters and held up a white plastic shopping bag where her smoking supplies were stored. Resident #2's left hand was in a black splint. She stated she was admitted to the facility two months ago and the facility's staff allowed her to go outside and smoke unsupervised whenever she wanted to. She said she was on oxygen, and she knew how to operate her own tank/concentrator when she returned to her room. Resident #2 stated she never smoked around oxygen, dropped cigarettes, or sustained burn holes in her clothes. Resident #3 Record review of Resident #3's face sheet dated 02/04/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with cerebral aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood), epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures), benign neoplasm of the brain (non-cancerous mass of cells that grow relatively slow in the brain), and vascular dementia (brain damage caused by multiple strokes). Record review of Resident #3's quarterly MDS dated [DATE] revealed she had a BIMS score of 8 (moderate cognitive impairment); she ambulated via wheelchair; she required partial/moderate assistance with toileting hygiene, bathing, upper body dressing, and personal hygiene; and she required substantial/maximal assistance with lower body dressing. Record review of Resident #3's care plan revised 11/27/2023 revealed the following care areas: * Communication impairment: Resident #3 has Dysarthria (slurred speech), late effects of CVA, and is at risk for further decline and injury. Goal included: Staff will anticipate and meet needs Resident #3 is not able to effectively communicate. Interventions included: Allow time for resident to digest information - do not rush. Approach in a calm manner using eye contact - call resident by name. Reduce or remove interfering environmental stimuli. Use communication tools, terms, gestures the resident can understand. * Cognitive impairment: Resident #3 has impaired cognition related to intracranial aneurysm and is at risk for further decline and injury. Goal included: Resident #3's needs will be met, and dignity maintained. Interventions included: Allow time for tasks and responses. Explain all procedures using terms gestures the resident can understand. Involve in care to maintain or increase level of independence. Praise for tasks the resident completes. Repeat information as needed. * ADL SELF CARE DEFCITS: Resident #3 has ADL self-care deficits related to history of stroke and is at risk for further decline in ADL functioning and injury. Goal included: Resident #3 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Anticipate needs - provide prompt assistance. Encourage independent function as able. Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide encouragement and cueing as needed to performed ADL cares. Provide privacy and maintain dignity. Further review of Resident #3's care plan, revised 11/27/2023, revealed smoking was not listed as a care area. Record review of Resident #3's Smoking Safety Screen dated 12/01/2023 revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (Yes) 6a. Does the resident or the resident's roommate use oxygen? (Yes) 7. Resident Need for Adaptive Equipment. 7a. Smoking apron . 8. Resident requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) 8b. Resident is safe to smoke independently but resident/roommate uses oxygen and needs facility to store lighter and cigarettes? (No) 8c. Resident is safe to smoke independently and to store own smoking materials? (Do not mark yes if resident or roommate is on oxygen) (No) . Resident #3 does need facility to store her cigarettes, but she refuses to allow us to store them. She also needs a smoking apron but refuses to use one. Team Decision: Safe to smoke with supervision. Rationale/conditions: Resident #3 needs supervision and a smoking apron but she refuses to use one and allow the facility to store them. Observation of Resident #3 on 02/02/2024 at 10:00 a.m. revealed she was outside in the courtyard smoking unsupervised with Resident #1, Resident #2, and several other residents without an apron on. Observation and interview with Resident #3 on 02/02/2024 at 1:20 p.m. revealed she was alert and self-ambulated via wheelchair. Resident #3 stated she was allowed to keep her own smoking supplies. She stated the facility's staff allowed her to go outside and smoke unsupervised whenever she wanted to. Resident #3 stored her cigarettes and lighter in her pocket. She stated she never smoked around anybody with oxygen or got holes in her clothes from cigarettes. Observation of Resident #3's room on 02/04/2024 at 10:30 a.m. revealed her roommate had an oxygen concentrator at bedside in the space between her bed and Resident #3's bed. In an interview with the Activity Assistant in the outside courtyard on 02/02/2024 at 10:10 a.m., she stated she usually supervised resident smoking during her shift. She stated the residents were scheduled to smoke four times per day and were allowed to smoke two cigarettes each time. She stated some of the residents kept their own cigarettes and lighters even though they were not supposed to. She said previously, staff kept all residents' supplies, but after management changed several times, the residents just started keeping their own supplies. She stated there were two residents outside at that time, Resident #2 and Resident #3, who were burners. She said that meant the residents sometimes got burn holes in their clothes (Resident #1 had already went inside the building at that time). She said Resident #1 kept his own cigarettes and lighters. She said the facility was supposed to keep Resident #1's supplies at his family's request, but even though the family member brought the supplies to staff, Resident #1 always came up with cigarettes and lighters. She stated Resident #1 kept his cigarettes and lighters in a stash, but she did not know where the stash was. She stated the staff needed to step up their game regarding storage of smoking supplies and supervision. She said she thought smoking times were 9:00 a.m., 11:00 a.m., 3:00 p.m., and 5:00 p.m., or something like that. She stated the staff shared smoking supervision duties, but she mostly went outside. She said Resident #1's chair had a couple of burn holes that probably happened when he smoked unsupervised. She stated Resident #1 was known to sneak outside to smoke. She stated she worked at the reception desk on weekends, and she often saw Resident #1 go outside and light a cigarette from the window (the outside courtyard was located in the center of the facility with windows all around it). She said she never reported Resident #1's behaviors because all the staff knew about it, and they saw what she saw when he went out and smoked unsupervised. In an interview with the Activity Director on 02/02/2024 at 11:15 a.m., she stated she was hired almost one year ago. She stated managing smoking had been a struggle since she was hired because residents did not follow smoking times and they refused to allow staff to keep their lighters and cigarettes. She stated they care planned the residents' refusal to adhere to the smoking policy. She said there were a lot of smoking residents and the staff tried to stay outside with them while they smoked. She said when the staff saw residents outside, they tried to go out and supervise. She said the staff tried to their best to encourage smoking at scheduled times. She said they tried to explain the importance of supervised smoking to some family members, but they continued to bring the supplies to residents. She said prior to her hire, the facility had residents sign smoking contracts, so some residents had them and some did not. She said Resident #1 kept his own supplies because he refused to give them up and he had been observed outside smoking alone. She said Resident #1's family member wanted her to keep his smoking supplies, but somehow, Resident #1 still got them. She stated Resident #1 refused to wear an apron. In a follow-up interview with the Activity Director on 02/02/2024 at 2:50 p.m., she stated she was responsible for completing each resident's safe smoking assessment. She said she determined if each resident was a safe smoker by observing if they could safely light their own cigarette. She stated she observed while the residents were unaware if they could hold the cigarette, if they dropped the cigarette, and if any ashes fell. She stated she also reviewed the residents' cognition and acuity. She stated Resident #1 had those burn holes in his cushion and his jacket when she was hired and she had been there almost a year. She said to her Resident #1 was a safe smoker. In an interview with the Interim DON on 02/02/2024 at 3:58 p.m., she stated she was the facility's Regional Nurse Consultant, and she was onsite that day because the facility did not have a DON. She said Resident #2 was on oxygen when she went to her room, PRN. She stated Resident #2 did not take her oxygen when she went outside to smoke. The Interim DON said she would go get Resident #2's lighters from her because she was not supposed to have them in her room with the oxygen. She said Resident #1 received weekly skin assessments, so they always monitored him for any burns. In a follow-up interview with the Interim DON on 02/02/2024 at 4:09 p.m., she stated Resident #2 refused to give up her lighter and stated she would bring the lighter to the nurse's station when she completed her breathing treatment. In an interview with LVN C on 02/04/2024 at 11:00 a.m., she stated some of the residents would sneak outside to smoke unsupervised because they kept their own supplies. She stated the staff could take their lighters 10 times, but they still came up with more lighters. In a telephone interview with CNA F on 02/04/2024 at 11:15 a.m., she stated she worked on the 10:00 p.m. - 6:00 a.m. shift and she previously seen residents try to go outside and smoke during her shift. She stated the residents kept their own smoking supplies. She said when she saw residents go outside to smoke, she reported them to her nurse. In a telephone interview with CNA I on 02/04/2024 at 11:30 a.m., he stated he worked on the 2:00 p.m. - 10:00 p.m. shift and as far as he knew, the residents were previously able to smoke at will because they kept their own smoking supplies and he often saw residents smoking unsupervised. Record review of the facility's Smoking Policy revised 06/2019 revealed, To provide a healthy living environment with respect for the health and well-being of each resident, staff member, and visitor. It is also the objective of this policy to communicate to each resident/POA that they are responsible for following each rule and on-going compliance with the Resident Smoking Policy. Policy: It is the policy of this facility to provide smoking policies and procedures supporting residents' preference to smoke. Our policies have been developed to reduce risk related to smoking behaviors and to support the well-being of residents residing in the facility. Smoking will occur in a designated smoking area, at designated times. Residents who desire to smoke will be evaluated to determine level of smoking dependence. A Smoking Behavior Contract must be completed, signed, and followed by each resident/representative who smokes. Failure to honor the Smoking Behavior Contract and the Smoking Policy will be addressed to minimize potential risk to residents residing in the facility, up to and including involuntary discharge of the individual. Notice of Smoking Policy: 1. At the time of admission, each resident and legal representative shall be informed of and receive a written copy of the facility's Smoking Policy. 2. Each resident who desires to smoke shall receive and have explained the Smoking Behavior Contract. The resident/POA is required to complete, sign, and follow the Smoking Behavior Contract. Smoking Safety - Resident Assessment. 1. Residents who desire to smoke will be assessed using the Smoking - safety Screen, documented in the computer system, for their ability to smoke safely. Assessments will be conducted at the time of admission, quarterly and at the time any condition or behavioral change impacts their ability to smoke safely. 2 . A plan of care shall be developed consistent with the resident's smoking risk assessment . 4. Residents who are determined by the interdisciplinary team as needing [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their own established smoking policy for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance. 1. The facility failed to effectively intervene or implement their own smoking policy when Residents #1 was known to be non-compliant and continued to store his own smoking paraphernalia. 2. The facility failed to assess Resident #2 for safe smoking upon admission on [DATE] until 02/02/2024. Resident #2 and Resident #3 did not sign smoking contracts until 02/03/2024. 3. The facility failed to implement their smoking policy and allowed Resident #2, who was prescribed oxygen and Resident #3, whose roommate was prescribed oxygen, to store their own smoking paraphernalia. An Immediate Jeopardy (IJ) was identified on 02/03/2024 at 8:33 a.m. The IJ template was provided to the facility on [DATE] at 8:33 a.m. While the IJ was removed on 02/04/2024, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed smoking residents and their roommates at risk of serious harm/injury from possible accidental cigarette burns and fires from lighter/oxygen ignition. Findings included: Resident #1 Record review of Resident #1's face sheet dated 02/02/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with diabetes (a chronic health condition that affects how the body turns food into energy; too much sugar in the blood), acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), acute respiratory failure (when the blood does not have enough oxygen or has too much carbon dioxide), vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized muscle weakness (muscle weakness due to a chronic condition or infection), aphasia (a disorder that affects how you communicate/speak), seizures (a sudden, uncontrolled burst of electrical activity in the brain), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted flow to the brain; ischemic stroke) affecting left non-dominant side, and traumatic subdural hemorrhage (a pool of blood between the brain and the outermost covering) with loss of consciousness. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had unclear speech/slurred or mumbled words; he had impaired vision - saw large print, but not regular print in newspaper/books; he had a BIMS score of 4 (severe cognitive impairment); he had functional limitation in range of motion on one side (upper and lower extremity); he was wheelchair bound; he required setup or clean-up assistance with eating; he required supervision or touching assistance with oral hygiene; he required partial/moderate assistance with upper body dressing; he required substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, and personal hygiene; and he was always incontinent of bowel and bladder. Record review of Resident #1's care plan revised 12/12/2023 revealed the following care areas: * Smoking: Resident #1 had a potential for injury related to smoking. He was evaluated to be a safe smoker. His family preferred the facility to keep his cigarettes for him. Resident #1 had impaired cognition related to dementia and encephalopathy (a broad term for any brain disease that alters brain function or structure). Revised 12/01/2023. Goal included: Resident #1's risk for injury and danger to himself and the environment related to smoking in his room, will be minimized with interventions. Interventions included: Evaluation for assistive devices as indicated. Inform resident of facility's smoking policy and potential consequences of noncompliance. Orient to designated smoking area(s). Provide information and education in smoking cessation options as indicated. Reinforce to Resident #1 that smoking is not permitted in rooms, only in designated areas. Smoking apron if indicated. Smoking assessment upon admission, quarterly, annually, and significant change. Smoking material to be maintained by staff if indicated. Supervised Smoker (Date initiated 06/23/2023). * Resident #1 had difficulty with communication related to chronic aphasia, late effects of CVA (stroke). Goal included: Resident #1 will communicate basic needs over the next 90 days. Interventions included: Allow resident time to communicate needs. Approach in a calm manner. Praise resident for all efforts to communicate. Provide writing tablet for resident to communicate with staff. Speech Therapy referral as needed. * ADL self-care deficits: Resident #1 had ADL self-care deficits related to muscle weakness, deconditioning, and dementia. He was at risk for further decline in ADL functioning and injury. Goal included: will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide assistance for ambulation per therapy orders. Provide encouragement and cueing as needed to performed ADL cares. Provide extensive assist x1 for eating. Provide extensive assist x1 for personal hygiene/grooming. Provide extensive assist x1 for upper/lower body dressing. Provide extensive assist x2 for bed mobility. Provide extensive assist x2 for toileting/incontinent care. Provide privacy and maintain dignity. Provide total assist x1 for bathing. Provide total assist x1 for locomotion on/off unit. Provide total assist x2 for transfers. * Dementia: Resident #1 has a diagnosis of vascular dementia and metabolic encephalopathy, and is at risk for increased confusion and decline in ADLs as the diseases progress. Goal included: Resident #1's needs will be anticipated and met by staff. Interventions included: Administer medication(s) as ordered by MD. Assist resident with ADLs as needed. Re-assure resident when confusion has increased. Re-orient resident daily as needed. Verbal reminders and cues to assist resident with daily orientation. Record review of Resident #1's, Resident Smoking Behavior Contract dated and signed by Resident #1 on 08/01/2022 revealed, . I understand that I must follow each and every rule governing smoking and should I violate even one rule, even one time, I am aware that the facility may temporarily suspend, revoke, and/or initiate discharge proceedings and I will not be allowed to live in this building . I agree to only soke in the designated area. I agree that, if my assessment shows I need assistance, I will only smoke at the designated times, unless with my family. I agree that, if my assessment shows I need assistance, I am not allowed to have in my possession and must permit the facility to store smoking materials (cigarettes, tobacco, rolling papers, lighters, matches) . I will smoke carefully to minimize risk for burning my clothes or fingers (or any other person). I know that careless smoking will cause my privileges to be suspended. I agree to allow staff to check/search my room for contraband (such as hidden cigarettes, lighters, and matches) at staff discretion Record review of Resident #1's, Smoking Safety Screen dated 07/05/2023 (the name of the staff who completed the assessment was not listed on the document) revealed, 1. Does resident have cognitive loss? (Yes) 2. Does resident have any visual deficits? (Yes) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (No) 7. Resident Need for Adaptive Equipment - Supervision . 8. Resident Requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) . 8c. Resident is safe to smoke independently and to store own smoking materials? (No) . Resident #1 wants to smoke more than the designated smoking times. He can become very angry if not given the opportunity to smoke his cigarette. He has good ability to understand others however due to his dementia, his speech is not clear. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: Resident #1 is safe to smoke with supervision. Resident #1 does not like to be supervised and will go out on pass or go out in order to find cigarettes. This is another reason he is an unsafe smoker. Record review of Resident #1's, Smoking Safety Screen dated 12/01/2023, competed by the Activity Director revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (Yes) 7. Resident Need for Adaptive Equipment - (Nothing was checked) . 8. Resident Requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) . 8c. Resident is safe to smoke independently and to store own smoking materials? (No) . Resident can smoke safely without supervision but per the family request, they would like for the facility to store his cigarettes. 2. Team Decision: Safe to smoke without supervision. 3. Rationale/conditions: Resident #1 can smoke safely without supervision but per the family request, they would like for the facility to store his cigarettes. Observation of Resident #1 on 02/02/2024 at 10:00 a.m. revealed he was alert and self-ambulated via wheelchair. Resident #1's left arm and leg were immobile (due to cerebral infarction). Resident #1 was outside in the courtyard smoking a cigarette with Resident #2, Resident #3, and several other residents. No staff were observed outside with the residents for approximately eight minutes until the Activity Assistant went outside. Observation and interview with Resident #1 on 02/02/2024 at 11:30 a.m. revealed he was outside in the courtyard smoking a cigarette unsupervised. Resident #1's speech was slurred, and he also communicated by shaking his head and making other gestures. Resident #1's left arm/hand rested in his lap. The left armrest of his wheelchair was wide and was covered with a black, soft cushion. The cushion had 7-8 holes (the orange-colored foam of the cushion could be seen through the holes) of varied sizes with the largest approximately dime-sized. Resident #1 stated he was allowed to keep his own cigarettes and lighters in a small bag which was hanging from his neck. He stated the facility's staff allowed him to go outside to the smoking area alone as he pleased. He indicated, by holding up his lit cigarette when asked what caused the holes on his armrest, the holes in the cushion of his armrest were caused by cigarettes. Resident #1 demonstrated how he placed lit cigarettes on the cushioned armrest while he reached for his bottle of water which was located on the section of the cushioned armrest behind the lit cigarette, opened it, and drank from it all with his right hand. Resident #1 stretched out the left sleeve of his jacket with his right hand and pointed out 4-6 holes. He indicated the holes on his jacket were caused when the lit cigarettes fell from the cushioned armrest, onto his jacket. He indicated when the lit cigarettes fell from the armrest onto his jacket, he brushed the cigarettes down to the ground with his right hand. He stated that happened multiple times with at least one recent incident (he could not say when the incident occurred). He stated he sometimes burned himself when the cigarettes fell onto his clothes, but he did not have any visible skin injuries. Observation of Resident #1's arm at that time revealed no skin injuries. He stated his clothes never caught on fire and he got scared when the cigarettes fell onto his clothes, but he never reported the incidents to staff. Further review of Resident #1's care plan, revised 12/12/2023, revealed no plan or interventions regarding the burn holes in his clothes or the armrest of his wheelchair. Resident #2 Record review of Resident #2's face sheet dated 02/02/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with hypertensive heart disease (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), acute and chronic respiratory failure with hypoxia (sudden respiratory failure and over time; when you do not have enough oxygen in your blood), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease affecting right dominant side. Record review of Resident #2's admission MDS dated [DATE] revealed she had a BIMS score of 7 (severe cognitive impairment); she had upper extremity impairment on one side and bilateral (both sides) lower extremity impairments; she ambulated via wheelchair; she required partial/moderate assistance with toileting hygiene, bathing, upper body dressing, and lower body dressing; and she was frequently incontinent of bowel and bladder. Record review of Resident #2's care plan revised on 02/01/2024 revealed the following care areas: * Resident #2 has episodes of inappropriate behaviors and is at risk for further increased episodes and injury as evidenced by: 1) Refusal of Care. 2) Requesting to smoke outside of designated smoking times. 3) Agitation (yelling/hitting walls). Goal included: episodes of inappropriate behaviors will be reduced no more than 2 episodes weekly and will be free from injury. Interventions included: Encourage to attend social activities of preference. Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Provide psych consult as ordered. * SMOKING: Resident #2 has a potential for injury related to smoking. Goal included: Resident #2's risk for injury related to smoking will be minimized with interventions. Interventions included: Evaluation for assistive devices as indicated. Inform resident of facility's smoking policy and potential consequences of noncompliance. Orient to designated smoking area(s). Provide information and education in smoking cessation options as indicated. * COGNITIVE IMPAIRMENT: Resident #2 has impaired cognition and is at risk for further decline and injury. Goal included: Resident #2's needs will be met, and dignity maintained. Interventions included: Allow time for tasks and responses. Explain all procedures using terms gestures the resident can understand. Involve in care to maintain or increase level of independence. Praise for tasks the resident completes. Repeat information as needed. * SHORTNESS OF BREATH: Resident #2 is at risk for respiratory distress/failure and increased episodes of SOB related to COPD (disease that causes airflow blockage and breathing-related problems) and history of acute/chronic respiratory failure. Goal included: Resident #2 will be free from any respiratory distress/failure and will have minimal/no further episodes of shortness of breath. Interventions included: Allow breaks when performing tasks - do not rush. Apply O2 per order - encourage to take slow, deep breaths. Check pulse oximetry as ordered. Minimize stress/anxiety - allow to verbalize feelings when appropriate. Observe for s/sx of respiratory infection - report any noted to MD. Provide respiratory treatments as ordered - observe for signs of relief from SOB. * ADL SELF CARE DEFCITS: Resident #2 has ADL self-care deficits related to muscle weakness, history of CVA with right hemiplegia, and is at risk for further decline in ADL functioning and injury. Goal included: Resident #2 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Anticipate needs - provide prompt assistance. Encourage independent function as able. Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide encouragement and cueing as needed to performed ADL cares. Provide privacy and maintain dignity. Record review on 02/03/2024 at 10:35 a.m. of Resident #2's Clinical Physician Orders for February 2024 revealed the following order: * Oxygen @ 2-3 LPM via nasal cannula continuously while in room. Monitor O2 saturation. Every shift. Start Date: 02/02/2024. Revision Date: 02/02/2024 at 6:00 p.m. (while in room was added to the order) Record review on 02/02/2024 at 3:07 p.m. of Resident #2's MAR for February 2024 revealed: * Oxygen @ 2-3 LPM via nasal cannula continuously. Monitor O2 saturation every shift. Order Date: 01/24/2024. The order was followed on 02/01/2024 and 02/02/2024. Observation of Resident #2 on 02/02/2024 at 10:00 a.m. revealed she was outside in the courtyard smoking unsupervised with Resident #1, Resident #3, and several other residents without an apron on. Record review of Resident #2's Smoking Safety Screen dated 02/02/2024 at 10:30 a.m. revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (No) . Safety: 6. Can resident light own cigarette? (Yes) 6a. Does the resident or the resident's roommate use oxygen? (Yes) . 8. Resident requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) 8b. Resident is safe to smoke independently but resident/roommate uses oxygen and needs facility to store lighter and cigarettes? (No) . Resident #2 is safe to smoke without supervision however, she uses O2 and needs the facility to store smoking material. Team Decision: safe to smoke without supervision. Rationale/conditions: Resident #2 is safe to smoke without supervision however, she uses O2 and needs the facility to store smoking material. Record review of Resident #2's Resident Smoking Behavior Contract revealed it was signed and dated 02/03/2024. Observation and interview with Resident #2 on 02/02/2024 at 1:15 p.m. revealed she was outside smoking unsupervised with several other resident. Resident #2 was alert and self-ambulated via wheelchair. Resident #2 stated she kept her own cigarettes and lighters and held up a white plastic shopping bag where her smoking supplies were stored. Resident #2's left hand was in a black splint. She stated she was admitted to the facility two months ago and the facility's staff allowed her to go outside and smoke unsupervised whenever she wanted to. She said she was on oxygen, and she knew how to operate her own tank/concentrator when she returned to her room. Resident #2 stated she never smoked around oxygen, dropped cigarettes, or sustained burn holes in her clothes. Resident #3 Record review of Resident #3's face sheet dated 02/04/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with cerebral aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood), epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures), benign neoplasm of the brain (non-cancerous mass of cells that grow relatively slow in the brain), and vascular dementia (brain damage caused by multiple strokes). Record review of Resident #3's quarterly MDS dated [DATE] revealed she had a BIMS score of 8 (moderate cognitive impairment); she ambulated via wheelchair; she required partial/moderate assistance with toileting hygiene, bathing, upper body dressing, and personal hygiene; and she required substantial/maximal assistance with lower body dressing. Record review of Resident #3's care plan revised 11/27/2023 revealed the following care areas: * Communication impairment: Resident #3 has Dysarthria (slurred speech), late effects of CVA, and is at risk for further decline and injury. Goal included: Staff will anticipate and meet needs Resident #3 is not able to effectively communicate. Interventions included: Allow time for resident to digest information - do not rush. Approach in a calm manner using eye contact - call resident by name. Reduce or remove interfering environmental stimuli. Use communication tools, terms, gestures the resident can understand. * Cognitive impairment: Resident #3 has impaired cognition related to intracranial aneurysm and is at risk for further decline and injury. Goal included: Resident #3's needs will be met, and dignity maintained. Interventions included: Allow time for tasks and responses. Explain all procedures using terms gestures the resident can understand. Involve in care to maintain or increase level of independence. Praise for tasks the resident completes. Repeat information as needed. * ADL SELF CARE DEFCITS: Resident #3 has ADL self-care deficits related to history of stroke and is at risk for further decline in ADL functioning and injury. Goal included: Resident #3 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury. Interventions included: Anticipate needs - provide prompt assistance. Encourage independent function as able. Encourage resident to ask for assistance for ADL cares as needed. Ensure call light is within reach and answer in a timely manner. Provide encouragement and cueing as needed to performed ADL cares. Provide privacy and maintain dignity. Record review of Resident #3's Smoking Safety Screen dated 12/01/2023 revealed, 1. Does resident have cognitive loss? (No) 2. Does resident have any visual deficits? (No) 3. Does the resident have any dexterity problems? (Yes) . Safety: 6. Can resident light own cigarette? (Yes) 6a. Does the resident or the resident's roommate use oxygen? (Yes) 7. Resident Need for Adaptive Equipment. 7a. Smoking apron . 8. Resident requires supervision to smoke and needs facility to store lighter and cigarettes? (Yes) 8b. Resident is safe to smoke independently but resident/roommate uses oxygen and needs facility to store lighter and cigarettes? (No) 8c. Resident is safe to smoke independently and to store own smoking materials? (Do not mark yes if resident or roommate is on oxygen) (No) . Resident #3 does need facility to store her cigarettes, but she refuses to allow us to store them. She also needs a smoking apron but refuses to use one. Team Decision: Safe to smoke with supervision. Rationale/conditions: Resident #3 needs supervision and a smoking apron but she refuses to use one and allow the facility to store them. Record review of Resident #3's Resident Smoking Behavior Contract revealed it was signed and dated 02/03/2024. Observation of Resident #3 on 02/02/2024 at 10:00 a.m. revealed she was outside in the courtyard smoking unsupervised with Resident #1, Resident #2, and several other residents without an apron on. Observation and interview with Resident #3 on 02/02/2024 at 1:20 p.m. revealed she was alert and self-ambulated via wheelchair. Resident #3 stated she was allowed to keep her own smoking supplies. She stated the facility's staff allowed her to go outside and smoke unsupervised whenever she wanted to. Resident #3 stored her cigarettes and lighter in her pocket. She stated she never smoked around anybody with oxygen or got holes in her clothes from cigarettes. Observation of Resident #3's room on 02/04/2024 at 10:30 a.m. revealed her roommate had an oxygen concentrator at bedside in the space between her bed and Resident #3's bed. In an interview with the Activity Assistant in the outside courtyard on 02/02/2024 at 10:10 a.m., she stated she usually supervised resident smoking during her shift. She stated the residents were scheduled to smoke four times per day and were allowed to smoke two cigarettes each time. She stated some of the residents kept their own cigarettes and lighters even though they were not supposed to. She said previously, staff kept all residents' supplies, but after management changed several times, the residents just started keeping their own supplies. She stated there were two residents outside at that time, Resident #2 and Resident #3, who were burners. She said that meant the residents sometimes got burn holes in their clothes (Resident #1 had already went inside the building at that time). She said Resident #1 kept his own cigarettes and lighters. She said the facility was supposed to keep Resident #1's supplies at his family's request, but even though the family member brought the supplies to staff, Resident #1 always came up with cigarettes and lighters. She stated Resident #1 kept his cigarettes and lighters in a stash, but she did not know where the stash was. She stated the staff needed to step up their game regarding storage of smoking supplies and supervision. She said she thought smoking times were 9:00 a.m., 11:00 a.m., 3:00 p.m., and 5:00 p.m., or something like that. She stated the staff shared smoking supervision duties, but she mostly went outside. She said Resident #1's chair had a couple of burn holes that probably happened when he smoked unsupervised. She stated Resident #1 was known to sneak outside to smoke. She stated she worked at the reception desk on weekends, and she often saw Resident #1 go outside and light a cigarette from the window (the outside courtyard was located in the center of the facility with windows all around it). She said she never reported Resident #1's behaviors because all the staff knew about it, and they saw what she saw when he went out and smoked unsupervised. In an interview with the Activity Director on 02/02/2024 at 11:15 a.m., she stated she was hired almost one year ago. She stated managing smoking had been a struggle since she was hired because residents did not follow smoking times and they refused to allow staff to keep their lighters and cigarettes. She stated they care planned the residents' refusal to adhere to the smoking policy. She said there were a lot of smoking residents and the staff tried to stay outside with them while they smoked. She said when the staff saw residents outside, they tried to go out and supervise. She said the staff tried to their best to encourage smoking at scheduled times. She said they tried to explain the importance of supervised smoking to some family members, but they continued to bring the supplies to residents. She said prior to her hire, the facility had residents sign smoking contracts, so some residents had them and some did not. She said Resident #1 kept his own supplies because he refused to give them up and he had been observed outside smoking alone. She said Resident #1's family member wanted her to keep his smoking supplies, but somehow, Resident #1 still got them. She stated Resident #1 refused to wear an apron. In a follow-up interview with the Activity Director on 02/02/2024 at 2:50 p.m., she stated she was responsible for completing each resident's safe smoking assessment. She said she determined if each resident was a safe smoker by observing if they could safely light their own cigarette. She stated she observed while the residents were unaware if they could hold the cigarette, if they dropped the cigarette, and if any ashes fell. She stated she also reviewed the residents' cognition and acuity. She stated Resident #1 had those burn holes in his cushion and his jacket when she was hired and she had been there almost a year. She said to her Resident #1 was a safe smoker. In an interview with the Interim DON on 02/02/2024 at 3:58 p.m., she stated she was the facility's Regional Nurse Consultant, and she was onsite that day because the facility did not have a DON. She said Resident #2 was on oxygen when she went to her room, PRN. She stated Resident #2 did not take her oxygen when she went outside to smoke. The Interim DON said she would go get Resident #2's lighters from her because she was not supposed to have them in her room with the oxygen. She said Resident #1 received weekly skin assessments, so they always monitored him for any burns. In a follow-up interview with the Interim DON on 02/02/2024 at 4:09 p.m., she stated Resident #2 refused to give up her lighter and stated she would bring the lighter to the nurse's station when she completed her breathing treatment. In an interview with LVN C on 02/04/2024 at 11:00 a.m., she stated some of the residents would sneak outside to smoke unsupervised because they kept their own supplies. She stated the staff could take their lighters 10 times, but they still came up with more lighters. In a telephone interview with CNA F on 02/04/2024 at 11:15 a.m., she stated she worked on the 10:00 p.m. - 6:00 a.m. shift and she previously seen residents try to go outside and smoke during her shift. She stated the residents kept their own smoking supplies. She said when she saw residents go outside to smoke, she reported them to her nurse. In a telephone interview with CNA I on 02/04/2024 at 11:30 a.m., he stated he worked on the 2:00 p.m. - 10:00 p.m. shift and as far as he knew, the residents were previously able to smoke at will because they kept their own smoking supplies and he often saw residents smoking unsupervised. Record review of the facility's Smoking Policy revised 06/2019 revealed, To provide a healthy living environment with respect for the health and well-being of each resident, staff member, and visitor. It is also the objective of this policy to communicate to each resident/POA that they are responsible for following each rule and on-going compliance with the Resident Smoking Policy. Policy: It is the policy of this facility to provide smoking policies and procedures supporting residents' preference to smoke. Our policies have been developed to reduce risk related to smoking behaviors and to support the well-being of residents residing in the facility. Smoking will occur in a designated smoking area, at designated times. Residents who desire to smoke will be evaluated to determine level of smoking dependence. A Smoking Behavior Contract must be completed, signed, and followed by each resident/representative who smokes. Failure to honor the Smoking Behavior Contract and the Smoking Policy will be addressed to minimize potential risk to residents residing in the facility, up to and including involuntary discharge of the individual. Notice of Smoking Policy: 1. At the time of admission, each resident and legal representative shall be informed of and receive a written copy of the facility's Smoking Policy. 2. Each resident who desires to smoke shall receive and have explained the Smoking Behavior Contract. The resident/POA is required to complete, sign, and follow the Smoking Behavior Contract. Smoking Safety - Resident Assessment. 1. Residents who desire to smoke will be assessed using the Smoking - safety Screen, documented in the computer system, for their ability to smoke safely. Assessments will be conducted at the time of admission, [NAME][TRUNCATED]