**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 32 residents (Resident #93 and Resident #13) reviewed for adequate supervision. - The facility failed to ensure Resident #93 who was on continuous oxygen did not smoke while oxygen was being administered from 03/20/25 through 06/03/25. The facility documented they found cigarettes and a lighter in Resident #93's room on 03/22/25 and was observed smoking while on oxygen in front of the facility on 4/18/25 and 06/03/25. -The facility failed to ensure Resident #13 bed rail/assistance bar was attached to the bed securely. when the rail/assistance bar was observed on the floor on 06/03/25. This deficiency exposed residents living in the facility to potential harm, injury or death due to not being adequately monitored. An Immediate Jeopardy (IJ) was identified on 6/23/2025 at 4:59 PM. The IJ template was provided to the Administrator and DON on 06/23/25 at 4:59 PM. While the IJ was removed on 06/24/25 at 5:19 PM. the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #93's face sheet dated 06/03/26 revealed an [AGE] year-old male was admitted on [DATE]and readmitted on [DATE]. Resident #93 had diagnoses which included: heart failure (heart cannot pulp enough blood to meet the body's need), hypertension (when the pressure in the blood vessels is too high), and COPD (lung disease that make it hard to breath). Record review of Resident #93's admission MDS assessment, dated 03/24/25, revealed the BIMS score was 12. Record review of Resident #93's care plan initiated 03/20/25 revealed Resident #93 was a current smoker at risk for adverse effects and has noncompliance with policy. Entered Behavioral contract: (refusals. resistive to care, safety rule regarding smoking) resident agreed to follow all safety and regulations. Date Initiated: 03/20/2025. Date revision on 06/03/2025. goal: Resident #93 will not smoke while a resident in facility through the review date initiated: 03/20/2025. target Date: 07/14/2025. Interventions: Discuss residents smoking habits with resident/family date initiated 03/20/2025. Elicit family input for best approaches to resident date initiated: 03/20/2025. Praise resident for demonstrating consistent desired/acceptable behavior date initiated: 03/20/2025. Discuss residents smoking habits with resident/family date initiated 03/20/2025. Elicit family input for best approaches to resident date initiated: 03/20/2025. Revised 06/03/2025. Provide reminders that we are a non-smoking facility which includes the surrounding areas as well. Date initiated: 03/20/2025. Behavior contract: If not followed, resident has agreed to immediate discharge with social worker involvement. date initiated 06/03/2025. Record review of Resident #93's NP progress noted dated 4/8/25 4/15/25,5/20/25, 5/22/25, 5/23/25 and 5/27/25 did not address Resident #93 behavior of noncompliance with smoking policy. Record review of Resident #93's progress notes dated 03/22/25 revealed Resident #1 had cigarette and lighter in his room. Record review of Resident #93's progress notes dated 03/24/25, 03/26/25,04/02/25, 04/03/26, 04/06/25, 04/18/26, 04/19/25, 04/20/25, and 06/03/35 revealed Resident #93 smoked out the facility. During an interview on 06/03/25 at 12:12 p.m., the Corporate Nurse said he observed Resident #93 smoking with his oxygen on and in use in a parking lot of the building next to the NF today (06/03/2025. The Corporate Nurse said he took Resident #93's lighter and cigarette away from him. Corporate Nurse said he was going to initiate Resident #93's discharge today. During an interview on 06/03/25 at 12:24 p.m., Resident #93 said he went to where his friend resides in the building next to the NF to get a cigarette and lighter to smoke. Resident #93 said he was admitted to the NF as a smoker, and the NF was upset with him today because the State was in the building. Resident #93 said the NF and Administrator knew he was a smoker. Resident #93 said he would sign himself out to smoke with the oxygen in his wheelchair. He said since he smoked outside, where the wind blew his smoke away, he did not know that smoking could ignite the oxygen. During an interview on 06/03/25 at 1:00 p.m., LVN K said Resident #93 had not gone out to smoke today, but he had been going out to smoke in the past. LVN K said he had seen Resident #93 smoke in front of the building with his oxygen on in his wheelchair. She said she told the administrator and the DON. She said the Administrator and the DON told Resident #93 that the facility was non-smoking. She said after they had talked to him, Resident #93 started to sign himself out to go and smoke in the parking lot of the building next to the facility with his oxygen on. LVN K said Resident #98 told her once to remove the oxygen because he was going to smoke, and she did remove the oxygen tank. During an interview on 06/03/25 at 3:54 p.m., the DON who said Resident #93 smoked in front of the facility when he was first admitted to the facility. The DON said she and the Administrator told Resident #93 that he could not smoke in front of the facility building because the facility was a non-smoking facility. The DON said staff had told her Resident #93 would sign himself out and go to the next building to smoke while he had his oxygen. She said it was care planned that the resident was a smoker, and the intervention was to educate the resident not to smoke because this was a non-smoking facility. The DON said it was hazardous because he had oxygen, and the smoking could cause the oxygen to blow up. The DON was asked what the facility did when the intervention did not work because he had continued to smoke since March. The DON responded that the facility would discharge him today (06/03/25). During an Interview on 06/03/25 at 5:59 p.m., the Unit Manager who said Resident #93 used to smoke in front of the facility building, and later, he started to go to the next building to smoke with his oxygen. The Unit Manager said Resident #93 signs out when he goes to the next building to smoke. She said it was not safe to smoke with oxygen because it could blow up. The Unit Manager said she had talked to Resident #93 and documented twice. She said the resident was his own responsible party and there was no family member. The Unit manager said Resident #93 had no family members and did not know why the family member was put in the care plan. She did not respond when she was asked what other intervention was put in place since educating the resident did not stop him from smoking. The Unit Manager said the resident oxygen tank could blow up while he was smoking. During an interview on 06/03/25 at 4:21 p.m., the Administrator who said he had not seen Resident #93 smoke, but he heard once that he smoked, and he and the DON had a conversation with him. The Administrator said he told Resident #93 that this building was not a smoking facility. He told him they had another building that was a smoking facility, and they had staff that would go out with residents to smoke. The Administrator said the smoking facility had a smoking blanket and fire extinguisher, but he declined to go to the smoking facility. He said she could not recoil any staff telling him Resident #93 still smoked. The Administrator said he would have Resident #92 sign a behavioral contract that he would not smoke between now and tomorrow, which was his planned discharge. The Administrator said If the staff saw him smoking, he would be discharged immediately. The Administrator said Resident #93 smoking would have been a major issue because the resident could had caught on fire if the oxygen had combusted. During an Interview on 06/03/25 at 6:24 p.m., NP said the facility told her Resident #93 goes out to smoke with his oxygen on. NP said when she talked to the resident, he would say he did not smoke, and she could smell that he smoked on him. NP said the staff had showered her picture where the resident was smoking. Some other staff told her that the resident had sneaked out to smoke, and she said she could not remember the names of the staff members. The NP said the facility should be able to answer what other intervention that was put in place when educating Resident #93 did not stop him from smoke. She said if Resident #93 was smoking with his oxygen on, the oxygen could ignite. During an interview on 06/03/25 at 6:40 p.m., CNA I said she had not seen Resident #93 smoke, but some of the staff had seen him smoking with an oxygen tank. CNA I said she could not remember the names of the staff who told her Resident #93 goes out to the next building park lot to smoke. CNA I said the oxygen could blow up from the cigarette and hurt the resident. On 6/3/25 at 9:14 AM, an observation of Resident #13 he was asleep in his bed covered in blankets and his call light was placed on his bed. There was also a bed rail/assistance bar on the floor by his bed on the right side. Observation and interview with CNA F on 6/3/25 at 9:57 AM revealed that the bed rail that was on the floor had been repaired. She said that she told the Maintenance Director immediately once she saw the bed rail on the floor and he (the Maintenance Director) repaired the bed rail. She said the resident could have rolled out of bed and hurt himself, she added all staff are responsible for reporting repairs needed. She added that Resident #13 was a fall risk, and this was why she had his bed lowered. Record review of Resident #13's facility admission record revealed an [AGE] year-old male with an original admission date of 9/1/20 and re-admission date of 7/20/24 with diagnoses that included History of Falling (The history of falling is crucial for diagnosis. Falls are the second leading cause of unintentional injury deaths worldwide), Parkinsonism Disease (Parkinson's disease is a progressive movement disorder of the nervous system that causes symptoms such as tremors, stiffness, and difficulty with balance and coordination. It is a brain condition that worsens over time and can also affect mental health, sleep, and other bodily functions) and dementia in other diseases classified elsewhere, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (Dementia describes a group of symptoms affecting memory, thinking and social abilities) (It indicates that a patient has dementia as a result of an underlying disease that is not otherwise specified and without associated behavioral, psychotic, mood, or anxiety symptoms). Record review of Resident #13's Annual MDS dated [DATE] revealed Resident #13 had a BIM score of 7 out of 15 indicating he had severe cognitive impairment. Resident #13 required substantial/maximal to partial/moderate assistance with ADL's. He had an indwelling urinary catheter and was frequently incontinent of bowel. Record review of Resident #13's comprehensive care plan revealed a care plan to address fall risk with the date initiated of 9/9/20 and revised on 8/22/23 and target date of 7/29/25. Interventions included make sure to resident frequently to make sure resident needs are met, low bed, fall mats and ensure floors are free and clear from clutter. Interview on 6/4/25 at 2:15 PM with the Maintenance Director he said the screw fell out of Resident #13's bed rail and he replaced the screw. He said that staff directly told him that the repair to the bed was needed, they also communicated through a email that connected to the Administrator and management team regarding the incident, this alert went to everyone, he said that he was responsible for making repairs and all staff monitored for needed repairs. He added that the resident could have rolled out of bed and hurt himself. Interview on 6/5/25 at 1:15 PM with the Administrator who said that the bed rail could cause the resident to fall, that the Maintenance Director was responsible for repairs, but it was all staff's responsibility to report repairs needed. Interview on 6/5/25 at 2:49 PM with the DON, who said that she was made aware of the broken bedrail and acknowledged that it could be a hazard and could cause injury. She added the Maintenance Director was responsible for repairs, but all staff are responsible for reporting. Record review of the facility admission Packet read a resident may be discharged or transferred if a. Necessary for the resident's welfare and resident's needs cannot be met in the facility. c. The Resident is endangering the safety of other people in the facility. d. The Resident is endangering the health of other individuals in the facility: · ACKNOWLEDGEMENT OF SMOKING POLICY Non-Smoking Facility: I hereby acknowledge that the facility is a NON SMOKING facility, and I was made aware. Residents may not use or keep cigarettes, cigars, matches, or any smoking paraphernalia in their room or on their person at any time during their stay at the facility. Residents must adhere to the smoking schedule and cannot smoke without supervision. Failure to adhere to this policy may result in immediate discharge. (Resident/Responsible Party Initials) Record review of the facility police on safety and supervision of resident dated 2001 MED- PASS, Inc. (Revised July 2017) read in part .Our facility strives to make the environment as free from accident hazards as possible . Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Individualized, Resident-Centered Approach to Safety . #1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents .#4. Implementing interventions to reduce accident risks and hazards shall include the following: 1. Communicating specific interventions to all relevant staff; 2. Assigning responsibility for carrying out interventions; 3. Providing training, as necessary. 4. Ensuring that interventions are implemented; and 5. Documenting interventions . #5. Monitoring the effectiveness of interventions shall include the following: 1. Ensuring that interventions are implemented correctly and consistently; 2. Evaluating the effectiveness of interventions; 3. Modifying or replacing interventions as needed; and 4. Evaluating the effectiveness of new or revised interventions. The following Plan of Removal submitted by the facility was accepted on 6/23/2025 at 8:36 p.m. Plan of Removal F689 June 23rd, 2025. What corrective actions have been implemented for the identified residents? Resident #93 was no longer a resident at the time of this plan of removal. No corrective action is was possible to be taken for resident #93. How were other residents at risk to be affected by this deficient practice identified? An audit of all residents was conducted on 6/23/25 by the DON/designee. No other residents reside in the facility who smoke. All residents who reside in the facility have the potential to be affected by the alleged deficient practice, however, none were affected. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? Resident #93 was no longer a resident of the facility as of 6/23/25. All facility staff, including CNAs, MAs and nurses were in-serviced by DON/Designee on facility actions to be taken for residents who fail to follow facility smoking policies. This was completed 6/6/2025. This includes notifying the administrator, DON and regional support staff in situations of non-compliance with smoking policies. What corrective actions were taken? 1. The following actions were initiated immediately on 6/4/25. a. On 6/4/2025 the Administrator and DON were in-serviced by the Regional [NAME] President of Operations on immediately discharging residents who do not comply with facility smoking policies. b. All facility staff in-serviced by the DON/Designee on 6/4/2025 regarding facility smoking policies and what to do if they witness residents smoking on the facility premises or surrounding areas while utilizing oxygen. c. An ad-hoc QAPI regarding residents who are non-compliant with smoking policies was completed on 6/4/25. The facility medical director was included. d. The facility reviewed their smoking policies on 6/4/2025 with the medical director and it remains a non-smoking facility at this time. e. All current residents and their responsible parties were notified of facility smoking policies via the e-alert system on June 4th, 2025. f. All new residents will be educated on facility smoking policies upon admission. How will the system be monitored to ensure compliance? The facility administrator, as part of the morning stand-up process, will review any new issues with residents not following the facility smoking policy and address those concerns on a case-by-case basis. An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/23/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of the plan of removal on 6/24/2025 included: Record review of a facility document titled Daily Census Report, dated 6/20/2025 to 6/22/2025, revealed residents who were non-smoker. The census revealed 104 residents of which all were nonsmokers. Record review of a facility document titled Education of New Residents, not dated, read in part: 1) All referral portals that offer an opportunity to place a notation or ask the question if we offer smoking, are noted appropriately to show that we are a non-smoking facility, 2) Residents are notified prior to admission by our Director of Business Development that we are a non-smoking facility, 3) Residents are provided with a Welcome booklet that states we are a non-smoking facility, 4) During the initial care plan meeting, the Social Services Director asks new admissions if they are a smoker, and shares that we are a non-smoking facility and that we are able to offer nicotine patches or lozenges to assist individuals with quit smoking by providing a controlled release of nicotine into the blood stream, which helps to reduce nicotine withdrawal symptoms and cravings. Record review of a facility document titled Ad Hoc Qapi, dated 6/4/2025, revealed: Area of concern identified 1) Resident observed smoking with oxygen in place, 2) Resident leaving facility without signing himself out, 3) Facility not evaluating resident's BIMS's score to asses capability of safety awareness (First BIMS score was documented 12/15), and 4) All staff needing to enforce we are a non-smoking facility and report any infarctions immediately; Investigation of allegations: Resident observed smoking with oxygen in place. Resident observed smoking off premises next door at a local apartment complex. Resident's sign-out log appears that someone else was signing him out and has ditto marks versus actual signatures. Sign-out log also has no signatures for resident's return to the facility to show return; Possible outcome if situation is confirmed: Resident smoking with oxygen in place creates a significant safety concern. Resident leaving our premises without signing himself out and back in upon return is against policy for signing out; Five Whys: Resident smoking with his oxygen on. 1) Resident has history of noncompliance in other areas ie. Care, medication, etc, 2) Resident feels he has the right to smoke, 3) Resident states he will not allow anything to happen as he is [AGE] years old, 4) Resident states the sign on the front of the facility says No smoking in the facility, and 5) Resident has been a habitual smoker for years; Interventions: 1) Resident was offered and accepted, nicotine and lozenges, 2) After resident observed smoking, nicotine patches and lozenges were discontinued for health reason, 3) When resident continued joking about going out to smoke and signed himself out to go smoke, DON and Administrator spoke with resident regarding possible outcomes of safety issues (oxygen catching on fire, E-tank exploding, both of which can cause injury and death)., 4)Resident observed by RVP and Clinical Services Director smoking with his oxygen on, and spoke with resident and provided education on safety issues, and 5) Resident discharged home at his request due to his dislike of our facility policies on smoking. Record review of a facility document titled In-Service Training Report, dated 6/4/2025, revealed that all staff to include the RN's, LVN's, CNA's, MA's Supervisors, Dietary staff and Housekeeping staff were in-serviced by the DON on the smoking policy which read in part If you see a resident smoking you are to come and report it to managers, Administrator etc. You need to tell the resident they cannot smoke here and to put the cigarette out. Always make sure that you report it to the managers. Record review of a facility document titled In-Service Training Report, dated 6/4/2025, revealed that the Administrator and DON were in-serviced by the Regional [NAME] President on the smoking policy revealed in part Resident who are non-compliant with facility smoking policies. Signing out pass. Any resident who is habitually non-compliant with the facility smoking policy needs an immediate discharge from the facility. Documentation of education of facility smoking policies needs to be included in the resident chart. Additionally, residents who go out on pass must be signed out when leaving the facility and signed in when they return. This includes resident who are self-responsible. Interviews with Residents began on 6/24/2025 at 1:00 p.m. Residents #6, # 86, # 167, #169, #170, #171, #172, #174 and # 175 stated they were aware that this nursing facility was a smoke free facility. Interviews with CNA's I, K, M, P, Q, R, S, T, V, W and X; LVN's C, K, P, Q, R and S; MA's A, B, C, and D; RN B; Unit Manager; Dietary Manager; House Keeping Supervisor; House Keeper's A and B on 6/24/2025 beginning at 11:33 a.m. staff were able to explain the smoking policy. Staff stated that this nursing facility was a smoke free facility. Staff stated that if a resident was observed smoking staff should retrieve the cigarette from the resident, inform the resident that this facility was smoke free, and report the incident to the Administrator and/or supervisor. Interview with the DON on 6/24/2025 at 4:48 p.m., who stated that staff was in-serviced on the smoking policy on 6/23/2025 and 2 or 3 weeks ago. She stated that staff are aware that this facility is a non-smoking facility. She stated that if staff see any resident smoking, they must report it immediately to management team. She stated staff was expected to ask the resident to put the cigarette out and educate the resident that this nursing facility was a non-smoking facility. Interview with the Administrator on 6/24/2025 at 5:03 p.m. stated that staff were in-serviced on 6/3/2025, 6/4/2025 and 6/23/2025. He stated that staff are aware that this facility was a non-smoking facility. He stated that if staff observe a resident smoking staff should ask the resident to put the cigarette out and educate the resident as to the facilities smoking policy. Staff was expected to report the smoking incident to the Administrator and/or Nursing Supervisor. He stated that if the resident continues to be noncompliant the resident will be discharged . He stated that current residents /and RP's have been educated about the smoking policy. He stated that on 6/4/2025 the smoking policy was texted and emailed to residents and/or RP'S. He stated that that the facility has started a stand up meeting whereby managers discuss any issues to include smoking. He stated that moving forward the smoking policy will be reviewed at the Resident Council meeting. He stated that all staff have been in-serviced on the smoking policy. The Administrator and DON were informed the Immediate Jeopardy was removed on 6/24/2025 at 5:19 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is no immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.