**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide supervision to prevent accidents for 5 (Resident #1, Resident #2, Resident #3, Resident#4, and Resident #5) of 11 Residents reviewed for residents having lighters. The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident#4, and Resident #5 were not in possession of an unauthorized lighter. 1 of the 5 residents (Resident #1) used a lighter to burn the gauze bandage, which was secured to her right foot, resulting in second degree burns to her right foot. An Immediate Jeopardy (IJ) situation was identified on 4.4.25. The IJ template was provided to the facility on 4.4.25 at 3:10pm. While the IJ was lowered on 4.6.25 at 5:52 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of a isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could put residents at risk of burn injuries related to smoking paraphernalia that is not monitored/secured by the facility. Findings included: Resident #1 was a [AGE] year-old female admitted to the facility on 4.4.24with diagnoses of traumatic amputation, urinary tract infection, cognitive communication deficit, dementia, and type 2 diabetes. Resident #1's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident was safe to smoke unsupervised, at this time. Resident #1's quarterly BIMS was completed on 2.27.25 with a score of 13, indicating no cognitive impairment. Resident #2 was a [AGE] year-old male admitted to the facility on 1.10.25 with diagnoses of hypertension, pneumonia, and dementia. Resident #2's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident was safe to smoke. Resident #2's initial BIMS was completed on 1.16.25 with a score of 9, indicating moderate cognitive impairment. Resident #3 was a [AGE] year-old male admitted to the facility on 6.7.24 with diagnoses of pneumonia, Alzheimer's disease, and type 2 diabetes. Resident #3's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident was safe to smoke. Resident #3's quarterly BIMS was completed on 3.27.25 with a score of 14, indicating no cognitive impairment. Resident #4 was an [AGE] year-old male admitted to the facility on 8.28.20 with diagnoses of hypocalcemia (a condition where the level of calcium in the blood is too low), amputation of leg below left knee, and anemia. Resident #4's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident is safe to smoke. Resident #4's quarterly BIMS was completed on 2.20.25 with a score of 13, indicating no cognitive impairment. Resident #5 was a [AGE] year-old female admitted to the facility on 11.21.22 with diagnoses of seizures, anemia, and muscle weakness. Resident #5's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident is safe to smoke. Resident #5's quarterly BIMS was completed on 1.8.25 with a score of 13, indicating no cognitive impairment. During an observation on 4.1.25 at 11:15am Resident #1 had one large blister on the side of right foot and 3 smaller blisters on top of the right foot. Record review of EMS report dated 3.31.25 at 8:18 pm indicated: patient stated that she was trying to cut a piece of her bandage off her foot and then light that cut piece on fire. The cut piece was still attached to the rest of the bandage on her foot, and it all caught on fire including her foot. Patient had superficial burns to her right foot. First degree burns 9%. Record review of assessment dated 4.1.25 completed by LVN A (treatment nurse) indicated: Right dorsal with blister 8cm x 4 cm and multiple small blisters on lateral right food. Type of burn: 2nd degree burn. Wound assessment: length 8cm width 4 cm and depth 0.1 cm. Record review of Resident #1's medical record from local hospital dated 3.31.25 indicated: Resident #1 arrived at local hospital for assessment but refused both assessment of burns and treatment. Record review of facility's Event Nurses' Note-Burn dated 4.2.24 by RN A indicated that on 3.31.25 at 6:53 pm- While this nurse was on break, was alerted by staff that resident #1 had set her bandage on fire. Found water on ground where the aid put out fire. Resident was angry and stated that she wanted water on her burn; attempted to explain that we needed immediate treatment at hospital and that they would be able to assess severity of burn. Resident refused initially to go to hospital despite EMS and police presence. Was able to convince resident to go to hospital but resident decided against treatment. Interview with Resident #1 on 4.1.25 at 11:35 am who was alert and oriented to person, place and event stated she had gauze wrapped around her right foot that was hurting and too tight. She stated she requested help and was told someone would be right there. She stated she began to unwrap the gauze off her foot and to cut the gauze she used a lighter. She stated the fire moved quickly down the gauze onto her foot and burned her foot. During an interview on 4.1.25 at 2:10 pm CNA A stated she was working the night of the incident. She stated that she went down to Resident #1's room because her call light was on. She stated she went to her room and the resident stated her wrapping on her foot was too tight and was hurting. She stated she will let the nurse know and come back. She stated she went to the nurse's station and let the nurse know- - because charge nurse was on her break. She stated that nurse said OK give me a few minutes and she will go help the resident. She stated not even 10mins went by and she was walking hallway 100 when she looked into Resident 1's room and there was a fire going on her foot. During an interview on 4.1. 25 at 2:25 pm RN A stated she was on break when the incident occurred. She stated that the resident is usually very good with her. She stated the resident is extremely impatient. She stated that this behavior is very abnormal for the resident. She stated the night of the incident she was in the breakroom on hallway 300. She stated she heard yelling and stopped her break and went to see what was going on. She stated that when she went into the resident's room there was water all over the floor and gauze was singed and wet laying on top of the resident's foot. She stated the resident was yelling in pain. She stated she told staff to call EMS and police to get someone here asap because she was not sure how bad the burn was. She stated the resident was extremely upset and was yelling in pain. She stated she ultimately calmed the resident down. She stated EMS showed up and the resident refused to go with EMS, same with the police that showed up as well. She stated EMS left and told her if she does need them to come back to please call them. She stated about 15min later she convinced the resident to go to the ER and just let them look at it. She stated she called EMS back, the resident went. She stated she is not exactly sure how long it was, but the hospital called stating they are sending the resident back because the resident is refusing everything, and the facility needs to come get her. She stated they got the resident back; she was still very upset. During an interview on 4.1.25 at 2:35 pm RN B stated she was one of the RNs on shift during the incident. She stated that she was sitting at the nurse's station when a CNA went and checked the residents call light and came back to report that Resident #1 was saying her wrapping on her foot was too tight and that she wanted it to be changed. She stated she told the CNA that she would go and look at it shortly, just to let her finish up what she was doing. She stated the next thing she knew; the CNA was walking back down hall 100 and started yelling for help. She stated as she got close to the resident's door the CNA yelled, fire and grabbed a water cup and put out the flame. She stated she saw the water and singed gauze on the resident's foot. She stated shortly after showed up and was the one who started to assess and try to help calm down the resident. She stated police and EMS were contacted. She stated EMS did come to the facility, but the resident would not allow them to assess or help her. She stated EMS left but did return because the resident finally agreed to go to the ER. Interview with Administrator on 4.1.25 at 12:35 pm stated she was contacted by phone at 6:57 pm on 3.31.25 with details of the incident. She stated she went to the facility immediately. She stated she spoke with all 11 smokers, and ultimately confiscated 5 lighters from the Residents. She stated none of the residents could notate exactly where they got the lighters from or how long they had had them for. She stated that they have verbally discussed the procedure with the staff that do take the residents out to smoke, but the facility does not have a written procedure. Interview with Staff A on 4.1.25 at 2:55 pm stated he was not exactly sure how any of the residents got the lighters they had. He stated that there was a possibility that when he handed a resident their lighter to light the cigarette and he never asked for the lighter back. He stated there was a policy in place that he knew about regarding smoking residents, but no procedure in place. Interview with SW on 4.1.25 at 2:40 pm she stated that she does take the residents out to smoke each day. She stated she has no idea how they got the lighters but should not have had them. She stated she is not sure if other employees are giving the residents lighters and not getting the lighters back. Interview with Staff B on 4.2.25 at 2:45 pm stated that she does not believe there is a procedure in place for smoking or taking the residents out to smoke. she stated there is a policy but no actual procedure she can think of that is in place for taking the residents out to smoke. She stated this was why she believed residents had lighters. During an interview with the Administrator on 4.1.25 at 12:05 pm she stated that Resident #1 should not have had a lighter on her person. She stated the incident occurred Monday night, 3.31.25. She stated she came up to the facility immediately. She stated upon speaking with her staff, she understood that Resident #1 was trying to cut the gauze from her foot because it was too tight. She stated Resident #1 used a lighter to cut the gauze resulting in burns to her foot. She stated she never imagined anything like this ever happening. She stated after the incident that night she did rounding on all smoking residents and found that Residents #1, #2, #3, #4, and #5 all had lighters on them. She stated she did confiscate them. She stated the policy states residents are not supposed to have lighters. She stated the policy was not followed and due to this, Resident #1 got injured. During an interview with the DON on 4.1.25 at 12:35 pm she stated she received a call from her staff around 7:00 pm stating that Resident #1 had burned her foot with a lighter. She stated she came up to the facility and upon speaking with her staff, she found out that Resident #1 was trying to remove gauze from her foot because it was too tight. She stated she had never had anything like this happen before. She stated the policy stated that no resident was to have a lighter or anything like that on them. She stated there were multiple other lighters confiscated by the Administrator from other residents. She stated policies and procedures were in place for the residents' safety, but the policy and procedures were not followed. During interview with Resident # 2 on 4.2.25 at 3:15 pm he stated that when he goes out to smoke with the group daily, after the residents were done smoking, he was never asked by any employee if he had a lighter on him. He stated he knows multiple Residents have lighters on them all the time because staff do not ask for them back. He stated he knows about the smoking policy, but never thought about having a lighter as an issue. During an interview with Resident #3 on 4.2.25 at 3:35 pm stated there has been many times where the employees will take the group outside give them everything including the lighter and then go back inside to work. He stated there have been a few times where he will get back to his room and look down and realize he still has the lighter he was given to smoke with outside. He stated the employee's do not ask for the lighters back if they gave lighters to the residents. Interview with DR A stated on 4.1.25 he was informed of the incident and did not know the severity of the burns or how many on the night of the incident 3.31.25. He stated but the blisters started to form on the morning of 4.1.25 and this was communicated to him by LVN A who did an assessment of Resident #1's food. He stated he has no idea where Resident #1 got a lighter, but she should not have had one. Record review of Resident #1's orders dated 4.1.25 indicated Dr. A ordered silver sulfadiazine 1% cream to be used one time a day for burn on foot. During phone interview with NP on 4.3.25 at 12:50 pm she stated she was at the facility on 4.2.25 to see Resident #1. She stated Resident #1 had gauze on right foot that was clean and intact. She stated she did not remove the gauze to assess the injury. Record review of facility policy dated 11.1.17 indicated: 1. Matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in a resident's room. Record review of facility smoking procedure indicated: Facility does not have a written smoking procedure. This was determined to be an Immediate Jeopardy (IJ) on 4.4.25 at 3:10 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 4.4.25 at 3:10. Record review of Plan of Removal accepted on 4.5.25 at 3:37 PM reflected the following: 4/4/25 Plan of Removal Problem: IJ F689 Free of Accidents/Hazards/Supervision/Devices called on 04/04/2025 Interventions: On 3/31/2025 Resident #1 was sent to the emergency department for assessment after initially refusing any treatment. She turned the first away, so a second ambulance had to be dispatched after facility administrator got her agreement. The hospital records did not indicate injury, and she returned to the facility with antibiotic for diagnosis of cellulitis. was contacted and assessed for psychiatric screening for inpatient psychiatric care, the resident refused screen. Resident placed on 1:1 observation until 4/3/2025. Psychiatric services in facility referral were made. All other residents who smoke including those discovered with cigarette lighters had a skin assessment completed on 4/1/2025 with no visible signs of injury related to cigarettes or lighters. On 3/31/2025 the facility administrator, director of nurses and regional compliance swept all resident rooms for items not allowed in resident's rooms and to check for cigarette lighters. They removed those offending items found from the resident rooms. A log was completed with items found of items removed. Facility administrator/DON/Compliance nurse will keep a log of any medications/items to include cigarette lighters not allowed found at bedside during champion rounds five times weekly. Any items discovered will be reported to the DON/Administrator at the time of discovery. On 4/4/2025, the Regional Compliance Nurse in serviced the DON and administrator on items not allowed. If a resident is found with a cigarette lighter, the item is to be removed from the room. Smoke breaks are to be supervised by the facility staff assigned to the scheduled smoke breaks, and residents will not give a lighter to keep during that smoke break. The facility staff member will light the cigarette for the resident and return the lighter to the smoking lock box after use. A log will be placed in the lock box to verify the count of cigarette lighters at the start and end of the smoke break. The facility staff education provided on the new process on 4/3/2025 with a completion date of 4/4/2025. This was done both in person and via Covr. The facility administrator, director of nursing or compliance nurse will review this log 5x weekly for discrepancies. Staff were given a copy of the new process and verbal checks by DON and compliance nurses are being conducted each shift to verify understanding. On 4/4/2025, Regional Compliance Nurse educated the DON/Administrator that this incident and any other incident related to smoking paraphernalia including cigarette lighters to be reviewed monthly by the QAPI committee. The Area Director of Operations or Regional Compliance Nurse attend QAPI committee meetings and will verify continued compliance. On 3/31/2025 nursing staff education was begun by the Director of Nurses with a completion date of 4/4/2025 to ask residents that return from being out of facility to smoke if they have cigarette lighters in possession. If they returned with any items that are not allowed to include cigarette lighters, we are to re-educate and take them items or return them to the family. These incidents are to be reported to the DON/Admin immediately. Facility staff have been given written fact sheets to keep with them during the learning process and verbal questioning is being done of three staff members at least 5 times weekly and PRN. On 3/31/2025, Facility completed education/notification in form of an email to all RPs of residents with a list of the items not allowed in residents rooms to include cigarette lighters and the smoking policy. A physical copy of the items not allowed in residents rooms will be mailed out to resident RP's on 4/5/2025 For all future residents, list of items not allowed in room will be provided upon admission as part of the admission packet. On 3/31/2025 education/in-service begun for all staff by facility director of nursing to reiterate the policy of items not allowed in residents rooms to include cigarette lighters, smoking policy, by phone, COVR (scheduling portal/message board) and in person. Staff will not be able to return to work until education has been provided. Education will be completed by 4/5/2025. Signature or acknowledgement of this education will be confirmed by an audit list. This will be monitored for continuous compliance to include new hires by the Administrator, DON, or Regional Compliance Nurse. Facility staff have been given written fact sheets to keep with them during the learning process and verbal questioning is being done of three staff members at least 5 times weekly and PRN. On 3/31/2025 The Facility provided a copy of list of items not allowed to include cigarette lighters and the smoking policy to residents and keep a singed copy. Residents that are alert but unable to physically sign will be confirmed by two witnesses. This was completed by facility on 4/1/2025. The signed copy is scanned into the documents section of the resident's electronic medical record. 100% was completed and verified by the regional compliance nurse and facility administrator. On 4/4/2025, a sign was placed at the front door of the facility with the items not allowed to include cigarette lighters and the smoking policy for reference and education. On 4/1/2025 The physical environment of all residents was observed to include the closet, nightstands, and any other storage containers to ensure that no cigarette lighters were retained in their room by the facility administrator, director of nurses and the regional compliance nurse. This was completed on 4/1/2025. On 4/4/2025 MD was notified of IJ F689 Free of Accidents/Hazards/Supervision/Devices On 4/4/2025 All facility staff were educated by the director of nursing that no residents may be left alone on the smoking patio, staff are to light the resident cigarettes and return lighter to the receptacle for safe keeping. The facility administrator will review the lighter logs 5x weekly for compliance. All in-service education will be completed by new hires at orientation and before assuming duties in the facility. This will be verified by the Administrator, Director of Nurses, or the Regional Compliance Nurse. Monitoring: Facility department heads or weekend manager on duty will conduct champion rounds 5x a week indefinitely in every resident room and look for items not allowed per written company guidelines to include cigarette lighters. They will remove items not allowed if they identify any then report to DON/Administrator. Monitoring will start 4/5/2025. Regional Compliance Nurse will monitor during weekly visits and ask DON and Administrator what items are not allowed in residents room to include cigarette lighters and what to do if any are identified. They will be questioned about the smoking policy and any identified violations. Monitoring will start 4/5/2025 and will continue for at least 8 weeks and prn thereafter. The administrator / DON will assess five resident rooms for posted items not allowed to include cigarette lighters, 5 days a week to ensure residents do not have any items not allowed in room to include cigarette lighters. Regional Compliance Nurse will assess for compliance with posted items not allowed to include cigarette lighters, once weekly by verification of completion of facility assigned monitoring as listed above and visual verification of five rooms each week. Monitoring will start 4/5/2025and will continue for at least 8 weeks and prn thereafter. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 4.6.25. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record review from 4.5.25 at 3:37 PM to 4.6.25 at 5:52 PM as follows: During an interview on 4.6.25 at 10:10 am FT stated she is one of the employees that takes them out for the smoke break. M-F 7a to 4p. She does the smoking break from 8:30-8:50 am. She stated she attended an In-service on items not allowed in room-she stated that they went over a list of items residents should not have in their rooms. She stated items such as scissors, lighters, glasses, anything that says, keep out of reach of children, corded things like air dryers, etc. she stated this was done to make sure there is nothing in the room that anyone could hurt themselves with. She stated she was to keep an eye out for any of these items while working throughout the day. She stated if she does find something she would let the DON or Administrator know and they would go take care of it. She stated she attended an in-service on smoking policy-she stated there were no real changes to the smoking policy. She stated it was still to watch the residents if you are the one that takes them out. Residents are to have one cigarette at a time. And that the residents are to not be left alone at any time while outside smoking. She stated that residents should not have lighters or any other smoking related items. She stated she attended an in-service on smoking procedure-she stated that the new process for taking residents out to their smoking break was to get the smoking box which has all residents' cigarettes in it. She stated there was one lighter in the box now and you sign out that one lighter onto the log sheet, also you put the time the smoke break is happening on the log sheet. She stated you give each resident one cigarette, you light the cigarette, do not let resident do it, and watch the residents while they smoke. She stated once everyone has completed their cigarette, and everyone is back inside, you sign the one lighter back in and return the smoke box back to the med room. Record review of in-services completed by FT with signature for the smoking policy on 3.31.25, items not allowed on 4.4.25, and smoking procedure on 4.3.25. During an interview on 4.6.25 at 10:15 am Staff B stated she was the employee Monday through Friday that would take residents out to smoke break from 6:15 am to 6:35 am Monday through Friday. She stated she attended an in-service on items not allowed in room-she stated the discussion covered all items that could be used to hurt themselves or others, may it be intentional or by accident. She stated things like sharp objects, aerosol cans, she said anything that can hurt anyone. She stated if she were to see anything in a resident's room that was not allowed, she would take the item to DON or Administrator and have them explain to the resident why it was not allowed, or she would just inform either one of them of the item. She stated she attended an in-service on smoking policy she stated the smoking policy is pretty much the same, they just went over it. She stated it covers who can smoke, when to smoke, what is allowed, where its allowed. She stated the smoking policy is straight forward. She said oh, an assessment must be completed by any resident that is out there for a safe smoker assessment. She stated she attended an in-service on smoking procedure- she stated the new procedure was to get the box with all the residents' cigarettes in it. She stated that once everyone was outside, she would give each residents a cigarette, if they wanted a second cigarette, they must finish the first one first. She stated she would then light the cigarette for the residents individually, never giving the lighter to any of them. She stated that after everyone was done smoking and back inside, she would fill out the smoking log which indicated how many lighters she started the break with, how many ended with and her signature, with time of the smoke break. Record review of in-services completed by Staff B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25. During an interview on 4.6.25 at 10:30 am CNA B stated she normally works 6a to 2p. She stated she is one of the employees that will take the residents out on smoke break. She stated she attended an in-service on items not allowed in room, she stated this was one she kind of all did already, but it was nice to see it written. She stated basically while she was working at any time, she was to keep a look out for any items in residents' rooms or on their persons that was not allowed. She stated these items were like scissors, glasses, aerosols, electrical wires, etc. she stated this was being done to protect the residents and make sure everyone is safe in the building and no accidents to occur. She stated she attended an in-service on smoking policy she stated the smoking policy did not change. She stated that it was an overview of the smoking policy and the importance of sticking to it. She stated it covers what residents were allowed to smoke, where they were allowed to go what items should not be left with them etc., she stated it was straight forward. She stated she attended an in-service on smoking procedure she stated that the new procedure is to get the smoking box and check for a lighter and how many. She stated she was to go outside with the residents, hand out 1 smoke to each resident, light the smoke for them, and monitor the residents while they were outside smoking. She stated that she was to fill out the smoking log sheet, which indicated how many lighters smoke break started with, how many ended with, smoke break time and her signature indicated she did take them out and that the lighter was returned. Record review of in-services completed by CNA B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25. During an observation on 4.6.25 at 10:30 am smoke break with employee CNA B she handed all resident one cigarette at this time, she individually lit the residents a cigarette. She watched all the residents until they were done, and they all headed inside. Once they were all inside, she signed the log she indicated the one lighter was still with her and she returned the box to the med room. Observation of log was documented and fully completed since yesterday 4.5.25. During a phone interview on 4.6.25 at 10:50 am LVN B stated she works Monday through Saturday. She stated she usually takes the residents out for the 10:30pm smoke break every day. She stated that this week was a lot of in-services, covering smoking procedure, smoking policy, and items not allowed. She stated she attended an in-service on items not allowed in room-she stated that the was not just focused on lighters but focused on all items that could be harmful to the resident. She stated that the in-service was done to have all staff look out for lighters, scissors, electrical wires, glass that could break, etc. she stated basically anything that could be used or could be an accident to the resident was removed from the residents' rooms and family member was contacted regarding the item that was removed. She stated she attended an in-service on smoking policy she stated the smoking policy is the same, assessment must be completed on any resident going out to smoke. She stated where they are allowed to smoke, monitoring the resident while smoking. She stated never leaving the residents alone and that none of the items can be kept on the residents that have to do with smoking. She stated she attended an in-service on smoking procedure-she stated the new procedure is to get the smoke box with all the cigarettes for the residents, take the residents out, give each resident 1 smoke, light it for them, once finished if the resident wants a second cigarette they are allowed if the first was completed. She stated once everyone was done smoking, she would fill out the log indicating that she started with one lighter and ended with one lighter. She stated that if she were to find the box with no lighter, she would inform the administrator or don immediately. Record review of in-services completed by LVN B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25. During an interview on 4.6.25 at 11:10 am HR stated she works m-f from 8a to 5p. she stated she is the staff that takes the resident outs for smoke break at 4pm. She stated she attended an in-service on items not allowed in room she stated that this in-service was over all the items that are not allowed in residents rooms that could cause harm to them or their roommates or anyone in the building. She stated that she was to look out for items such as lighters, electrical devices like coffee makers and items like that. she stated anything that could cause any sort of harm. She stated anything that had a label that stated keep out of reach of children would be removed as well. She stated she was part of the champion rounds which would be done daily by her and other heads of departments. She st[TRUNCATED]