Based on clinical record review, staff interview, and review of facility documents, the facility failed to ensure adequate supervision and implement interventions for non-compliance with smoking materials for one of seven residents (Resident #3). Multiple occurences of non-compliance with smoking materials, designated smoking times, designated smoking areas, and smoking supervision was revealed in Resident #3's clinical record, as well as through staff interviews. No evidence was found that the facility implemented interventions to address the unsecured smoking materials repeatedly observed in R3's possession. While R3 was in therapy on 2/1/24, a fire occurred in R3's room and unsecured smoking materials were again retrieved from the room, which had been accessible to other residents. On 2/13/24, the survey team determined that no focused interventions or the additional measures indicated per facility policy had been implemented to address R3's ongoing noncompliance, putting all residents at risk for serious injury, harm, impairment, or death. This resulted in the identification of immediate jeopardy (IJ), as well as substandard quality of care. Once the facility's removal plan was approved and verified on 2/14/24, the IJ was removed, and the scope and severity were lowered to a level 2, isolated. The Findings include: On 2/12/24, a review was conducted of the 2/2/24 facility synopsis of a fire that occurred in R3's room on 2/1/24. The facility synopsis of the fire event did not evidence that R3 had caused the fire in his room. However, the result of the investigation did lead to deficient practice. Diagnoses for R3 included: Chronic obstructive pulmonary disease, bipolar, schizoaffective disorder, anxiety, epilepsy with partial seizures, and tobacco use. The most current MDS (minimum data set - assessment tool) was a quarterly assessment, with an ARD (assessment reference date) of 1/15/24, which assessed R3 as being cognitively intact for daily decision making, with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. Review of R3's current care plan for smoking, created on 2/2/23 and revised on 8/22/23, documented R3 as being a supervised smoker. The care plan did not indicate that R3 was non-compliant with smoking policies or that any interventions had been implemented to address R3's non-compliance. Review of R3's progress notes revealed the following exerpts: 1/20/24 at 10:20 PM: resident went out side door to smoke outside of smoking hours, resident stated he knows hes [SIC] not supposed to but is going to do it anyway, resident did not sign himself out. 1/20/24 at 10:43 PM: writer caught resident smoking vape with O2 [oxygen] in his nose in his room, contacted on call supervisor made her aware. 1/26/24 2:32 AM: per CNA [certified nursing assistant] resident went to front lobby and asked to be let out to smoke, she stated she wasn't allowed to then resident became verbally abusive with the CNA. it has been explained to resident on numerous occasions that it is a safety concern for him to be out at night by himself and he was only allowed to smoke at designated times in designated areas per policy he stated he doesn't care and proceeded to let himself out. Review of R3's notes written by the nurse practitioner included the following exerpts: 1/31/24: Patient found vaping in his room per nursing. 2/1/24 at 12:41 PM: Smoking materials were found in the resident's room. He had a multicolored vape and a black lighter. These items were turned in to Social Services. Social Services turned the items over to the Director of Nursing. On 2/12/24 at 4:45 PM, certified nursing assistant (CNA #5) was interviewed. CNA #5 verbalized working with R3 a few days prior to the fire and verbalized catching R3 vaping (e-cigarette) in his room, while handing out meal trays. CNA #5 stated that she had reported it to the nurse (identified as license practical nurse (LPN #6), who she thought had taken the vape away and stored it in the med cart. When questioned further, CNA #5 verbalized, [R3] is non-compliant with smoking and does what he wants to do. On 2/12/24 at 5:00 PM, R3 was interviewed. When questioned about smoking, R3 verbalized that he was noncompliant with the smoking/vaping policy and has kept smoking materials in his room (a vape pipe). Questioned further, R3 verbalized finding a lighter while at dialysis, picked it up, and had put it in his room because it looked to be in good condition. R3 stated that he had never used the lighter, as he no longer smokes. When questioned about the types of smoking materials used, R3 verbalized only vaping. When questioned about noncompliance, R3 admitted to going outside at night to vape, .even when staff tells me I'm not supposed to . but it helps me with my anxiety. On 2/12/24 at 7:20 PM, LPN #6 (working on unit where R3 resided) was interviewed. LPN #6 verbalized catching R3 vaping in his room on 1/20/24, collecting the vape, and putting it in the med cart at that time. When questioned further, LPN #6 said that R3 goes out at night unsupervised and vapes, has been caught multiple times vaping in his room. When asked what happens when R3 was caught, LPN #6 stated that the smoking materials are confiscated and re-education attempted, but that R3 continues to vape and hide smoking materials in his room. On 2/13/24 at 8:50 AM, CNA #6 (working on unit where R3 resided) was interviewed regarding compliance with smoking materials. CNA #6 verbalized that R3 had been caught several times with smoking items in his room and vaping unsupervised in and out of the facility. On 2/13/24 at 9:00 AM, LPN #7 (working on the unit where R3 resided) was interviewed. LPN #7 denied personally catching R3 smoking but was aware of R3's non-compliance and that R3 had previously asked LPN #7 to order vape products off the Internet. On 2/13/24 at 9:55 AM, LPN #1 (assigned to R3 at this time) was interviewed. LPN #1 denied personally catching R3 vaping in a room or smoking at non-smoke times, but stated knowing of R3's non-compliance with smoking. LPN#1 said that R3 could be manipulative and demanding when wanting to smoke. LPN#1 stated that after it was given to him when leaving for dialysis, LPN #1 suspected that R3 did not turn the vape back in when returning from dialysis. On 2/13/24 at 10:40 AM, the nurse practitioner (Other Staff, OS #7) was interviewed regarding a progress note dated 1/31/24. OS #7 verbalized being aware that R3 had been caught vaping the night of 1/30/24 or the early morning of 1/31/24. OS #7 verbalized knowing of R3's non-compliance and that R3 had been educated several times regarding his health, but continues to smoke. On 2/13/24 at 11:15 AM, R3 was interviewed again. When asked how the smoking materials are kept, R3 verbalized, When I go to dialysis, I don't turn in my vape or if I go to the scheduled smoking breaks, I just smuggle it back to my room with me . I'm slick like that and very observant. The survey team extended the sample to include three additional residents that smoke (Resident #'s 1, 4, and 5) and had the potential to keep lighters and smoking materials. Rooms of all residents that smoked were observed and did not evidence unsecured smoking materials. Resident smoke breaks were observed throughout the survey process and did not evidence concern. The facility had a total of 7 smokers at the time of the survey. Review of the facility Smoking Policy with a revision date of 8/1/23 included these excerpts: 1. Smoking in the facility is prohibited in all areas except the designated smoking area. 2. e. Prohibition of oxygen use in or near the smoking area. 3. Electronic cigarettes will be treated the same as any other smoking product 6. Residents who desire to continue smoking will be assessed to determine recommendations for safe smoking safety interventions. Residents will be educated on and must agree to the terms outlined in the facility resident smoking agreement 8. If a resident contributes to an unsafe environment related to smoking the plan of care may be revised to include additional measures up to and including: room searches, increased supervision, or appropriate discharge proceedings 11. For the safety of all residents, those residents who have agreed to the smoking terms must have their materials to include cigarettes, e-cigarettes, vaping pens and all devices secured in a locked system that is not accessible to other residents and in an area that is supervised by the facility staff. On 2/13/24 at 3:20 PM, the administrator was made aware in a meeting with the survey team of the above findings and serious concerns regarding Resident #3, which had been discussed with the state agency. Thus, the administrator was notified that the survey team had identified IJ (Immediate Jeopardy) and substandard quality of care (SQC) findings, based on the facility's failure to ensure adequate supervision of a non-compliant smoker and failure to implement interventions for non-compliance with smoking materials, putting all residents and staff in danger. When a written plan of removal regarding adequate supervision and interventions to address the non-compliance with the facilities smoking policy by R3 was requested, the administrator verbalized that it would be hard to come up with a plan of removal involving R3, as R3 is non-compliant with smoking. On 2/13/24 at 7:30 PM, LPN #5 was interviewed (via telephone) regarding a progress note written by LPN #5. LPN #5 verbalized documenting an incident based on what a CNA had reported. LPN #5 said that R3 had demanded to go outside to smoke and had smoking material with him. When the CNA refused to allow R3 to go outside to smoke, R3 proceeded to enter the door code to the outside, and let himself out. On 2/14/24 at 8:20 AM, LPN #4 (assigned to R3 on the day of the fire) was interviewed. LPN #4 verbalized at the time of the fire R3 had been in therapy for close to an hour before the staff began to smell smoke and realized the smoke was coming from R3's room. LPN #4 stated feeling certain that R3 had not started the fire but verbalized that R3 was non-compliant with keeping smoking materials in his room and had been caught multiple times vaping in the room. On 2/14/24 at 8:50 AM, the survey team was presented with a plan of removal for failure to ensure hazardous smoking materials were secured and failure to address R3's repeated non-compliance with smoking policies, which put all residents and staff in danger, related to the risk of fire. The facility's plan of removal included the following interventions: Resident #3 was issued a discharge notice on 2/13/24. Resident #3 will sign out for his vape when going to appointments and will be required to sign it back in after each trip. Resident educated on this on 2/13/24. Resident #3 will have random room searches completed as he permits following appointments. Should resident refuse, he will be placed on 1:1 supervision. Resident educated on this 2/13/24. Resident #3's plan of care has been reviewed and updated to reflect non-compliance. Resident updated smoking assessment completed 2/13/24. DON immediately secured the found smoking material in a lock box on 2/1/24. Room rounds conducted starting on 2/1/24 for 7 days to ensure the absence of cigarettes and other fire-starting materials. Identified like residents of current residents in facility by auditing current smokers. All smoking residents had updated smoking assessments completed on 2/13/24. All smokers had their smoking contracts reviewed with them and re-educated to the smoking process on 2/1/24. All smokers found to be non-compliant with smoking by: smoking off times, locations, or by not following the smoking contract will be issued a 30-day discharge from facility and placed on increased supervision checks until no longer in the facility. DON held ad-hoc safety meeting on 2/13/24 to discuss survey IJ findings and create removal plan. DON notified medical director of IJ findings and action plan on 2/13/24. Findings of like resident reviews discussed at QAPI ad-hoc meeting on 2/13/24. Care plans of smokers reviewed and updated 2/13/24. AIT (Administrator in Training) educated all staff present in the building on 2/13/24, regarding locked safety box process and what to do if violation. Education will remain ongoing for any staff that did not attend prior to working their next assigned shift. Staff will be required to sign out and in for resident vape pens. Staff on duty were educated on 2/13/24 and others educated prior to their next worked shift. Education regarding assessment of smoking, monitoring unsafe behaviors and smokers' safety lock box will be added to new hire orientation. DON/administrator will educate the interdisciplinary team, other department heads and receptionists on the facility smoking material safety box lock process upon entry to the center on 2/13/24. Education will remain ongoing for any facility staff that did not attend prior to their next shift. Data obtained during the audit process will be analyzed for patterns and trends and reported to QAPI by the administrator/DON for 3 months. QAPI committee will determine effectiveness of interventions and determine need for continued auditing to maintain compliance. On 2/14/24 at 9:40am, the facility administrator was again interviewed. The administrator acknowledged that R3's non-compliance with the smoking policy began in December 2023. When asked about the facility's QA program, the administrator identified the purpose of QA is to identify concerns and trends, review operations, systems and quality improvement. The administrator stated that the QA team meets on a monthly basis. When asked to identify how items are identified for the QA committee to work to improve, he said, we use a standard format, look at quality measures, survey issues, and anything of that nature. When asked about the QA's involvement to ensure ongoing compliance once R3's was known to be non-compliant with the use and storage of smoking materials, the administrator stated, When we had issues, we did room sweeps. For the most part we haven't had issues until the [R3's name redacted] issue. When asked what the QA team did to ensure the safety of all residents, once R3's non-compliance became known in December 2023, the administrator looked through the QA meeting minutes from December 28, 2023 through January 29, 2024, and stated, There is nothing in there. When asked if R3's noncompliance would have been an opportunity for the QA committee to identify and monitor ongoing compliance with the smoking policy and storage of smoking materials, the administrator stated, Yes, I can't disagree with that. On 2/14/24, the survey team verified the plan of removal through observations of resident rooms for smoking materials, ensuring smoking lock box materials were secured and accounted for, and the review of newly implemented tool used to sign out E-cigarettes. The survey team also verified the removal plan through staff interviews regarding education on smoking policy and what to do if smoking materials were found unsecured. The survey team also reviewed inservices, as well signatures of staff receiving education, and all other documentation indicated in the plan of removal. No concerns were identified. The IJ was removed by the survey team on 2/14/23 at 11:55 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #6 (R6), who verbalized having feelings/thoughts of self-harm and/or being better off dead, the facility staff failed to respond and implement interventions to address the resident's behavioral health needs. On 2/12/24 at approximately 4:30 p.m., a review of R6's clinical record was conducted. R6's most recent MDS (minimum data set - an assessment tool) with an ARD (assessment reference date) of 12/20/23, was a quarterly assessment. R6 was coded in section D0150, question I, which asked if the resident has Thoughts that you would be better off dead, or of hurting yourself in some way. R6 reported having these feelings 2-6 days (several days), out of 14 days. There was no evidence within the clinical record that the facility responded to or implemented any interventions to address R6's mental/behavioral health needs. According to the clinical record, R6's diagnosis included but were not limited to major depressive disorder, mood disorder, and anxiety disorder. On 1/29/24, R6 was seen by the doctor who documented Chronic MDD [major depressive disorder]. Not optimal control. Sertraline was increased to 100 mg daily 1/22/2024. F/u [follow-up] psychiatry team provider as well There was no evidence that R6 was seen by psychiatry following this order. According to the clinical record, R6's feelings of depression and suicidal ideation were not noted in the progress notes indicating that any facility staff had any further conversation with the resident about their feelings. The care plan did not mention the event nor any interventions. On 2/12/24 at 4:55 p.m., an interview was conducted with RN #2, who was a MDS coordinator. RN #2 confirmed conducting the interview on 12/20/23, during which R6 had expressed suicidal ideation. Following , RN #2 stated that R2's response had been reported to the director of nursing (DON) and facility Administrator. When asked what is done when a resident verbalizes feelings of depression and/or suicidal ideation, RN #2 said, It is left up to them [Administrator and DON], but we need to get some type of psychiatric services that day, either in-house or at the ER [emergency room]. When questioned about the provision of psychiatric services, RN #2 reviewed R6's clinical chart and confirmed that R6 was last seen by psychiatric services in December 2022. RN #2 also confirmed that there was no evidence of any facility response to R6's verbalizations of feelings that he/she would be better off dead and/or self-harm once facility leadership had been made aware. RN #2 provided the survey team with a copy of an email where RN #2 had notified the facility administrator and director of nursing of R6's response to the MDS question/suicidal ideation. On 2/13/24 at 8:30 a.m., during an interview, the Director of Nursing (DON) stated that psychiatric services have continued to be available at the facility with on-site visits and 24-hour telehealth visits. On 2/13/24 at 8:44 a.m., an interview was conducted with the facility administrator. The administrator stated that when a resident verbalizes such feelings of depression and suicidal ideation that It should be escalated to the DON and provider, and they will handle it and implement interventions. When asked about the timing of such interventions, the administrator said, It should be addressed immediately. On 2/13/24 at 10:03 a.m., an interview was conducted with the facility's social worker (SW - Administrative Staff #5 - AS#5). The SW stated that when a resident verbalizes suicidal ideation, she usually hears about it in morning meeting. When asked about R6's expressions of suicidal ideation on 12/20/23, the SW stated that she was unaware of this. On 2/13/24 at 10:19 a.m., an interview was conducted with the nurse practitioner (NP). When asked about the availability of psychiatric services, the NP stated, psychiatric services are available and if urgent, we can do telehealth. The NP was asked about when orders are placed for psychiatry is ordered when she would expect this to be implemented, the NP said, Typically psych services rounds once a week or every other week, I would expect them to be seen on the next visit, unless it is urgent. When asked about R6's feelings of depression and expressions of suicidal ideation shared with facility staff on 12/20/23, the NP said, This is the first I'm hearing of this. On 2/13/24, in the afternoon, R6 was interviewed in their room by the surveyor. When questioned, R6 denied having any suicidal ideation at that time. On 2/13/24 at 3:20 p.m., the facility Administrator was made aware of the above findings when Immediate Jeopardy (IJ) was identified. On 2/14/24, the facility administrator and corporate nurse consultant both explained that each day the facility holds a morning meeting with the department managers and IDT (interdisciplinary team) to review items and areas of concern that need addressing. During this meeting, the 24-hour report is reviewed, new physician orders, and risk areas. On 2/14/24, the facility staff provided the survey team with the 24-hour report and documentation of the morning meetings. According to these documents, there was no evidence that R6 was a topic of discussion following his verbalization of suicidal ideation on 12/20/23. On 2/14/24, an IJ removal plan was presented to the survey team, which, in addition to the action noted above, included the following measures that specifically addressed R6's needs: NP assessed resident on 2/13/24 with no presenting danger to self; Will have PHQ-9 repeated weekly x 4 weeks to ensure no noing issues; Will be seen by the psych provider with the next in house visit on 2/14/24. The survey team verified the evidence that R6 had been seen by the NP on 2/13/24, which documented that during this assessment, R6 denied having feelings of depression and denied suicidal ideation. The NP's orders were reviewed and noted to include one dated 2/13/24, for consult psych. Although the facility administration reported R6 was seen by psychiatry that morning (2/14/24), the notes from this visit were not available prior to the conclusion of the survey. Care plan updated to reflect PHQ-9 responses that indicate expressions of self-harm and associated interventions/actions. Staff on R6's unit including those assigned to care for R6, were interviewed to verify knowledge about the resident's self-harm risks and interventions in place for prevention of self-harm. No concerns noted. No further information was provided prior to exit. 3. For Resident #7 (R7), who reported suicidal ideation, the facility staff failed to respond and implement interventions to address the resident's behavioral health needs. On the afternoon of 2/12/24, a review of R7's clinical record was conducted. R7's had a current MDS (minimum data set - an assessment tool) in progress, which was a quarterly assessment with an ARD (assessment reference date) of 2/12/24. Section D0150, question I, which asked Thoughts that you would be better off dead, or of hurting yourself in some way, coded R7 as having these feelings 12-14 days (nearly every day), out of 14 days. There was no evidence within the clinical record that the facility implemented any interventions to address R7's suicidal ideation. According to the clinical record, R7 has diagnosis included but were not limited to vascular dementia, major depressive disorder, and generalized anxiety disorder. According to the clinical record, a progress note entry was made on 2/12/24 at 4:13 p.m., that read, Resident scored a 24 on PHQ-9, answered yes to question concerning thoughts of hurting herself, resident does not have a plan in place. Administrator aware, Director of clinical services aware. On 2/12/24 at 4:55 p.m., an interview was conducted with RN #2 and RN #3, who were MDS coordinators. RN #3 confirmed conducting the 2/12/24 assessment, during which R7 had expressed suicidal ideation. RN #3 stated that R7's response had been reported to the director of nursing (DON) and facility Administrator. When asked what is done when a resident verbalizing feelings of depression and/or suicidal ideation, RN #2 said, It is left up to them [Administrator and DON], but we need to get some type of psychiatric services that day, either in-house or at the ER [emergency room]. On 2/12/24 at 5:15 p.m., R7 was interviewed in their room. R7 denied any suicidal ideation to the surveyor, but memory loss was evident. On 2/13/24 at 8:30 a.m., during an interview, the Director of Nursing (DON) stated that psychiatric services have continued to be available at the facility with on-site visits and 24-hour telehealth visits. On 2/13/24 at 8:44 a.m., an interview was conducted with the facility administrator. The administrator stated that when a resident verbalizes such feelings of depression and suicidal ideation that It should be escalated to the DON and provider, and they will handle it and implement interventions. When asked the timing of such interventions, the administrator said, It should be addressed immediately. On 2/13/24 at 8:50 a.m., a review of the doctor's book for the nursing unit where R7 resides,was conducted. This book is where facility staff communicates resident needs with the medical doctor and/or nurse practitioner, but it was noted that R7 was not listed among those needing to be seen and that no information about R7's suicidal ideation was noted. On 2/13/24 at 9 a.m., an interview was conducted with LPN #1, who was assigned to care for R7 on 2/12/24 and 2/13/24. When asked about R7's report of suicidal ideation on 2/12/24, LPN #1 said, That was new to me. Yesterday about 3:20 p.m., the MDS lady [RN #3] came to me and had to do an assessment and wanted to know where the resident was. Then about 4 p.m., the unit manager came to me and said that I'm doing 15 min checks on the resident. I went to see [R7] in the tv room and he/she was ok. LPN #1 went on to say she called the on-call psych provider, but it went to voicemail, so I left a message, and put it in the book. When asked if she had received a return call, LPN #1 said, No. When asked if notification of the medical provider had been attempted, LPN #1 said, No. On 2/13/24 at 9:05 a.m., the director of nursing (DON) was at the nursing station and showed the surveyor where R7 had been placed in the book for the psychiatric provider. The entry read, reported to staff, she's suicidal. The DON also provided the surveyor with a copy of the 15-minute checks form for R7 where staff were to note the location of the resident and what the resident is doing. There was no indication of what the staff were to be watching for, assessing for, etc. There was also no indication of who conducted the 15-minute checks from 4 p.m. until 7:45 p.m., on 2/12/24. The 15 minute checks form also revealed that there was no record of R7 being checked since 7 a.m., on 2/13/24. On 2/13/24 at 10:03 a.m., an interview was conducted with the facility's social worker (SW) (Administrative Staff #5- AS#5). The SW stated that when a resident verbalizes suicidal ideation, she usually hears about it in morning meeting. When asked about R7's expression of suicidal ideation on 2/13/24, the SW stated being was unaware of that report. On 2/13/24 at 10:19 a.m., an interview was conducted with the nurse practitioner (NP). When asked about the availability of psychiatric services, the NP stated, psychiatric services are available and if urgent we can do telehealth. When asked about R7's feelings of depression and suicidal ideation shared with facility staff on 2/12/24, the NP reported being unaware of that. When notified that the facility staff reported they had called the on-call psychiatric provider and left a voicemail with no return call, the NP said, They should have called back. On 2/13/24, the facility Administrator was made aware of the above findings when Immediate Jeopardy was identified at 3:20 p.m. On 2/14/24, the facility administrator and corporate nurse consultant both explained that each day the facility holds a morning meeting with the department managers and IDT (interdisciplinary team) to review items and areas of concern that need addressing. During this meeting, the 24-hour report is reviewed, new physician orders, and risk areas. On 2/14/24, the facility staff provided the survey team with the 24-hour report and documentation of the morning meetings but reported that due to the survey team being on-site, the meeting was not held on 2/13/24. On 2/14/24, an IJ removal plan was presented to the survey team, which, in addition to the action noted above, included the following measures that specifically addressed R7's needs: Placed on 15-minute checks on 2/12/24; NP assessed resident on 2/13/24 with no presenting danger to self, 15-minute checks discontinued, referred for psych evluation, psych assess resident on 2/14/24; Will have PHQ-9 repeated weekly for 4 weeks to ensure no ongoing issues. The survey team verified evidence that R7 was seen by the NP on 2/13/24. The NP documentation noted, . being seen today for concerns for having thoughts of self-harm. Provider met with the patient to evaluate facility concerns . When asked if the patient feels sad, blue, depressed, the patient replies no. Patient ask [sic] if she wants to harm/hurt self, the patient responds no. The patient is unable to complete simple tasks, such as picking up an ink pen with her left hand and placing it on the table . Consult Psych NP. On 2/14/24, the facility administration reported that R7 was seen by psychiatry that morning, but the notes from this visit were not available prior to conclusion of the survey. Care plan updated to reflect PHQ-9 responses that indicate expressions of self-harm and associated interventions/actions. Staff on R7's unit including those assigned to care for R7, were interviewed to verify knowledge about the resident's self-harm risks and interventions in place for prevention of self-harm. No concerns noted. No further information was provided prior to exit. Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to assess and implement behavioral health interventions following statements of suicidal intent for three of seven residents in the survey sample (Residents #2, #6 and #7), resulting in the identification of immediate jeopardy. The findings include: 1. Facility staff failed to identify and implement interventions to address Resident #2's behavioral health needs following statements of self-harm reported to staff on 12/26/23. Resident #2 attempted self-harm on 1/19/24 by wrapping the bed remote cord around her neck. After an emergency department visit/assessment, Resident #2 was readmitted to the facility with no updated plan of care implemented for suicide prevention. Five days later (1/24/24), Resident #2 was found again with the bed remote cord wrapped around her neck along with continued suicidal statements. Resident #2 was hospitalized for five days following this suicide attempt and was readmitted to the facility on [DATE] with a recommendation for restricted access to cords/ligatures. Resident #2 was observed on 2/12/24 with the bed remote/cord accessible on the resident's bed rail and no plan of care addressing the recent suicide attempts with the cord. Resident #2 (R2) was admitted to the facility with diagnoses that included bipolar disorder, major depression disorder, affective mood disorder, borderline personality disorder, dementia with agitation, psychotic disturbance, generalized anxiety disorder, cognitive communication deficit, cerebral infarction, hypertension, diabetes, atrial fibrillation, ischemic heart disease, urinary tract infection, COPD (chronic obstructive pulmonary disease) and asthma. The MDS (minimum data set - an assessment tool) dated 12/12/23 assessed R2 with severely impaired cognitive skills and as being dependent on staff for bed mobility and transfers. R2's clinical record documented on 12/21/23 that R2 had been verbally abusive to staff, using racial slurs, in addition to refusing blood sugar checks and meals. A social services (SS) note dated 12/26/23 documented, .Resident came to Social Services on 12/26/23 around noon and stated that she wanted to go 'home to live with her mom at her house' .Then [R2] proceeded to state that if SS didn't get her out of the building soon she would harm herself. She was descriptive. SS notified the nurse on duty and the nurse notified the NP on duty. The nurse practitioner (NP) assessed R2 on 12/27/23 but documented no assessment or mention of the resident's statement on 12/26/23 of self-harm. The NP progress note dated 12/27/23, .patient is being seen today for mood disorder. Patient is refusing care and medications. Nursing reports patient is combative at times and hitting at staff. She is not easily redirected. She has a diagnosis of dementia, which is likelyprogressing [likely progressing] .Mood euthymic .Start Hydroxyzine 25 mg [milligrams] .every 8 hours as needed X 7 days for anxiety . Nursing notes documented on 1/11/24 that R2 continued to refuse medications & meals and made verbally aggressive statements toward staff. The NP assessed R2 again on 1/12/24 in reference to mood disorder, refusing medications and verbal aggression. On 1/12/24, the NP ordered the Hydroxyzine 25 mg every 8 hours as needed for an additional 14 days. The NP documented no assessment or mention of the resident's statements of self-harm. A social services note dated 1/12/24 documented a conversation with R2 about the verbally aggressive behaviors but made no mention of the resident's status regarding the expression of suicidal intent or self-harm. The SS note dated 1/12/24 documented, .spoke to resident [R2] today about the inappropriate language .She was asked to please use kind words when speaking to staff . R2's Nursing notes on 1/13/24 and 1/14/24 documented incidents in which R2 refused care, refused medications, made multiple verbal threats to staff that included wanting to blow this Nurses brains out, threatened to get a machine gun and kill, and demonstrated physical aggression by grabbing a nurse's arm saying she was going to break it, and throwing a cup of water on a nurse. The Nursing notes documented that after some time, R2 settled down and went to sleep. There was no notification to a provider about the aggressive behaviors, threats, or care refusals on 1/13/24 and 1/14/24. R2's medication administration record (MAR) documented no administration or refusal of the Hydroxyzine 25 mg that was ordered every 8 hours as needed for anxiety. There was no psychiatric referral or assessment in response to these behaviors. R2's last psychiatric evaluation was documented on 5/5/23. R2's Nursing note dated 1/19/24 documented, .Around 4pm today resident stated that she wanted to kill herself. Patient was caught in her room with the cord from her bed remote controller around her neck. Unit manager was notified .instructed nurse to send resident out to the hospital for further evaluation. R2's emergency department (ED) note dated 1/19/24 documented, .Patient arrives by ems [emergency medical services] from [nursing facility] with thoughts of SI [suicidal ideation], patient denies HI [homicidal ideation] but per ems stated 'I am going to burn this place down' .presents to the emergency department with suicidal thoughts .states she has been depressed for 'a good while' .over the last several weeks, she has had thoughts of not wanting to live. She reports that she prays she will die. She has been suicidal with several plans to harm herself. She has thought of buying a gun and shooting herself. She has also considered running off a mountain ledge. She is currently at a skilled care nursing facility and states that today, she wrapped a cord around her neck to try to suffocate herself .does have a distant history of a mental health admission . The hospital documentation revealed that Mental Health evaluated R2 in the hospital's ED on 1/19/24 and recommended admission since the resident had suicidal thoughts with plans. The hospital's ED disposition note dated 1/20/24 documented, presents to the emergency department with suicidal thoughts .has been increasingly depressed with worsening suicidal thoughts over the last several weeks. She has several plans to harm herself . she wrapped a cord around her neck . head and neck exam is unremarkable . I do not suspect traumatic injury from her actions . I do not suspect an acute medical process . Mental health has evaluated her and is recommending admission. Disposition pending bed placement . According to the hospital documentation, R2 was discharged to the nursing facility on 1/20/24, with orders to start the antipsychotic medication Seroquel 12.5 mg at each bedtime and an antibiotic for 7 days for treatment of a urinary tract infection. Upon readmission to the facility on 1/20/24, R2's chart revealed that there were no other physician orders or any care plan interventions implemented to address the attempted suicide or suicide prevention. According to the progress notes, the physician assessed R2 on 1/22/24 but documented no assessment of and/or reference to the suicide attempt of 1/19/24 or the status of the R2's intent for self-harm. The physician's progress note dated 1/22/24 listed no changes regarding R2's bipolar affective disorder or generalized anxiety diagnoses and no changes in treatment. There were no physician orders for any safety monitoring or preventative measures in response to R2's suicide attempt with the bed remote cord. Progress notes reveal that the NP assessed R2 again on 1/24/24 regarding follow up for the treatment of the urinary tract infection. The NP's note dated 1/24/24 documented review of R2's medication and a physical examination, but made made no mention or reference to the resident's mental state, status of self-harm intent, or interventions in place for suicide prevention. On 1/24/24, R2 was found again with the bed remote cord wrapped around her neck. A nursing note dated 1/24/24 at 6:54 p.m. documented, .Resident observed lying in bed with bed remote cord wrapped around her neck. Resident verbally voiced that she does want to kill herself and she plans to do so using the bed remote cord. On call physc [psych] contacted and made aware that resident has suicidal ideations, has plan, and this is her 2nd attempt within this month. Verbal order given to send patient to hospital . The hospital's ED report dated 1/24/24 documented, .pt [patient] from facility for trying to wrap telephone cord around her neck; pt stated 'if i wanted to hurt myself, then i should have that right to do so . Mental health evaluated R2 and recommended psychiatric admission with pending bed placement with assessment listed as suicidal ideation, Alzheimer's dementia and affective mood disorder. The ED Discharge summary dated [DATE] documented, .Patient has been in the emergency department over 120 hours at this point and has been declined from most acute inpatient psychiatric units due to medical needs .today she denies all SI and HI .We are approaching 6 days in the emergency department .remaining in the emergency department indefinitely pursuing an unlikely bed search would be detrimental to patient's overall mental health and wellbeing given this prolonged length of stay .increased frequency of Seroquel to 12.5 mg with meals and at bedtime .Imminent risk for suicide is low at this point .recommend nursing facility restrict access to ligature risks such as phone cords given she has attempted this in the past . R2 was readmitted to the nursing facility on 1/29/24 with orders for the increased frequency of Seroquel and referral for psych services. R2's clinical record documented that the Seroquel dose was increased as ordered upon readmission on [DATE], but there were no orders or updated care plan interventions addressing the repeated suicide attempt, safety monitoring, or the restricted access to ligatures/cords as recommended by the ED physician. According to the chart, R2 was assessed by psychiatry on 1/31/24 and 2/7/24, which documented R2 as denying thoughts of self-harm. Psychiatry recommended non-pharmacological interventions in addition to medication that included a quiet environment, gentle redirection/reassurance, reinforcement of self-efficacy, identify/address/eliminate underlying causes of distress, approach in way the does not increase distress, safety monitoring for falls, and redirection as needed. R2's comprehensive care plan included no updates regarding the statement of suicidal intent on 12/26/23, the suicide attempts with the bed remote cord on 1/19/24 and 1/24/24, or the restricted access to cords for suicide prevention. R2's care plan documented the diagnosis of depression and a history of suicidal ideation that was listed as being resolved on 5/22/23. Interventions to minimize depression, anxiety, and sad mood were last updated on 5/22/23 and included, Arrange for psych consult, follow up as indicated . Discuss with resident/family caregiver any concerns, fears, issues . Monitor/document/report PRN [as needed] any risk for harm to self; suicidal plan, past attempt at suicide, risk actions . intentionally harmed or tried to harm self, refusing to eat or drink, refusing med [medication] or therapies, senses of hopelessness or helplessness, impaired judgement or safety awareness . Monitor/document/report PRN any s/sx [signs/symptoms] of depression .pharmacy review monthly R2's plan of care had been updated on 1/29/24 noting, Touch call bell at bedside for use when assistance is needed . The touch bell was not associated with any care plan problem/concern and there was no explanation listed as to why R2 needed/used a touch call bell. On 2/12/24 at 10:50 a.m., R2 was observed in bed with eyes closed. There were quarter length bed rails raised on each side of the bed near the head/upper portion of the bed. The bed remote with a coiled cord was observed mounted on R2's right bed rail, near R2's side. A manual tap bell was observed on the over-bed table. On 2/12/24 at 2:30 p.m., R2's physician/medical director (administration staff #6) was interviewed. The physician stated that R2 had been assessed on 12/22/23 concerning blood pressures and insomnia, but was aware the resident had behaviors as she called him a quack during the visit. When questioned about the R2's ED visits, the physician reviewed the clinical record and stated that R2 was seen in the ED on 1/19/24 due to an attempt to self-harm and returned to the facility because there was no psych bed available. When questioned further, the physician stated that he had assessed R2 on 1/22/24 and that there was nothing in his note speaking to the suicide attempt because he was unaware of the event at that time. The physician stated that he had not been notified of R2's statement of self-harm of 12/26/23 or the 1/19/24 suicide attempt. The physician stated the ED notes from the 1/19/24 visit had not been scanned for his review when he saw the resident on 1/22/24. The physician R2 went to the ED again on 1/24/24 with another suicide attempt and was kept for five days because inpatient psych care was not available. The physician stated that he saw R2 after the readmission to the facility on 1/29/24, along with the director of nursing (DON) and assistant director of nursing (ADON) and anything with a cord was removed. The physician stated psych services were available whenever needed and could be provided at the request of a provider and/or nursing at any time. On 2/12/24 at 2:10 p.m., R2 was observed in bed. The bed remote with coiled cord was hanging from the bed rail with the remote portion laying on the floor. R2 was interviewed at this time about why she had a tap bell. R2 stated that she had tried to choke herself with a cord a couple of times. When asked about her access to the cords, R2 stated that staff did not get rid of the cords right away but later removed the call light cord and gave her the tap bell. R2 did not know why the bed remote with cord was not removed. On 2/12/24 at 2:20 p.m., the social worker (administration staff #5) was interviewed about R2. The social worker stated on 12/26/23, R2 came to her and voiced that she did not want to be in the facility and threatened to harm herself. The social worker stated she reported this to the ADON, who she thought told the nurse practitioner. The social worker stated she thought R2's name was put in the book for a NP visit. The social worker stated R2 was found with the bed control cord wrapped around her neck on 1/19/24. When questioned further, the social worker stated that the cords were not removed from R2's room until after the second suicide attempt on 1/24/24. The social worker did not know why the cords were not removed after the first attempt on 1/19/24. The social worker stated that she thought nursing had taken measures to protect R2 and prevent self-harm. On 2/12/24 at 3:20 p.m., R2 was observed in bed with the bed rails in the up position. The bed remote with cord was mounted on R2's right bed rail near the resident's side. When asked if able to reach/use the bed remote, R2 stated, I can reach it but barely. On 2/12/24 at 3:22 p.m., the licensed practical nurse unit manager (LPN #8) was interviewed about R2 and interventions to prevent self-harm. LPN #8 reviewed R2's plan of care and stated that the interventions for attempts of suicide included arranging for psych services, psych medications, and documenting any reports of self-harm. When questioned why the interventions had not been implemented, LPN #8 stated that nobody had reported any recent issues to her about R2. On 2/12/24 at 3:30 p.m., LPN #9, a nurse who routinely cared for R2, was interviewed. LPN #9 stated that bR2 had frequent behaviors of refusing medicines, refusing meals, and verbal threats/racial slurs. LPN #9 stated that he found R2 on 1/24/24 with the bed cord wrapped around her neck. LPN #9 stated that the cord had been wrapped around the neck several times, as tight as she could get it, and that R2 made statements that she wanted to die. LPN #9 stated that he was not working the first time R2 wrapped the cord around the neck (1/19/24). When questioned about safety interventions, LPN #9 stated that the call light cord was replaced with a tap bell, but this was done after the second suicide attempt on 1/29/24. LPN #9 stated he did not know why the cords were not removed after the first suicide attempt. When questioned about the which cords had been removed, LPN #9 stated that R2 still had the bed remote/cord, but that staff were supposed to keep the bed remote/cord out of the R2's reach. On 2/13/24 at 8:00 a.m., the DON was interviewed about R2 and any interventions or care plan updates following R2's expressing suicidal intent on 12/26/23. The DON stated that she started working as the DON on 12/27/23 and was not aware of behavioral issues with R2 until January 2024. The DON stated R2 was found with the bed remote cord wrapped around her neck on 1/19/24 and was sent for emergency evaluation. When questioned about interventions implemented, the DON stated that R2 returned to the facility on 1/20/24 with orders for Seroquel. The DON stated that the interdisciplinary team had a discussion upon R2's return, and that someone on the team had stated that R2 usually exhibited behaviors (verbal, aggressive, self-harm) with a UTI (urinary tract infection), but did not remember who had made that statement. The DON stated R2 was scheduled to be evaluated by psyc[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/12/23 the abbreviated survey resumed. The above information was verified through documentation. On 1/12/23 at 12:50 PM LPN #1 (the nurse that wrote the progress note on 12/24/22 at 4:35 PM) was interviewed. LPN #1 said that he was not assigned to Resident #1 that day but was floating and helping out other nurses. Resident #1 seemed upset because the activities assistant director was not taking the resident's out to smoke due to very low temperatures that day. A fire was discovered in Resident #1's room (room [ROOM NUMBER]) and the fire department was called out. Resident #1 was moved to another room and seemed to be getting more agitated and began roaming throughout the facility. Another fire was started in the lobby around 2:30 PM and two other fires broke out in rooms [ROOM NUMBERS] where Resident #1 was moved to after the first fire. Resident #1 denied starting the fires and LPN #1 did not observe Resident #1 with a lighter. LPN #1 verbalized that the facility staff are not allowed to search a Resident or a Resident's room. According to LPN #1 the fire Marshal also did not search Resident #1 or his belongings, as there was no proof that Resident #1 had started the fires. LPN #1 was asked about supervision for Resident #1. LPN #1 said that Resident #1 was put on 30 or 60 minute time checks but he (LPN #1) did not document any time checks as he was not assigned to Resident #1. LPN #1 said that after the 4th fire, LPN #1 personally put Resident #1 on one to one supervision but Resident #1 was taken out of the facility shortly after. On 1/12/23 at 3:30 PM the activities assistant director (other staff, OS #1) was interviewed. OS #1 verbalized she is the primary person that takes residents out to smoke on day shift and on 12/24/22 had decided not to do smoke breaks due to the cold temperatures. OS #1 said that on the day of the fires, Resident #1 did not speak to her or ask to go outside to smoke but others were asking and she (OS #1) took other residents out to smoke at 1:00 PM and Resident #1 did not go. OS #1 was asked about the process of taking resident's out to smoke. OS #1 said that we have a box with packs of cigarettes and usually 2 lighters. The resident's are handed one or two cigarettes and she (OS #1) would light the cigarettes for the resident's. OS #1 was asked, how does she (OS #1) ensure lighters don't go missing. OS #1 said that she counts the lighters before and after the smoke breaks. OS #1 went on to say that every once in a while a staff member might take a lighter out of the box and forget to put it back. OS #1 was asked how could a resident get a lighter. OS #1 verbalized that sometimes family members or friends might bring cigarettes and lighters in and give them to the resident's and the resident's are supposed to turn them in to the facility but was not sure if that always happened. On 1/12/23 at 3:45 PM LPN #2 was interviewed (the nurse that wrote the progress note on 12/24/22 at 11:05 AM). LPN #2 said that she was not assigned to Resident #1 on 12/24/22, but was the nurse that discovered the first fire and called the fire department. LPN #2 verbalized Resident #1 was showing signs of behaviors due to not being allowed to go out and smoke so she (LPN #2) took Resident #1 out to smoke around 1:30 PM. LPN #2 said that she helped clean up Resident #1's room after the fire was put out and noticed 2 cigarettes in Resident #2's coat pocket but did not take them as the director of nursing (DON) said we could not take Resident's belongings. LPN #2 verbalized that there was no observation of a lighter, but she did ask Resident #1 to hand over the cigarettes to which Resident #1 refused. LPN #2 said that Resident #1 was placed on 30 or 60 minute checks by the maintenance director but due to not being assigned to Resident #1 she did not document checks and assumed the nurse assigned to Resident #1 would do the documentation of the checks. During the interviews of LPN #1, #2 and OS #1 all were asked if any education was provided after the incident regarding what to do if someone is suspected of starting fires and providing supervision. All three staff members verbalized that they did not receive education on high risk resident's starting fires or supervision, but was educated on extinguishing fires using the acronym RACE (remove, alert, confine, extinguish) and PASS (pull pin, aim, squeeze, sweep). On 1/12/23 at 4:10 PM the DON was interviewed via telephone. The DON verbalized that she was notified by the floor nurse that a fire had broke out in Resident #1's room and the fire department was called to extinguish the fire. The DON was also aware that the maintenance man had told the nurses to put Resident #1 on 30 minute checks. The DON was asked if there was anything she could have done differently regarding supervision. The DON verbalized looking back on things Resident #1 should have been placed on one to one supervision and the physician should have been notified. The DON was asked if there was any education that was provided after the incident. The DON verbalized that the facility did training in what to do in case of a fire and how to use the fire extinguishers. On 1/12/23 at 4:30 PM the previous administrator (AS #4) to the facility was interviewed via telephone in regards to staff not being allowed to search a resident's room. AS #4 verbalized based on new regulations we are not to search a resident's room and that's why we called 911, so that the Fire Marshal could search the room, but the Fire Marshal did not conduct a search as he could not prove Resident #1 started the fires. The current administrator was asked for a copy of the new regulation regarding searching rooms, but the survey team was not provided a copy of the regulation. Review of Resident #1's 30 minute checks were hand written on a piece of paper and not part of the electronic medical record. The documentation had no signature and entries made to the documentation were not consistent with 30 minute intervals, with the longest period between documentation was from 11:15 AM to 12:30 PM. In response to the request, the administrator was able to provide the staff member's name that documented the Resident #1's observation checks. The staff member [LPN #3] was not available for interview. The survey team extended the sample to include ten additional residents (#'s 6 through 15) and included all residents that smoked and had potential to keep lighters and smoking material. The survey team did not find concerns with the resident's in the extended sample. The Facility's Policy implemented on 12/01/22 read in part: 1. Smoking is prohibited in all areas except the designated smoking area. 12. If a resident or family member does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional measures such as room searches, prohibited smoking, or even discharge. On 1/12/23 at 5:35 PM, the administrator and regional director of clinical services (Administration Staff, AS #2) were made aware in a meeting with the survey team of the above information and serious concerns regarding Resident #1. The administrator and AS #2 were notified at this time that the survey team had consulted and discussed the above information with the state agency and the survey team had identified IJ (Immediate Jeopardy) and substandard quality of care (SQC) due to the facilities failure to ensure adequate supervision for Resident #1 suspected of starting fires in the facility and putting residents and staff in danger. At this time the survey team advised the administrator and AS #2 to develop and present a plan of removal regarding supervision for Resident's suspected of starting fires. On 1/12/23 at 7:20 PM , the administrator and AS #2 presented a plan of removal for review of the survey team. The facility's plan of removal for the immediate jeopardy for adequate supervision for resident's exhibiting behaviors of starting fires included the following interventions: 1). Resident #1 was discharged from the facility on 12/24/22. 2). 100% of in-house staff educated by nursing administration regarding protocol for staff in the event that residents exhibit fire starting behavior: Staff to immediately assure residents safety and safety of all residents in the affected area. Staff are to initiate 1:1 direct supervision with the resident exhibiting fire starting behavior. Staff to then call 911. MD (physician) and RP (responsible party) are to be notified. Any staff on leave will receive the required education prior to starting their next shift, this protocol will be added to new hire education for all staff. 3). In the event that residents exhibit fire starting behavior they will be placed on 1 on 1 direct supervision and 911 initiated. Resident will remain on 1:1 until either emergency services arrives, or higher level of care arrangements are made; Other residents will be removed from the affected area to safety; MD/RP will also be notified of the occurrence. 4). Once the facility is secured, room rounds will be conducted immediately to ensure absence of fire of fire starting materials. 5). Safety stand down will be conducted to review incident with all staff and provide education as necessary. The survey team reviewed and accepted the plan of removal for IJ status on 1/12/23 at 7:30 PM. On 1/13/23 the survey team observed and interviewed staff in regard to education, the team also reviewed inservices as well signatures of staff receiving education. The survey team abated the IJ on 1/13/23 at 12:35 PM. This is a complaint deficiency. 3. The facility staff failed to ensure residents' smoking materials (cigarettes and lighters) were secured and inaccessible to residents; the residents' smoke box with materials (cigarettes and lighters) was left unlocked and unsecured at the nurse's station, readily accessible to residents, which resulted in IJ (Immediate Jeopardy) and SQC (Sub-Standard Quality of Care). On 01/12/23, a complaint investigation resumed from 01/03/23. The complaint alleged that the facility failed to maintain an environment for residents' safety and prevention of injury related to a resident, identified as Resident #1 (no longer a resident of the facility and discharged on 12/24/22), who had started multiple fires in the facility on 12/24/22 prior to being discharged . On 01/12/23 at approximately 11:00 AM, a list of all residents who smoke was requested from the acting administrator. These residents were added to the survey sample. On 01/12/23 at approximately 11:45 AM, Resident #12 was interviewed in his room. Resident #12 was assessed as being cognitively intact for daily decision making (Cognitive score of 14 out of 15) on the most recent MDS (minimum data set), an admission assessment dated [DATE]. During the interview on 01/12/23 at 11:45 AM, Resident #12 was asked about smoking in the facility. Resident #12 acknowledged that he was a current smoker. When asked if he is allowed to go out to smoke or do staff take him out, Resident #12 stated, That's the only way you can go out to smoke, is if you have staff with you. Resident #12 further stated that the door is locked to the smoking area and that the designated staff member will open the door during smoke times. Resident #12 then stated that he had cigarettes and Black and Milds (cigars) stolen. When asked where the cigarettes were stolen from, Resident #12 stated that they were stolen from the box. This resident went on to explain that staff make the residents keep your cigarettes (and lighter if you have one) in the 'locker' box, but added, most of the time, they don't lock it up. This resident stated that the locker box is supposed to be kept locked and inside the medication room. The resident stated that the box had been left out at the nurse's station and it isn't locked. When asked how anything could be stolen from a locked box, Resident #12 stated that there isn't a lock on the box and that as far as he knew, there hadn't been a lock on the box for a long time. When asked if he keeps cigarettes and/or lighters on his person, Resident #12 stated that he did not, adding that smoking materials (cigarettes/lighters/cigars, etc.) are kept by staff and that the residents aren't allowed to keep the smoking supplies on them. When questioned further, Resident #12 stated that the smoking supplies are kept in the box that is supposed to be locked and kept in the medication room, which is also locked. When asked to explain the 'locker box', Resident #12 stated that the box is a small plastic type toolbox/lock box, which most of the time staff doesn't lock up, but is left at the nurse's station on a shelf. When asked why staff was not putting the smoke box in the medication room to secure it, Resident #12 stated that everyone doesn't have a key to the medication room. On 01/12/23 at approximately 12:50 PM, the smoking area was observed. The door giving access to the smoking area was locked and could not be opened without a key. A small poster with smoke times was observed and documented who was responsible for taking residents out to smoke at the designated times. According to this poster, Activities was responsible for two smoking breaks on day shift (9:30 AM to 9:50 AM and 1:00 PM to 1:20 PM) and Nursing was responsible for two smoke breaks on evenings (4:00 PM to 4:20 PM and 7:00 PM to 7:20 PM). On 01/12/23 at 1:00 PM, the Activity Assistant (OS #1) unlocked the door to the smoking area. The AA was holding a small plastic box (smoke box) that contained the residents' smoking materials. The residents went out to the smoking area. The AA opened the box (no lock seen) and passed out each individual resident a single cigarette and lit it, and then proceeded to the next resident, giving a single cigarette, and lighting it. The residents did not light their own cigarettes or handle the lighter at any time during the observation. When asked how the smoking process works, OS #1 stated that all resident smoking materials are kept in the smoke box, she opens it and gives out cigarettes and lights them for the residents. When asked if the smoke box was locked, as no lock was seen, the AA stated that there is no lock on the smoke box and further stated that someone had left the key inside of the box and the lock had to be cut off. The OS #1 stated that the smoke box has not had a lock since back in the summer. When asked where the smoke box is kept, OS #1 stated that it is kept at the nurse's station in a closet in the medication room. When questioned further, OS #1 stated that there is only one smoke box and that sometimes if it is not in the medication room, it is kept on the shelf at the nurse's station. OS #1 was asked if she had ever left the box at the nurse's station (not in medication room) without a lock on the box. When her past actions were questioned, OS #1 stated that she had left the unlocked smoke box at the nurse's station on a shelf. OS #1 was asked why the box would be left at the nurse's station if there a designated place to secure the box. OS #1 replied, Because you can't always find a nurse to get it out of the medication room or put it back. On 01/12/23 at 1:15 PM, LPN (Licensed Practical Nurse) # 1 was interviewed. LPN #1 was on duty the day the fires occurred (12/24/22). The LPN #1 confirmed awareness of the fires started on 12/24/22 and of Resident #1's involvement. When asked about the resident smoke box, LPN #1 stated that smoking materials stay behind the nurse's station, in the box, and is either on the shelf at the nurse's station (Riverside) or in the medication room. The LPN #1 stated that the key to the medication room is among the nurse's keys on Riverside. The LPN #1 stated that the smoke box itself has a 'snap lock', which doesn't have an actual lock to prevent access. When asked if the smoke box was ever left unlocked and accessible at the nurse's station, LPN #1 stated, Yes, I could get into it. LPN #1 added that the prior smoke box had a combination lock, but the facility got the current box approximately 6 months ago. LPN #1 explained, If a CNA [certified nursing assistant] takes them [residents] out, sometimes I have to pick it up [from the nurse's station] and put it in the med room. When questioned, LPN #1 stated that the normal routine is for the smoking assistant to ask the nurse to open the med room to get the box, make the smoke break announcement, and get the key to the outside smoking area out of the smoke box. After smoking, LPN #1 stated that the smoking area door is locked, and the box is returned to be locked up in the medication room. LPN #1 stated, I have seen the box on the counter, but if so, I get the nurse (who possesses the key) to put the box back in the med room. The LPN was asked about receiving any type of education and/or in-service after the fires on 12/24/22 that were started by Resident #1 or of any new processes that may have been initiated, because of the fires. LPN #1 stated, I don't recall, we may have, but I don't recall. I didn't get any information about smoking or the smoke box. On 01/12/23 at 3:15 PM, OS #1 was again interviewed. Asked if she had been in-serviced and/or received any education regarding fires being set (per the complaint) or on any supervision/fire safety/smoking/resident smoke box topics, OS #1 stated that she had not been in-serviced or received any education regarding that. OS #1 stated that it was so cold the day the fires occurred (12/24/22), but that she had let the DON (director of nursing) and the administrator know earlier that week that due to the severe cold temperatures being called for that day, that she was not going to take the residents out (12/24/22). OS #1 repeated, I wasn't going to take them to smoke because it was so cold, like 6 degrees. When questioned what the response had been to that plan, OS #1 stated that the administrator had said Ok. OS #1 stated that on that Saturday (12/24/22), Resident #1 did not ask her to go out to smoke. Stating that she routinely asked residents about having smoking materials on them, OS #1 specified that when Resident #1 was asked about having cigarettes or a lighter, Most of the time, he would give them to me. OS #1 stated that she had taken them out the day before (12/23/22) and that she didn't see any cigarettes or lighter on Resident #1 or any other residents. OS #1 again stated that no residents are supposed to have a lighter or cigarettes. OS #1 stated that she would open the door (smoking area) if they residents have cigarettes or lighter, they will give them to her when asked. The OS #1 stated she will give them a cigarette and she will light the cigarette for them. OS #1 was asked again about the smoke box and asked if she remembered the box being left unlocked at the nurses' station on 12/24/22 (the day of the fires). OS #1 stated that the box was on the shelf this morning (01/12/23 at 9:30 AM) and that it was left at the nurses' station unlocked on 12/24/22. OS #1 was asked how she knew that nothing was missing from the smoke box. OS #1 stated, I looked and didn't have any lighters missing. OS #1 was asked how many lighters are supposed to be kept in the smoke box and if there is an inventory sheet or check list to ensure all items are accounted for. Stating that there was no inventory sheet to account for the items in the smoke box, OS #1 added, I don't know how many lighters are supposed to be in the box. When questioned about where the smoke box was stored, OS #1 stated that she would bring the smoke box to the nursing station where smoke box is kept, sometimes sitting it on the shelf or under the desk, if she could not find a nurse. Asked how many times per week is the box not locked up in the medication room and left at the nurse's station, OS #1 stated that she could only speak for herself, but if she had to guess maybe two to three times per week. The OS #1 stated that whoever takes the residents out to smoke is responsible for them and for the smoke box security. On 01/12/23 at 3:40 PM, LPN #2 was interviewed via phone. LPN #2 confirmed that she was on duty on 12/24/22, when the fires were started in the facility. LPN #2 stated that the resident was agitated, repeatedly denying that he was trying to smoke and that he had set the room on fire. LPN #2 stated that his room was cleaned thoroughly after the fire and the resident returned to his room. The LPN stated that she didn't find any lighters when just looking around but stated that she did see two cigarettes in the resident's coat pocket that was sitting on the chair. LPN #2 was asked if she took the cigarettes. The LPN stated that she did not and further stated, We aren't allowed to search or take his stuff. He said he was allowed to smoke, and he said that he didn't have a lighter. LPN #2 stated that she reported the information to the DON via phone (who was not at the facility that day). LPN #2 stated that the DON reiterated, during that call, that staff cannot search the resident. LPN #2 stated that she did end up taking the resident out to smoke later that day (12/24/22), around 1:30 PM. LPN #2 stated that while outside smoking, Resident #1 said he didn't start the fire and complained about the facility being a smoking facility but that the staff wasn't taking the residents out to smoke. When questioned, LPN #2 stated that after the fires on 12/24/22, staff received education on fire extinguishers, but no education on resident's exhibiting high risk behaviors, smoking/smoke box security or supervision. On 01/12/23 at 4:10 PM, the DON was interviewed via phone (not in the building) by the survey team. When asked what education was provided, the DON stated that the education was on fire extinguishers, RACE and PASS. When asked if that was all of the education provided, the DON stated that, in hindsight, Resident #1's physician should have been called and Resident #1 on 1:1 (one to one observation) immediately. The facility's smoking policy was reviewed and included the following, but not limited to: 12/01/22 .all resident and family members will be notified of this policy during the admission process, and as needed .all residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment .Any resident who is deemed safe to smoke, WILL BE SUPERVISED and will be allowed to smoke in designated smoking areas (weather permitting, at designated times, and in accordance with his/her care plan .If a resident or family member does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas .the plan of care may be revised to include additional measures such as room searches, prohibited smoking or even discharge .smoking materials of residents requiring supervision with smoking will be maintained by nursing staff . On 01/12/23 at 5:25 PM, the resident smoke box was observed on a shelf, at the nursing station, by two surveyors. When the box was removed from the shelf, no lock was found on the smoke box. When the smoke box was opened, two cigarette lighters and 16 packs of cigarettes were found inside. The smoke box had been observed in plain view, unsupervised, and accessible to residents. On 01/12/23 at 5:35 PM, the acting administrator and corporate nurse were made aware in a meeting with the survey team of the serious concerns regarding the facility's failure to ensure smoking materials (specifically lighters) were supervised, secured and inaccessible to residents. The acting administrator and corporate nurse were made aware that after consulting with the state agency, IJ (Immediate Jeopardy) and SQC (Sub-Standard Quality of Care) had been identified at that time. On 01/12/23 at 7:30 PM, the survey team reviewed and accepted a plan of removal for the IJ identified. The facility's IJ Plan of Removal included the following: .The facility took immediate action to resolve the Immediate Jeopardy related to accident hazards/supervision/devices .In the event residents exhibit fire starting behavior they will be placed on 1 on 1 direct supervision and 911 initiated .MD/RP will also be notified .Resident cigarette box was immediately secured with lock (key to lock kept in the locked utility closed); Cigarette box will be maintained behind locked door (a combination locking door) in Riverside Central Supply closet when not being utilized during smoking times; Interim Administrator notified facility medical director on 01/12/23 at 6:55 PM of the IJ and was made aware of the action plan; Immediate education regarding the new lock process (storage area) to all staff presently in building conducted by unit manager, maintenance director, and rehab director at 7:00 PM (01/12/23); Department heads will conduct room rounds to ensure absence of cigarette lighters or other fire starting materials; Care plans have been updated with new process for securing lighters and cigarettes; Emergency QAPI meeting held with all department heads to inform of IJ issued as F-689. In addition, the facility will take the following actions beginning 01/13/23: Current resident that smoke have had a new smoking assessment completed; 100 % of in-house staff educated by nursing administration on new lock process for cigarettes box and need for lighters and cigarettes to be secured within locked safety box at all times, when not in use. All staff on leave will receive the required education prior to starting their next shift, this education will be added to new hire education. Allegations of Compliance (AOC) date- 1/13/23 .signature of administrator. On 1/13/23 from 9:30 AM until 9:50 AM, residents were observed smoking in the outside designated area accompanied by the AA (OS #1). The smoking supply box was observed with a lock, prior to the activity assistant accessing a lighter and residents' cigarettes from inside. Residents were supervised by OS #1 during the entire observation and smoking was performed in a safe manner. At the end of the smoking session, the lighter and any remaining cigarettes/cigars were returned to the supply box and locked. OS #1 stored the locked smoking supply box in a locked utility closet on the nearby nursing unit. On 01/13/23 at 11:54 AM, the Activity Director (identified as AD) was interviewed. When asked about taking residents out to smoke, the AD stated that she had taken residents out to smoke and had most recently taken them out last Wednesday (01/11/23). The AD stated that she usually takes the residents out on Wednesdays because the AA (identified as Activity Assistant) is off on Wednesdays. The AD was asked if she was aware of the smoke box not having a lock on it. The AD stated that she did know that the box didn't have a lock on it and that there hadn't been one for approximately 6 months. When asked if she had reported that to the administrative staff, the AD replied that she had reported it to the administrator at the time. When asked for the name of the administrator, the AD stated that she didn't remember the name but that it was the administrator before Admin #4. The AD then added that she had reported it to the maintenance director (who was still in the same role). The AD was asked if she had reported it to anyone since, the AD stated that she had just reported it then and had not to anyone since. When asked why, the AD stated, I didn't. We just went along. The key got left in the box and the lock got broke off .never replaced it. On 01/13/23 at 12:15 PM, the maintenance director was interviewed. The maintenance director was asked if he was aware that the resident smoke box had not had a lock on it for approximately 6 months according to interviews. The maintenance director stated that he did not know anything about it and that no one had reported it to him. On 01/13/23 at 12:35 PM, after verifying and reviewing the facility's credible evidence, as well as performing observations and interviews of both residents and staff, the IJ was abated. No further information and/or documentation was presented prior to the exit conference on 01/13/23 at 1:15 PM. Based on complaint investigation, clinical record review, staff interview, and review of facility documents, the facility failed for one of fifteen residents in the survey sample (Resident #1) to provide adequate supervision for the resident who was suspected of starting several fires in the facility. The resident was placed on 30-minute checks, but continued to move about the building, setting several more fires, before being transferred to the hospital. Upon review of the initial survey findings, further investigation was deemed necessary, and the survey was extended, subsequently finding that the facility failed to implement any interventions to prevent reoccurrence, after the first fire was discovered. In addition, the facility failed to ensure that smoking materials were secure and not accessible to residents. These combined findings were determined to have put all residents and staff at risk of serious injury/harm/impairment and/or death, which resulted in the identification of immediate jeopardy and substandard quality of care. The findings were: 1. Resident #1 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included wedge compression fracture of the second lumbar vertebra, acute osteomyelitis of the right ankle and foot, methicillin resistant staphylococcus aureus, chronic pain, hypertension, depressive disorder, legal blindness, chronic obstructive pulmonary disease, generalized muscle weakness, cognitive communication deficit, and anemia. According to the admission Minimum Data Set (MDS) with an Assessment Reference Date of 12/6/2022, Resident #1 was assessed under Section B (Hearing, Speech, and Vision) as having clear speech, able to make self-understood, and able to understand others. Under Section C (Cognitive Patterns), Resident #1 was assessed as being cognitively intact for daily decision making, with a Summary Score of 15 out of 15. A Safe Smoking Screen, dated 3/31/2020, found Resident #1 was safe to smoke. The screen also noted the following: D. Other: 3. Level of supervision required for resident when smoking: b. Resident requires supervision while smoking. No other smoking screens were found. The facility's Resident Smoking policy included the following: 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Review of the Progress Notes in the Resident #1's closed Electronic Health Record (EHR) revealed the following entries: 12/24/2022 - 11:05 a.m. - Writer and Housekeeper were in hallway talking with activities assistant. At this time writer smelled burning and housekeeper stated he smelled burning and saw smoke from the hallway. Nurse proceeded to walk down hallway and saw towels on resident's dresser on fire. Nurse immediately removed resident from the room, yelled fire and to activate the alarm. The CNA (Certified Nursing Assistant) brought the fire extinguisher to the room and the fire was put out. Fire department called, and DON (Director of Nursing) notified. [NOTE: The room in question was Resident # 1's room.] 12/24/2022 - 16:35 (4:35 p.m.) - Resident had a fire in his room this morning. Fire department was notified and came. Resident [TRUNCATED]