3. For Resident #45 (R45), the facility staff failed to assess the resident for safe independent smoking. Resident #45 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1) and diabetes mellitus (2). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 5/13/2024, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of the MDS documented no tobacco use. The comprehensive care plan documented in part, The resident is a smoker. Resident educated on facilities nonsmoking policy. Date Initiated: 07/22/2022. Under Interventions it documented in part, .Instruct resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 07/22/2022 . Review of the clinical record documented a smoking safety evaluation dated 1/13/2024 and 4/13/2024 which documented in part, .Does the resident currently smoke or vape? No. On 6/5/2024 at approximately 2:02 p.m., an interview was conducted with OSM (other staff member) #11, receptionist. When asked to describe the facility's procedure for residents who smoke, OSM #11 stated that she kept the resident's smoking materials, cigarettes, lighters and /or vape pens, in a locked file cabinet in the facility's business office. She stated that when a resident wanted to smoke, they came to the front desk (receptionist's desk in the facility lobby) and she gave the resident(s) their cigarettes, lighters and /or vape pens and when the resident came back into the facility she took the smoking items back and locked them in the cabinet. When asked if she knew the residents in the facility who smoked, OSM #11 stated (Name of three additional residents and Name of R45). On 6/5/2024 at approximately 2:53 p.m., an interview was conducted with OSM #12, activities director. When asked to describe the facility's procedure for residents who smoke, OSM #12 stated that the residents obtained and left their smoking materials at the receptionist's desk. When asked if she knew the residents in the facility who smoked, OSM #12 stated (Name of three other residents and Name of R45). On 6/6/2024 at 10:40 a.m., an interview was conducted with RN (registered nurse) #2. When asked who completed smoking assessments for residents, RN #2 stated the social worker and nursing staff. When asked when they were completed, RN #2 stated they were completed on admission, quarterly and if a resident desired to smoke. RN #2 further stated that the admissions office could ask questions regarding smoking upon admission. On 6/5/2024 at 3:15 p.m., 4:07 p.m. and 5:43 p.m. interviews were attempted with R45 however they were not available. No smoking materials were visible in the residents room. On 6/6/2024 at 8:50 a.m., an interview was conducted with R45 in their room. R45 stated that they had smoked for a few years and smoked when they had a craving. R45 stated that their smoking materials were stored at the front at the nurses station and they picked them up and smoked in front of the building and turned them back in afterwards. No smoking materials were visible in the resident room or on R45's person. On 6/6/2024 at approximately12:14 p.m., ASM (administrative staff member) #1, the administrator, ASM #3, the regional vice president of operations, ASM #5, the regional director of case management, ASM #6, the regional nurse consultant, ASM #8, regional director of social services, ASM #9, regional nurse consultant, and ASM #10, director of risk management, were made aware of the findings. No further information was provided prior to exit. Reference: (1) cerebrovascular disease, infarction or accident A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm . (2) diabetes mellitus A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to provide assessments and supervision for smoking for three of 50 residents in the survey sample, Residents #80, (R80), R85 and R45. For R80, the facility staff failed to ensure that smoking materials were not stored in the resident's room. For R85 and R45, the facility staff failed to conduct a safety assessment for smoking. The facility's deficient practice placed the facility's residents at risk for burns, fire, and respiratory distress. This resulted in a determination of Immediate Jeopardy (IJ), cited at a level J. After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2 (two) isolated, D. The findings include: For R80, the facility staff failed to safely secure a cigarette lighter and a vape pen (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 04/12/2024, R80 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R80 was cognitively intact for making daily decisions. On 06/05/20/2024 at approximately 8:50 a.m., an interview was conducted with R80 in her room. When asked if she smoked R80 stated that she uses a vape pen and smoked cigarettes. When asked where the vape pen, lighter and cigarettes were stored R80 reached under the pillow on her bed and showed the surveyor a vape pen. She then opened the seat on her rolling walker, reached in and pulled out a cigarette lighter and showed it to the surveyor. When asked about cigarettes, R80 point to a large clothing bag next to the bed and stated she kept her cigarettes in the bag. R80 stated she did not have any cigarettes at the time. R80 further asked the surveyor not to inform the administrator that she had retained her smoking materials. The comprehensive care plan for R80 dated 11/23/2023 documented in part Focus. I smoke r/t (related to) cigarette use. Date Initiated: 10/11/2023. Under Interventions/Tasks it documented, Educate me on the adverse effects of nicotine use as well as the importance, benefits, and available methods of smoking cessation. Nicotine patch. Date Initiated: 04/17/2024. I have been provided with education on e-cigarette/vaporizer safety, including battery and charger safety. Reinforce as needed. Date Initiated: 06/05/2024. I may smoke safely with supervision. Date Initiated: 11/22/2023. I need to smoke in backyard area and not patio. Date Initiated: 11/22/2023. I understand that for my safety, the facility will store my nicotine products and my lighter. Date Initiated: 10/11/2023. The facility's admission Agreement for R80 documented in part, Smoking: The Center will comply with state and federal law as it pertains to smoking. The safety of Patients and employees is the Center's first priority. Patients agree to follow the Center's smoking policy (a copy which has been provided to them). Each Patient wishing to smoke will be evaluated for safety purposes. If permitted to smoke, the Patient understands that he/she will be allowed to smoke in designated areas at designated times. The Patient understands that he or she will not be permitted to retain smoking materials in their personal possession or room. Further review of the document revealed it was signed by R80 on 10/25/2022. The facility's Smoking Safety Evaluation for R80 dated 04/17/2024 documented in part, 1. Does the resident currently smoke or vape? Yes. 2. Method of nicotine consumption? a. cigarette. 3. How frequently does the resident smoke or vape? Daily .16. Evaluation Generated Care Plan Interventions: I understand that for my safety, the facility will store my nicotine products and my lighter. The Health Status Note for R80 dated 04/17/2024 documented in part, A Nicotine patch was re-offered to the resident. Resident stated that she wants to remain a cigarette smoker. The Nursing Assistant Director of Nursing explained that (Name of Facility) is a non-smoking facility but the facility will continue to find a way to accommodate the resident cigarette smoking needs while the facility social workers continue working to find another placement for the resident. Smoking schedules were already arranged with the resident. Education was provided to the resident on the health risks associated with cigarette smoking and the rights of the resident to continue being a smoker. Resident is her own responsible party with a Bims score of 15 and verbalised [sic] understanding of the education provided. All the interventions put in place by the facility to accommodate the resident's desire to smoke cigarettes while in the facility were explained to the resident and the resident verbalised [sic] understanding. Resident stated that she doesn't need a smoking apron, cigarette holder, flameless lighter or any other special equipment to smoke cigarettes. The attending physician, (Name of Physician) made aware of the resident's intention to continue smoking cigarettes. The Assistant Director of Nursing also provided emotional support to the resident. The Psychological Note for R80 dated 04/22/2024 documented in part, Plan: The Resident was advised not to use drugs in or around the facility and not to distribute unauthorized items to other residents. The Social Service Note for R80 dated 05/01/2024 documented, SW (social worker) spoke with the resident's mother about the resident's plans to be discharged as she stated that she will be leaving the facility to live at an address that she refuses to give to the SW. She is moving with a friend/man since this is a non-smoking facility. The resident stated that she wants to be able to smoke and do what she wants to do. On 06/05/2024 at 10:19 a.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #3, regional VP of operations, were notified of Immediate Jeopardy (IJ). On 6/5/24 at 12:57 p.m., an interview was conducted with CNA (certified nursing assistant) #3. When asked to describe the facility's smoking policy CNA #3 stated that smoking was not allowed. When asked where smoking materials are stored if a resident does smoke CNA #3 stated that she never had it happen but would go to management if she saw anything. When asked if she found smoking materials in a resident's room CNA #3 stated she would take the items to the supervisor. When asked what would happen if a resident had smoking materials in their room CNA #3 stated that due to the danger to the rest of the residents it could cause a fire, putting the roommate in danger. When asked what was the likelihood that could happen CNA #3 stated it could happen. On 6/5/24 at 12:58 p.m., an interview was conducted with LPN (licensed practical nurse) #6 regarding resident smoking. She stated that the policy was there was no smoking. When asked that if a resident did smoke, where are smoking materials maintained? She stated that they would be kept at the front desk or by activities. When asked what she would do if she found a resident to have smoking materials on them or in their room, she stated she would remove the materials, report it to the supervisor and document it. When asked what could happen if the resident has those materials in their room, she stated that the resident could start a fire. When asked what was the likelihood that could happen, she stated very likely. On 6/5/24 at 1:00 p.m., an interview was conducted with LPN #3 regarding resident smoking. When asked to describe the facility's smoking policy LPN #3 stated the facility used to allow smoking but now is smoke free. When asked where smoking materials are stored if a resident does smoke LPN #3 stated they are at the front desk, the receptionist desk. When asked if she found smoking materials in a resident's room LPN #3 stated she Normally I report it to my immediate supervisor. When asked what would happen if a resident had smoking materials in their room LPN #3 stated there is a chance of catching on fire. When asked what was the likelihood that could happen LPN #3 stated it's a small chance but it it's higher if there is oxygen in use. On 6/5/24 at 1:00 p.m. LPN #7 was interviewed regarding resident smoking. She stated that the policy was that the facility was a non-smoking facility. When asked that if a resident did smoke, where are smoking materials maintained? She stated that they would be kept at the front desk or by activities. When asked what she would do if she found a resident to have smoking materials on them or in their room, she stated that she would let the supervisor know and educate the resident that it is not safe to keep the materials, especially a lighter. When asked what could happen if the resident has those materials in their room, she stated that it is a danger to them and the facility as a whole. She stated that there is a risk of fire. When asked what was the likelihood that could happen, she stated it was a great risk that it could happen. On 06/05/24 at 1:03 p.m., an interview was conducted with CNA #2 regarding resident smoking. When asked to describe the facility's smoking policy CNA #2 stated the facility is a no smoking zone and no one is supposed to smoke at the facility especially on the floor. When asked where smoking materials are stored if a resident does smoke CNA #2 stated the activities director keeps the smoking materials. When asked if she found smoking materials in a resident's room CNA #2 stated she would report it to her supervisor. When asked what would happen if a resident had smoking materials in their room CNA #2 stated there is a possibility of a fire. When asked what was the likelihood that a fire could happen CNA #2 stated it's likely. On 6/5/24 at 1:05 p.m. CNA #6 was interviewed regarding resident smoking. She stated that the policy was there is no smoking. When asked that if a resident did smoke, where are smoking materials maintained? She stated maybe with the nurse. When asked what she would do if she found a resident to have smoking materials on them or in their room, she stated she would report it to the supervisor. When asked what could happen if the resident has those materials in their room, she stated that they could start a fire. When asked what was the likelihood that could happen, she stated that it was a big likelihood that something could happen. On 06/05/2024 at approximately 1:05 p.m., an interview was conducted with OSM (other staff member) 9, director of social services. When asked to describe the facility's procedure for residents who smoke OSM #9 stated the facility was a non-smoking facility. She stated that for residents who smoked and wanted to quit the facility would provide them with a nicotine patch the help them stop smoking, for the residents who did not want to stop smoking, the facility would conduct a care plan meeting to try and persuade the resident to stop and would also try to find a facility that allowed residents to smoke and transfer them if a facility was available. She further stated that if the resident was at the facility and smoked, a CNA (certified nursing assistant) would accompany the resident outside of the facility, off facility property, behind the facility to smoke. OSM #9 stated that the facility had schedule smoking times three times a day. When asked where the resident's smoking materials were stored, she stated that that the smoking materials were kept at the receptionist's desk. When asked if she was aware that R80 smoked cigarettes and used a vape pen and stored a lighter and vape pen in her room OSM #9 stated no. When asked if there was the likelihood of an adverse effect of a resident keeping their smoking materials on their person or in their room, she stated it is likely that the resident could start a fire. On 06/05/24 at 1:06 p.m., an interview was conducted with CNA #4 regarding resident smoking. When asked to describe the facility's smoking policy CNA #2 stated the facility is a non-smoking building no residents or staff can smoke. When asked where smoking materials are stored if a resident does smoke CNA #4 stated she did not know. When asked if she found smoking materials in a resident's room CNA #4 stated she would report it to her supervisor. When asked what would happen if a resident had smoking materials in their room CNA #4 stated some residents on oxygen and there's a chance of fire. When asked what was the likelihood that a fire could happen CNA #4 stated it's a high possibility if someone is caught smoking in the facility. On 06/05/2024 at approximately 1:20 p.m., an interview was conducted with OSM (other staff member) 10, social services assistant. When asked to describe the facility's procedure for residents who smoke OSM #10 stated the facility was a non-smoking facility and had not seen any residents smoking. When asked if she was aware that R80 smoked cigarettes and used a vape pen and stored a lighter and vape pen in her room OSM #10 stated no. When asked if there was the likelihood of an adverse effect of a resident keeping their smoking materials on their person or in their room, she stated it is likely that the resident could start a fire. On 06/05/2024 at approximately 1:47 p.m., an interview was conducted with RN (registered nurse) #1. When asked to describe the facility's procedure for residents who smoke RN #1 stated the facility was a non-smoking facility but if a resident is identified as someone who smokes they try to encourage them to quit and offer the resident a nicotine patch to help the resident stop smoking. RN #1 further stated that if the resident wants to continue smoking, the staff keep the resident's smoking materials, and the resident is allowed to smoke off the facility grounds. When asked where the resident's smoking materials were stored RN #1 stated he did not know. On 06/05/2024 at approximately 2:02 p.m., an interview was conducted with OSM (other staff member) #11, receptionist. When asked to describe the facility's procedure for residents who smoke OSM #11 stated she keeps all the resident's smoking materials, cigarettes, lighters and /or vape pens, in a locked file cabinet in the facility's business office. She stated that when a resident wants to smoke, they come to the front desk (receptionist's desk in the facility lobby) and OSM #11 give the resident(s) their cigarettes, lighters and /or vape pens and when the resident(s) come back into the facility she takes the smoking items back and locks them in the cabinet. When asked if she knew the residents in the facility who smoked, OSM #11 stated (Name of R80, Name of R85, Name of R114 and Name of R45). When asked if she was aware of any residents who kept their smoking materials on their person or in their room, she stated no. When asked if there was the likelihood of an adverse effect of a resident keeping their smoking materials on their person or in their room, she stated that it is likely that the resident could share cigarettes or vape pens with other residents or likely of injury and a fire. On 06/05/2024 at 2:16 p.m., the Immediacy Plan was Accepted. The plan documented, 1. Smoking paraphernalia will be removed from the room of resident #80. 2. BIMS assessment to be completed to determine resident's cognitive state as it relates to comprehension of facility smoking policy. 3. Smoking safety evaluation to be completed for resident #80. 4. Resident to be reeducated on facility smoking policy. 5. Resident to be reeducated on the location of designated smoking areas. 6.A head-to-toe skin assessment will be conducted on resident #80 and variances will be reported to the physician. 7. Facility staff will be educated on community smoking policy. In addition to designated smoking areas. Items on the above checklist will be completed by 3:00 pm June 05, 2024. On 06/05/2024 at approximately 2:53 p.m., an interview was conducted with OSM #14, activities director. When asked to describe the facility's procedure for residents who smoke OSM #14 stated she stated the residents would obtain and leave their smoking materials at the receptionist's desk. When asked if she knew the residents in the facility who smoked, OSM #14 stated (Name of R80, Name of R85, Name of R114 and Name of R45). When asked if she was aware of any residents who kept their smoking materials on their person or in their room, she stated no. When asked if there was the likelihood of an adverse effect of a resident keeping their smoking materials on their person or in their room, she stated that it is likely that another resident could take the smoking materials from the resident's room or likely of injury and a fire. After multiple resubmissions, the facility presented the following IJ removal plan was accepted on 06/06/2024 at 8:00 a.m. Plan for Removal: 1.Resident #80 had a smoking re-evaluation on 6/5/24 by the licensed nurse for her ability to smoke safely and handle smoking materials. At that time the resident was also re-educated on the facility's smoking policy to include location of the designated smoking area, the storage of the smoking materials and approved smoking times. Resident #80 was offered a patch for smoking cessation which she declined. A skin evaluation was also completed by the licensed nurse with no new findings. The resident physician was also made aware of the findings of the evaluation, with no new orders noted at this time. The resident's care plan was also updated to include permission for safety rounds to validate that smoking materials are not on her person or in the resident's room. Completed 6/5/2024. 2. BIMS assessment to be completed to determine resident's cognitive state as it relates to comprehension of facility smoking policy. Completed 6/5/2024. 3. Licensed Nursing Home Administrator/designees with permission completed interviews, a visual audit and/or a search of current resident rooms for smoking materials. Any variances will be removed with the resident's knowledge for safe keeping and the resident re-educated. The physician and/ or psychosocial services will be updated as indicated. 4. Immediate Actions/Education: Nursing Administration completed an audit of current residents to validate smoking evaluations were completed and accurate per policy. Any identified variances were immediately corrected, and evaluation was completed. Completed 6/5/2024. Adhoc Resident council meeting conducted on 6/5/24 to review the facility smoking policy. Completed 6/5/24. Administrator sent an email to resident representatives on the facility smoking policy. Completed 6/5/2024. Voice friend sent to all facility staff regarding the smoking policy, designated smoking areas. Completed 6/5/2024. All Staff will be educated on smoking policy, designated smoking area, and storage of the smoking materials and approved smoking times. 36% completed 6/5/2024 and 100% completed by 6/6/2024 at 10AM. Staff will not be able to work until they are educated on smoking policy, designated smoking area, and approved smoking times. 36% completed 6/5/2024 and 100% completed by 6/6/24 at 10AM. All Staff will be educated in visually inspecting rooms during care and in-room visits for the presence of smoking material on the resident's person or at the bedside and the reporting requirements. Staff noting any variances will immediately report to the charge nurse and physician for follow-up. 36% completed 6/5/2024 and 100% completed by 6/6/2024 10AM. Resident #80 has an updated trauma-informed care evaluation and care plan mapping the pathway for individualized psychosocial care. 6/5/2024. Social Service designee will review current residents who smoke and / or have a history of non-compliance with smoking materials to validate that residents identified with similar concerns have been evaluated and care plans up to date and implemented. Resident rooms reviewed for Oxygen in use signs. Completed 6/5/2024. 5. Ongoing Compliance will be monitored by: 9/5/2024: General environment observation will be accessed during routine care delivery or ambassador rounds; such as the closets, bedside tables, and drawers for smoking materials daily for one week, then three times a week for 3 weeks, weekly for 4 weeks then monthly for one month. Any variance will be reported to the Supervisor on duty for immediate follow-up and then to the Administrator. Review of PCC smoking evaluation for new admissions and readmissions for completion, compliance and patterns/trends in resident responses or capabilities five days a week for three months. Any variance will be reported to the RN Supervisor on duty for immediate follow-up. The Administrator will be responsible for the execution and implementation of this abatement plan. The facility policy Smoking Policy - Residents documented, Policy Statement. This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation. 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 3. Approved area for smoking location: Back left section of patio area. 4. Smoking permitted in the approved location at the following times: 9:30 am, 1:30 pm, 6:30 pm. 5. Smoking is not allowed inside the facility under any circumstances. 6. Residents approved to smoke will have all materials (lighters, cigarettes, e-cigarettes) stored at the front desk of the facility. All items will be returned to the receptionist for storage upon completion of smoking activities. Smoking materials will be stored in a locked drawer at the receptionist's desk. Residents will be required to sign all materials in/out for tracking purposes. 7. Electronic cigarettes and smokeless tobacco are permitted in designated areas only. 8. Oxygen use is prohibited in smoking areas. 9. Metal containers, with self-closing cover devices, are available in smoking areas. 10. Ashtrays are emptied only into designated receptacles. 11. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 12. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 13. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 14. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 15. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 16. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member. 17. Residents are not permitted to give smoking items to other residents. 18. Staff members and volunteer workers are not permitted to purchase and/or provide any smoking items for residents. 19. This facility maintains the right to confiscate smoking items found in violation of our smoking policies. 20. Confiscated resident property is itemized and ultimately returned to the resident, or his or her legal representative. 21. If the facility policy changes to one that prohibits smoking (including electronic cigarettes), residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents, while considering the health and well-being of non-smoking residents. 22. Residents admitted after the Tobacco-Free Environment policy is adopted are informed of the policy on admission. Electronic Cigarettes 23. Electronic cigarettes (e-cigarettes, vapes) are not considered smoking devices with respect to the risk of ignition, but they are considered a risk for residents related to: a. potential health effects for the smoker, such as respiratory illness or lung injury which may present with symptoms of breathing difficulty, shortness of breath, chest pain, mild to moderate gastrointestinal illness, fever or fatigue; b. second-hand aerosol exposure; c. nicotine overdose by ingestion or contact with the skin; and d. explosion or fire caused by the battery. 24. To prevent accidents associated with e-cigarettes and to respect the rights of resident who do not want to be exposed to second-hand aerosol, residents are permitted to use e-cigarettes with supervision and in designated smoking areas only. 25. Residents who wish to use e-cigarettes are assessed for their ability to safely handle the devices (including batteries and refill cartridges) on an individual basis. 26.Residents who wish to use e-cigarettes are instructed on battery safety and tips to avoid battery explosions per FDA recommendations. Instruction specific to e-cigarette safety is documented in the resident care plan. On 06/06/2024 at 10:10 a.m., the survey team, through observations, interviews, and documentation review, verified the removal plan had been fully implemented by the facility. On 06/06/2024 at 11:45 a.m., ASM #1, the administrator, was informed the removal plan had been verified and the IJ had been removed. No further information was provided prior to exit. 2. For Resident #85 (R85), the facility staff failed to complete a smoking assessment on a resident who upon interview, stated he was a smoker. An interview was conducted with R85 on 6/5/24 at 2:30 p.m. When asked if he smoked, R85 stated he smokes a little bit. R85 was asked where he smokes, R85 stated he goes across the street at the doctor's office. Where do you keep your smoking materials, R85 stated he keeps them on himself. A second interview was conducted with R85 on 6/5/24 at 2:45 p.m. When asked if he smokes, R85 stated he likes to smoke around 9:30 a.m., before dinner and then before they lock up the front doors. When asked if his smoking materials were on his person, he stated they were not on him but are nearby. This writer explained the danger to others if they would get a hold of the lighter, R85 stated, Yes, there are many people in here that you wouldn't want to get a hold of a lighter. When asked where he smokes, R85 stated he goes up the hill to the doctor's office. He further stated that they told him there was a designated smoking spot but thinks it's somewhere in the back parking lot. On most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/2/24, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The admission assessment, dated, 1/24/24 documented in part, Smoking Safety Evaluation: History of Smoking - Does the resident currently smoke or vape? No. Further review of the clinical record failed to evidence any smoking assessments completed after 1/24/24. Review of the progress notes from 1/24/24 to 6/5/24, failed to [TRUNCATED]