Health inspection·October 3, 2024

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement their policy to adequately monitor residents during smoking times, ensure residents' turn over their smoking materials, and determine who is an active smoker for 2 (R6 and R81) of 3 residents reviewed for smoking in the sample of 48. Residents Affected - Few Findings include: 1. R6 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Benign Neoplasm of Meninge, Cognitive Communicating Deficit, Dysphagia, Weakness, Chronic Viral Hepatitis C, and Encephalopathy. According to R6's MDS (Minimum Data Set) assessment dated [DATE], under section C, R6 has BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. R6's care plan dated 11/20/2023 reads in part, (R6) is a smoker. Interventions: Instruct resident about the facility policy on smoking: locations, times, safety, concerns; Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. R6's Smoking assessment dated [DATE] reads in part, Which of the following products does (R6) use? Tobacco. No additional smoking safety or interventions documented in R6's smoking assessment. 2. R81 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus, Weakness, Major Depressive Disorder, Personal History of Transient Ischemic Attack, and Chronic Kidney Disease. According to R81's MDS (Minimum Data Set) assessment dated [DATE], under section C, R81 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. R81's care plan dated 07/23/2024 reads in part, (R81) is a smoker. Interventions: Instruct (R81) about the facility policy on smoking: locations, times, safety, concerns; Notify charge nurse immediately if it is suspected (R81) has violated facility smoking policy. R81's Smoking assessment dated [DATE] reads in part, Smoking Safety Notes: Does not smoke. 3. On 09/30/2024 at 11:35 AM V1 (Administrator) provided a list listing of residents who smoke, R6 and R81 not listed on the list. On 10/01/2024 at 03:24 PM Surveyor observed R81 smoking alone on the smoking patio. No smoke Page 1 of 3 145208 145208 10/03/2024 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monitor nor other staff present on the smoking patio at this time. Surveyor observed code pad leading to the smoking patio. On 10/01/2024 at 03:28 PM Surveyor interview R81 who stated, I have been smoking independently since I've been here, so for seven months. I keep my cigarettes and lighter in my room. Staff gave me the code to go outside. My (family member) came on Friday to bring me cigarettes. Usually, I buy my own cigarettes when I get my money by the end of the month. On 10/01/2024 at 03:30 PM Surveyor interviewed V1 (administrator) who stated, R81 should not be smoking independently, staff should be monitoring resident during smoking times. R81 signs himself in and out, R81 doesn't have money to buy cigarettes, his (family member) came here over the weekend though, so they probably brought R81 cigarettes. On 10/02/2024 at 11:15 AM Surveyor observed R6 smoking on the smoking patio. V23 (Activity Aid) present on the smoking patio. On 10/02/2024 at 11:24 AM Surveyor interview R6 who stated, I stopped smoking two months ago, but I restarted this morning. I had cigarettes from yesterday, somebody gave them to me, but there was no available staff to take me out to the smoking patio. I don't know who gave the cigaretts, I don't know if he works here or lives here but I see him all the time. On 10/02/2024 at 11:30 AM Surveyor interview V23 (Activity Aid) who stated, I am a smoking monitor. I assist smokers during smoking times. I get the cigarettes and lighter for the smokers from the receptionist, the receptionist holds on to the cigarettes and lighters. There are no residents who are allowed to keep cigarettes and lighters in their room. Before any resident is allowed to smoke, they have to sign a Smoker's Contract. There is no existing smokers' list, usually, the social service tells us who is allowed to smoke. I check with social service infrequently, usually, when there is a new resident who is trying to go out to smoke. R6 and one other resident are our only smokers. R81 is a smoker who can smoke independently and doesn't need assistance and monitoring. R81 is well enough to have a code to the security door an let himself out. I monitor smoking times it in the morning, at 11:00 AM and 1:30 PM. There is a 3rd smoking time 6:30 PM and that's when CNAs and nurses assist smokers. On 10/02/2024 at 11:52 AM Surveyor interview V25 (Social Service Director) who stated, there are two identified smokers in the facility, there are also additional smokers, who don't have cigarettes at this time but identify as smokers. They should be listed on the smokers' list. Cigarettes and lighters are labeled and stored at the front desk, residents should not have access to cigarettes and lighters without monitoring. The independent smokers still have to be monitored, no one should be on the smoking patio, smoking alone. Smoking residents always require supervision. On 10/02/2024 at 12:20 PM Surveyor interview V2 (Director of Nursing) who stated, nurses and CNAs monitor smokers during 6:30 PM smoke break, but I'm not sure who is assigned to do it. It's mostly CNA who is available. There is a list of smokers at the front desk. On 10/02/2024 at 12:25 PM Surveyor walked over to the front desk to verify the smokers' list; no list found. 4. The facility Smoking Program Details document dated 09/10/2024 reads in part, There are 3 designated smoking times daily for 15 minutes each time. Cigarettes and all smoking materials are kept at 145208 Page 2 of 3 145208 10/03/2024 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the receptionist desk and available for the designated staff member who is doing the monitoring. Smoking areas are located on the patios in the backyard and during inclement weather outside the front door. Residents are monitored during each smoking time. Current list of residents who smoke: (R6 and R81) not listed. The Facility Smoking Safety Policy dated January 2016 reads in part, Per facility policy, all residents who choose to smoke are required to turn over smoking materials for the health, safety, and security reason. All residents shall receive monitoring consistent with policy, and plan od care. 145208 Page 3 of 3