Health inspection·July 11, 2019

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview, observation, and record review the facility failed to ensure a resident was supervised while smoking and that he did not have smoking material including cigarettes and lighter on his person per his smoking assessment and care plan. This affected one resident (Resident #5) of twelve residents identified as smoking residents residing at the facility. Findings include: Record review for Resident #5 revealed an admission date of 07/28/18 and diagnoses included alcohol abuse, cannabis abuse, abuse of non-psychoactive substances, and schizophrenia. Review of care plan dated 07/30/18 for Resident #5 revealed he had health risks related to smoking. Interventions included staff were always to provide supervision for smoking and smoking items were to be kept at the nursing station. Review of quarterly Minimum Data Set (MDS) for Resident #5 dated 04/08/19 revealed he had cognitive impairments as his Brief Interview for Mental Status (BIMS) score was a ten. Review of smoking assessment labeled, Smoking Data dated 07/09/19 for Resident #5 revealed staff were to observe the resident while smoking as all residents would be supervised while smoking regardless of their capabilities. He required no appliances or assistance while smoking. Interview on 07/09/19 at 2:16 P.M. with State Tested Nursing Assistant (STNA) #601 revealed all residents were to be supervised to smoke and no residents, per policy, can have cigarettes or lighters on them as they had to be stored in the nursing station. She revealed staff had to light all cigarettes for the residents when they are smoking. She revealed Resident #5 had to sign out in the leave of absence book and go to the new patio the facility recently built off the path if he wanted to smoke unsupervised outside of smoking times. Interview on 07/09/19 at 4:10 P.M. with Licensed Practical Nurse (LPN) #603 revealed all residents were to be supervised when smoking and were not to keep cigarettes or lighters on them as smoking materials were stored at the nursing station. She revealed if Resident #5 wanted to smoke in between smoking times he had to sign out on leave of absence and go to a patio off the path to smoke. She revealed he then was not supervised. Interview on 07/09/19 at 4:20 P.M. with Resident #5 revealed he goes a few times a day to the new outside patio the facility just built to smoke which was located down the path. Resident #5 revealed he does not need to be supervised while smoking and can go anytime throughout the day. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365638 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Healthcare Center 222 E Beech St Jefferson, OH 44047 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)