La Bella Of Cahokia

jeopardy to resident health or safety

placed oxygen safety signage 8/25/2025 by Maintenance Director.Initiated a every 15-minute safety check on R3 by nursing staff on 8/25/2025.Director of Nursing or designee completed re- education on smoking policy and safety on 8/5/25, 8/10/2025 and 8/25/25.Admin, DON/ADON, and CNA Supervisor educated all staff on smoking policy, oxygen/fire safety, monitoring procedures, and procedures for reporting noncompliance.

Initiated on 8/25/2025 to all staff present and remaining staff will be educated prior to next shift.Smoking policy will be reviewed for implementation of additional interventions for safety of residents with oxygen.

Completed by Regional Nurse on 8/25/25.Actions to prevent re-occurrence:On 8/25/2025, smoke detectors to be placed in resident rooms who smoke and are on oxygen.

This will be completed by the maintenance Director.All residents with oxygen orders will receive a smoking risk assessment within 24 hours on all re-admissions starting on 8/25/2025 by charge nurse.

All care plans will be updated by the MDS nurse to include individualized interventions by 8/25/2025.All residents who smoke and/or are on oxygen will be educated on facility smoking policy, fire hazards, and oxygen safety by 8/25/25.Education will be documented in resident records and completed by the maintenance director.Ongoing quality assurance:DON/designee will complete daily audits for 14 days to ensure 15-minute checks and compliance with interventions for R3 starting on 8/25/25.Admin or Activity director will conduct weekly audits for 8 weeks, then monthly audits for 6 months starting 8/25/2025.Results reviewed in monthly QAPI meetings by IDT with corrective actions implemented as needed starting on 8/25/2025.On 8/20/2025 V4, Social Service Director, provided the facility resident roster identifying 89 residents residing in the facility.

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