Greenbriar Center

Review of the policy titled Resident Smoking Guidelines, undated, revealed that smoking was only permitted in designated smoking areas, the facility would store smoking materials in a secure area when not in use, and smoking items were to be returned to facility staff when smoking was completed.

The deficiency was corrected on 02/12/26 when the facility implemented the following corrective action: On 02/12/26 at 8:00 A.M. initial policy review with all 22 smokers was completed by the Administrator. On 02/12/26 Resident #4 was interviewed by Clinical Liaison LPN #555 and Regional Director of Clinical Operations for root cause analysis.

The Regional Director of Clinical Operations, Administrator, and Director of Nursing conducted a root cause analysis. On 02/12/26 all residents capable were interviewed by the Director of Nursing if anyone smoked in their room and if they kept smoking items in their room. On 02/12/26 skin checks were performed on residents unable to be interviewed, and no new concerns were identified. On 02/12/26 the Administrator and Director of Nursing were provided education on the new smoking policy and procedure by the Regional Director of Clinical Operations which included staff supervised smoking, designated smoking times, turning smoking items into facility staff at the conclusion of smoking times, and the facility was smoking free for all new admissions. On 02/12/26 the Administrator provided education to all facility staff on the new smoking policy and procedures.

Anyone scheduled off would receive education before working next shift. On 02/12/26 from 1:00 P.M. to 1:30 P.M. an ad hoc resident council meeting was conducted by the Administrator, Director of Nursing, and Activities Lead #405 to inform residents of the changes to the smoking policy and procedure.

The facility identified smokers were spoken to individually about the changes to the smoking policy and procedures. On 02/12/26 the facility had all smoking residents sign a smoking acknowledgment form, smoking materials were taken by a staff member to secure, a progress note was made that residents received education on the new smoking policy and procedure, the signed policy was scanned into Point Click Care (the electronic medical record), and a new smoking assessment was completed. On 02/12/26 an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted which included a root cause analysis, the new smoking policy and procedure, and the purchase of individual lockable bags to secure resident smoking items.

Staff present included the Administrator, Admissions Staff #807, Minimum Data Set (MDS) Registered Nurse (RN) #408, MDS RN #413, Social Services Designee (SSD) #409, Therapy Manager, Business Office Manager (BOM), Administrator in Training (AIT) #205 and the facility Medical Director. On 02/12/26 at 9:21 P.M. a report was made to the State Fire Marshal. On 02/12/26 new signage for designated smoking times were posted throughout the facility. On 02/13/2025 Resident #4's smoke detector in his room was tested by the contracted fire protection company to ensure correct function.

Room audits were conducted by the Administrator, Director of Nursing, and Unit Managers on 02/13/26, 02/14/26, 02/15/26, 02/16/26, and 02/17/26. An interview on 02/23/35 at 9:43 A.M. with the Administrator revealed room audits will be conducted of five smoking resident's rooms each week for two months and then re-evaluated at QAPI.

This deficiency represents noncompliance investigated under Complaint Number 2744541.