**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification, abbreviated (NY00359302), and extended surveys from 12/15/2024 to 12/22/2024, the facility failed to provide adequate supervision to prevent accidents related to smoking for 6 of 6 residents (#2, #6, #9, #29, #41 and #54) identified as smokers. Specifically, Resident #41 was a known smoker in a non-smoking facility and the facility failed to complete safety assessments or develop and implement a plan of care to ensure their safety, when it was known that the resident continued to smoke outside of the facility. On 11/1/2024 a fire was started on the outside patio when Resident #41 threw a cigarette butt into dry leaves. There were no facility staff supervising the resident during this smoking activity. Facility staff was alerted to the fire when the Director of Human Resources observed the smoke and fire from their office window. Facility staff had to remove residents from the area and extinguish the fire. Additionally, 2) Resident #54 had cigarettes and lighters with a strong odor of cigarette smoke in their room; 3) Residents # 2, #29, #41, and #54 were observed smoking on the patio without supervision. The patio was observed with cigarette butts in raised flower planters; there were no ashtrays or cigarette receptacles on the patio. The facility was aware the residents continued smoking and did not complete safety assessments or provide supervision. This resulted in Substandard Quality of Care, with no actual harm, that was Immediate Jeopardy with the likelihood for serious adverse outcome to all 102 residents in the facility. Findings include: The facility Smoking Policy and Procedure dated 1/21/2022 documented residents could smoke, and the Nursing Supervisor would assess the residents' ability to smoke safely by completing a smoking assessment that included an evaluation of the resident safety awareness, judgement, cognitive ability, and manual dexterity. The policy listed designated times for smoking and supplies would be marked with the resident's name and kept in a locked drawer in the copy room. The facility Smoking Policy dated 6/23/2022 documented smoking would not be permitted by residents. The policy did not address how to accommodate the residents that were smoking prior to the policy change. The policy did not address resident smoking contracts, agreements or participation in smoking cessation programs. 1) Resident #41 was admitted to the facility on [DATE] with diagnoses of Paraplegia (an impairment in motor or sensory function of the lower extremities), Schizoaffective and Borderline Personality disorder(Mental illness) . The Minimum Data Set (resident assessment tool) dated 10/18/2024 documented the resident had moderately impaired cognition and did not document tobacco use. Resident self ambulates by wheelchair. Resident #41's smoking assessment dated [DATE] documented the resident could only smoke while supervised. There were no further directions guiding the resident during smoking activity. There were no other smoking assessments in the resident's medical record. Resident #41's smoking care plan dated 9/1/2023, and a care plan review note dated 6/28/2024, documented the resident was found smoking in their room. Interventions included to review smoking policy with resident and family on admission, readmission and as needed. Staff will continue to counsel resident on a daily basis to ensure the safety of smoking in the facility is complied with. Resident has been referred to psychologist and psychiatrist due to his noncompliance with the facility policy of non-smoking, the resident will be educated and offered smoke cessation, visually observe residents clothing and surroundings regularly for signs of unsafe smoking including smoke, ashes and burns on hands and clothing. A nursing progress note dated 10/3/2024 documented staff approached Resident #41 regarding the aroma and visible smoke emanating from the resident's room. The resident was reminded that the facility was smoke free and instructed not to smoke in the facility. The resident acknowledged awareness of the policy and stated that smoking would not occur indoors in the future. A facility investigation dated 11/4/2024, completed by the facility Administrator, documented on 11/1/2024 around 4:15 PM, Resident #41 was smoking in the gazebo and put out a cigarette in the leaves behind the gazebo starting a fire. The root cause analysis determined Resident #41 was a smoker, frequently used the patio and put ashes on the gazebo and the ground surrounding it. The dry air and warm environment contributed to the cigarette butt lighting the dry leaves on fire. The immediate action was the patio was closed on the weekend and reopened on Monday 11/4/2024. The corrective action was Resident #41's patio privileges were revoked until further notice. The Director of Human Resources written statement, dated 11/1/2024, documented they smelled smoke from an open window, looked outside and saw a small fire starting to grow from behind the gazebo on the facility patio. Code Red was called, and they used extinguishers to put out the fire. The Social Worker was stomping the leaves, and Certified Nurse Aide #9 threw a fire blanket on the fire. Two residents were on the patio and taken back inside. Once the fire was out, they locked the patio door. There was no documented evidence Resident #41's comprehensive care plan was updated to reflect the need for increased supervision after the fire on 11/1/2024. During an interview on 12/15/2024 at 11:00 AM, at the entrance conference, the Administrator stated it was a non-smoking facility. They stated there were residents that smoked, and they were care planned for non-compliance. During an observation on 12/15/2024 at 1:15 PM, 12 cigarette butts were in the planter closest to the patio door with entrance into the building. The doors were labeled with no smoking signs. There were no ashtrays on the patio. During an interview on 12/15/2024 at 12:59 PM, Certified Nurse Aide #6 stated the facility was a non-smoking facility but there were residents that smoked. Cigarettes were taken from residents and held by the Administrator if the resident was a known smoker. They stated they believed there was a resident downstairs that got cigarettes and distributed them to other residents. Residents were not escorted outside to smoke by staff and could only smoke when on a leave of absence from the facility. They stated there was not a formal list of smokers but knew for certain that Resident #41 and Resident #6 smoked. - at 1:09 PM Licensed Practical Nurse #8 stated the facility was a non-smoking facility. They stated they thought there were residents that smoked but they were not tracked or listed anywhere. During an interview on 12/15/2024 at 1:10PM the receptionist stated the residents were allowed to go outside alone on the patio and the patio was open from 7:00 AM to7:00 PM. They stated no one should be smoking on the patio, not staff, residents, or visitors. They stated Resident #54 has an uncle that visits twice a week and takes the resident up by the entrance to smoke. They stated Residents #2, #6, #9, #29, #41 and #54 were known smokers. During an interview on 12/15/2024 at 1:25 PM Certified Nurse Aide #5 stated Resident #41 was a known smoker, and they had been advised by facility administration to watch the resident closely. They stated they had smelled cigarette smoke in the facility in the past but had not observed matches, cigarettes, or lighters in the resident rooms. During an interview on 12/15/2024 t 1:34 PM Certified Nurse Aide #1 stated Resident #54 and Resident #41 smoked on the patio and sometimes in their rooms. -at 1:46 PM the Registered Nurse Supervisor#2 stated it was a non-smoking facility and when the residents went out with their families they could smoke. They stated there was not supposed to be smoking on the patio, but some of the residents smoked on the patio including Resident #54. During an interview on 12/15/2024 at 1:11 PM, Resident #41 stated they were allowed to smoke when they were admitted to the facility and the facility changed the rules without discussion with residents. They stated no accommodations were made for smokers. They stated they had been accused of smoking and privileges had been taken away. During a follow up interview on 12/15/2024 at 4:25PM, Resident #41 stated they were not given a smoking contract or education regarding noncompliance after the fire. During an interview on 12/15/2024 at 2:00 PM the Administrator stated the facility was non-smoking but had residents who smoked. The Administrator stated residents who smoked were care planned for non-compliance with the smoking policy. They stated they were aware that smoking unsupervised on the patio, and residents could come and go freely. The Administrator provided a list of residents that smoked including Residents #2, #6, #9, #29, #41, and #54. During an interview on 12/16/2024 at 11:30 AM, the Administrator stated they were notified of the fire on 11/1/2024 but was out of the facility and did not return until Monday 11/4/2024. An investigation was initiated, and statements were taken immediately after the incident from staff and residents. The patio was closed for the weekend. Video evidence and interviews indicated that Resident #41 caused the fire. Resident #41 was indefinitely banned from the patio. The fire was investigated, and no new systematic interventions were put in place to prevent unsupervised smoking. Resident #41's patio privilege was revoked on 11/1/2024 and reinstated on 11/18/2024. During an interview on 12/16/2024 at 11:58 AM, the Director of Nursing stated they were aware that residents smoked on the patio unsupervised. They stated they viewed the video from the fire that occurred on 11/1/2024 and reviewed Resident #41's statement after the incident. They stated they did not put any interventions in place after the incident and stated the Smoking care plan documented regular monitoring. They stated the monitoring was not documented. During an interview on 12/16/2024 at 12:27 PM, the Director of Human Resources stated on 11/1/2024 the window was open, and they smelled burning leaves. They went to the patio and saw the fire by the gazebo. They told the receptionist to call Code Red and grabbed the fire extinguisher and used it. Neither the Administrator or Director of Nursing were in facility, both were notified and neither returned back to the facility. The Administrator directed them to lock the patio door. They did view the video and it showed Resident #41 going outside to the patio and then back inside. The Director of Human Resources stated the flames were high. They stated they were aware that residents smoked on patio, but no one including staff, visitors, or residents were allowed to smoke on facility property. During an interview on 12/16/2024 at 12:44 PM, the Social Worker stated when the fire code was called, they ran to the patio, staff was struggling with extinguisher, so they stomped on the fire. They were not notified of any resident patio privileges being lifted. They stated they had not witnessed residents smoking out on patio but stated that they had smelled smoke. During an observation and interview on 12/16/2024 at 1:15 PM, with the Maintenance Director, 2 residents were observed smoking in the gazebo located on the patio. There was no staff present and no ashtrays or metal containers with self-closing devices in the area. The Maintenance Director stated they told the residents many times that smoking was not allowed but the residents did not care and still smoked. They stated they could smell cigarette smoke coming from residents' rooms. They further stated that administration was aware that residents smoked unsupervised on the patio. The Maintenance Director stated that they did not know if the wooden gazebo was fireproofed. They stated that it was a nonsmoking facility, and that was why there were no ashtrays. During the resident council meeting on 12/16/2024 at 1:30 PM, multiple residents stated they knew there was smoking in resident rooms as well as outside. They stated they could smell both weed and cigarettes. The residents stated there was once a fire outside caused by smoking. The Resident Council did not complain about the smoking as a group. However, during the meeting several residents stated that they have complained to staff about residents smoking in the facility. During an observation on 12/17/2024 at 11:18 AM, Resident #41 was self-propelling their wheelchair on the patio heading to the gazebo. At the gazebo the resident took out their lighter and cigarettes, lit the cigarette and started smoking. No staff were observed monitoring the resident, patio area, or gazebo. During an observation on 12/17/2024 at 1:32 PM, Resident #41 was observed smoking cigarettes on the patio with Resident #6 and Resident #29. No staff was present on the patio while the residents were smoking. During an interview on 12/22/2024 at 2:30 PM, the owner of the facility stated they were aware the residents smoked, and they had some problematic residents which they had been trying to discharge. They stated the issue was not brought up at the Quality Assurance/Performance Improvement committee meetings. 2. Resident #54 was admitted to the facility on [DATE] with diagnoses including nicotine dependence, cannabis dependence, quadriplegia and muscle spasms. The Minimum Data Set, dated [DATE] documented intact cognition and functional limitations in range of motion to both upper and lower extremities. Resident utilizes a motorized wheelchair for mobility. A smoking evaluation, dated 7/8/2021, documented Resident #54 could smoke with supervision only. There were no other smoking assessments in the resident's medical record to determine if the resident could smoke safely. The care plan titled Non-Compliance last updated 5/22/2024, documented interventions to educate the resident on the nonsmoking policy, monitor resident for smoking regularly and upon return from leave of absence for signs of smoking. Report any issues to the supervisor immediately and smoking cessation support was to be offered. There was no documented evidence that smoking cessation materials were ordered or administered to the residents who smoke. The care plan titled Smoking last updated 10/1/2024, documented Resident #54 was a known smoker, including smoking marijuana. The interventions include to check the resident's clothing regularly and upon return from leave of absence for evidence of unsafe smoking practice. The smoking policy was to be reviewed with the resident and family upon admission and as necessary. Smoking cessation support was to be offered. A 12/4/2024 a physiatry note documented Resident #54 had bilateral upper extremity spasticity with some use of the right hand. On 12/15/2024 at 9:30 AM, Resident #54 was observed with smoking materials including cigarettes, 2 lighters and a dried shredded green/brown mix of stems, seeds, and leaves, on the resident's overbed table; a heavy odor of cigarette smoke was noted in their room. The resident was interviewed at the time of observation and stated the cigarettes and lighters belonged to them. They stated they smoked outside on the patio, without staff present and lit their own cigarettes. During an observation on the patio on 12/15/2024 at 1:15 PM 12 cigarette butts were identified in the planter closest to the patio door leading to the building. The doors were clearly marked with No Smoking signs. When interviewed on 12/15/2024 at 1:34 PM, Certified Nurse Aide #1 stated Resident #54 and Resident #41 smoked on the patio and sometimes in their rooms. 3. Resident #29 was admitted to the facility on [DATE] with diagnosis of Schizophrenia (mental disorder) diabetes and anxiety disorder. The 10/14/2024 Quarterly Minimum Data Set documented Resident #29 demonstrated intact cognition and is dependent on staff for activity of daily living. Resident utilizes a wheelchair for mobility. Review of the electronic health record revealed Resident #29 had no care plan for smoking or non-compliance. During an interview on 12/15/2024 at 1:27 PM, Resident #29 stated there were residents in the facility who smoked outside at night. During an observation of the patio on 12/15/2024 at 4:18 PM, Residents #29 and #2 were outside the patio door on their way into the facility. A strong odor of cigarette smoke was present, no staff members were observed providing supervision on the patio. The residents were interviewed at the time and Resident #29 stated they were not smoking but Resident #2 was. Resident #2 was aphasic (a disorder that impairs the ability to communicate) but shook their head no. Resident #29 stated they were allowed to smoke when they were admitted to the facility and one day they were told they could no longer smoke at the facility. During an observation on 12/16/2024 at 1:15 PM, with the Director of Maintenance present, Residents #29 and #54 were observed smoking in the gazebo located on the patio without supervision. Resident #29 was interviewed at the time and stated that they discarded their ashes in the snow. During an observation on 12/17/2024 at 1:32 PM, Resident #6, Resident #29, and Resident #41 were observed smoking cigarettes on the patio without staff supervision. The facility was notified of the Immediate Jeopardy on 12/18/2024 at 4:39 PM. The Immediate Jeopardy was lifted on 12/21/2024 prior to the completion of the survey based on the following corrective actions: 1. The Smoking Policy was reviewed and updated to include that residents admitted to the facility prior to the implementation of the nonsmoking policy would be given smoking privileges. These residents who desired to smoke would be permitted to do so if the facility Interdisciplinary Team determined that the practice was safe for the residents, and they do so in the facility designated area. 2. A nursing assessment by a Registered Nurse was done for all smokers. They examined the residents and clothing for any burns. This was completed this on 12/18/2024. 3. All residents that currently smoke were assessed to determine if they were safe to smoke or require supervision and or assistance. This was completed 12/18/2024. 4. Safe smoking contracts were established for residents that smoke. This was completed on 12/18/2024. 5. A safe smoking area 30 feet from the building was established on 12/18/2024. 6. Appropriate receptacle for cigarettes butts was installed. On 12/18/2024 the receptacle was ordered with a delivery date 12/23/2024. On 12/20/2024 a small metal step-on garbage can that self-closed was installed. Surveyors observed garbage can being utilized during smoking activity. Two residents (#29, #41) were observed smoking on the patio under staff supervision. Cigarettes were disposed of in the can under the supervision of the facility staff. On 12/21/2024 at 10:00 AM, Residents #54, #29, #2 and #41 were observed smoking on the patio in the designated area under staff supervision. The small metal step-on garbage can was in use. 7. Sign for supervised smoking area was posted on 12/18/2024. 8. Smoking aprons were placed by exit to patio for those residents assessed to need an apron. On 12/21/2024 two smoking aprons were observed stored in two tier plastic storage bins by the [NAME] room door. 9. A standard size all-purpose fire extinguisher was located near the patio door on 12/18/2024. 10. Smoking materials for all residents were removed from resident rooms and placed in a locked medication cart, completed 12/18/24. 11. Supervised smoking times were assigned for 10:00 AM, 2:00 PM and 6:30 PM; doors were locked when smoking was not in session, completed 12/18/2024. 12. Schedule of staff supervision was completed 12/19/2024. 13. Care plans for all 6 smokers were completed for safe smoking on 12/19/2024. 14. Physician orders for each smoker documented residents were care planned to smoke in facility designated area only. 15. The facility employs 109 staff members. Of these, 102 completed the in-service training, including supervisors. Dates of the in-service were 12/18/2024, 12/19/2024 and 12/20/2024. A sample of staff members from Nursing, Rehabilitation, Administration, and Recreation were interviewed and verified they received the education. 16. All supervisor staff were educated on facility procedures particularly their role to call 911 in the event of a fire. 17. An hourly smoking monitoring log was maintained to check resident rooms for signs of smoking. 18. The patio door was locked and remained locked except during the smoking times. Staff was observed supervising the smokers, unlocking the door to allow the residents into the smoking area and locking the door when smoking was completed. 10 NYCRR 415.5(f)(2)