**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY00293405), completed 5/23/22, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for two (Residents #150 and #152) of eight residents reviewed for accidents. Specifically, Resident # 150 was identified as a smoker when admitted [DATE]. Resident has a BIMS (Brief Interview of Mental Status) of 15 (out of 15). The Comprehensive Care Plan (CCP), dated 3/18/21, included the resident was non-compliant with facility smoking policy, had a history of declining smoking blanket and gloves as recommended by therapy and was supposed to sign out at nurse's station to go off property when smoking and smoking materials to be kept in the medication room. Incident/Accident (I/A) Report 1/27/22, identified burns on resident's fingers related to smoking and Occupational Therapy (OT) assessment at this time revealed the Resident was observed holding the cigarette too close to the blanket and clothing and suggested an ash tray for the cup holder on chair. The 3/30/22 OT assessment recommended use of a fire blanket due to hot ashes falling into resident lap creating holes. OT deemed no therapy needed at this time. (No new interventions were recommended). Both Smoking Assessments, dated 1/27/22 and 3/23/22 included risk scores of zero. An I/A report documented that on 4/6/22 the resident was noted to have three blisters to the right hand that resident reported were burns from their cigarettes. On 4/19/22 the resident was seen in the emergency department (ED) and documented significant burns to both hands from smoking and was started on antibiotics. Resident #150 was observed on 5/19/22 at 8:20 am exiting the facility via the front door in a motorized wheelchair, proceeded down the driveway, around a corner to a paved area (approximately 40 yards from building) and was observed smoking. Resident had a grey blanket and mesh glove to the right hand. Glove noted to have holes in web area of index and middle finger and a burn hole was noted on the lap blanket. The resident stated he/she had burned the blanket to see if it was fire retardant. When ask where they disposed of the cigarette butts, the resident stated he/she had their own ash tray in the cup holder of the chair. The resident stated they empty the ash tray in the garbage can by the front door and/or in their room trash bin, none of which are observed to be fire retardant receptacles. Resident #152 reported they were unable to extinguish their cigarettes, allowing them to burn out in the ashtray and disposed of them in the trash can in their room. This resulted in immediate jeopardy with the likelihood for serious harm to Resident health and safety and is Substandard Quality of Care. This is evidenced by the following: The facility policy Smoke Free Work Environment, dated 5/1/19, included smoking or tobacco use is prohibited on the grounds within 15 feet of respective property line. Current nursing home residents who smoke will be able to continue smoking in a designated area 30 feet from the building. New residents must abide by our smoke-free policy. The policy did not include information related to storage of residents smoking materials or requirement for residents to sign out of the facility to smoke. 1.Resident #150 was admitted [DATE] with diagnoses that included diabetes, end stage renal disease with hemodialysis and was a chronic smoker. The Minimum Data Set (MDS) Assessment, dated 5/6/22, revealed the resident was cognitively intact. A Smoking Policy Acknowledgement, dated 3/18/21, signed by Resident #150 and approved by Occupational Therapy (OT), documented that Resident #150 smoked and would comply with the facility policy or agree to transfer to another facility that allows smoking. The current CCP and Certified Nursing Assistant (CNA) Care Card included that Resident #150 was independent in a motorized wheelchair outside on facility property and was noncompliant with the facility smoking policy. The CCP included the resident was at risk for burns related to smoking and that staff should encourage Resident #150 in use of a smoking apron, a burn blanket, fire- proof glove and a cigarette holder when going outside to smoke. Interventions also included to sign out at the nurses' station when going off property to smoke and that their smoking materials should be kept in the medication room or in a locked drawer in their room. A nursing progress note and an I/A Report both dated 1/27/22, documented that Resident #150 had 3 small brown circular areas on their right middle finger. Resident #150 had reported they were burns from their cigarette. The medical provider and Director of Nursing (DON) were notified, and an OT referral ordered to evaluate the resident's smoking ability. There was no documented evidence in Resident #150's Electronic Medical Record (EMR) that the resident was assessed by a medical provider following the 1/27/22 incident. An OT evaluation, dated 2/1/22, documented that Resident #150 had burned their hands and clothing while smoking due to difficulties with fine motor coordination that was needed to safely hold a cigarette. Resident #150 agreed to trial safety equipment (cigarette holder) to assist in increasing safety with smoking. OT treatment documentation from 2/1/22 to 2/14/22 documented that Resident #150 had difficulties managing a cigarette holder, continued to forget to hold burning cigarettes away from blanket and clothes and brought cigarette butts into the facility on the blanket in their lap or in their pants pocket. The OT discharge note dated 2/14/22, documented that Resident #150 did consistently use an ashtray in a cup holder and had no new burn marks noted on the blanket or gloves. Tobacco Screen and Safety assessments dated 1/27/22 and 3/23/22, documented a risk score for Resident #150 as zero. The assessments did not include a history of noncompliance with facility smoking policy or a history of burns from smoking. An OT note dated 3/30/22, documented that a referral was again made by nursing due to decreased safety with smoking. The OT note documented that therapy was not necessary at that time and that Resident #150 had agreed to use the fire blanket due to hot ashes falling on their blanket and burning small holes. A nursing progress note and I/A Report both dated 4/6/22, documented a large hole was observed in Resident #150's lap blanket. The resident stated that the hole was from their cigarette. Three blisters were observed on the resident's right index finger and one blister on the right second finger. Resident #150 was re-offered a smoking apron which was accepted, and a new blanket was ordered. The I/A Report documented that the resident's CCP and CNA Care Card were updated, and the medical provider was made aware. There was no documented evidence in Resident #150's EMR that the resident was assessed by a medical provider following the 4/6/22 incident until 4/18/22. In a medical progress note dated 4/18/22, Physician Assistant (PA) #1 documented that the mobile surgical team was consulted for management of burns to Resident #150's right hand. A description of the burn wounds included multiple burns of various stages to the second and third fingers on the right hand in various stages of healing with pus and serous (clear or slightly yellow plasma) drainage with burn tissue noted. The treatment plan included cleansing the wounds, applying Silvadene cream (a sulfa antibiotic used to prevent and treat infections with burns), a non-stick dressing cover and wrapping with gauze. Additionally, oral antibiotics were ordered for 10 days. The PA documented a concern that if Resident #150 continued to smoke and a cigarette dropped that the gauze wrap would catch on fire. The PA documented that staff were aware of the concerns and were working with the resident on safer practices and smoking cessation. There was no documented evidence in the resident's EMR that smoking cessation products had been attempted. In a medical progress note dated 4/19/22, Nurse Practitioner (NP) #1 documented that Resident #150 had new onset upper extremity unpredictable tremors, lethargy, and had missed a dialysis treatment. NP #1 recommended transfer to the hospital to evaluate for sepsis (serious infection of the blood stream). An ED visit note, dated 4/19/22, documented that Resident #150 had significant burns on both hands secondary to burns from smoking and cellulitis (an infection in the tissues). Sepsis was ruled out and recommendations were to continue antibiotics and wound treatments. OT daily treatment notes dated 5/1/22 to 5/7/22, documented that Resident #150 complained the fire gloves were too tight and the Occupational Therapist cut web space on gloves. Resident #150 stated at the time that they were going to test the gloves to see if they burn. The note documented that the therapist informed the resident they would be deemed unsafe to smoke if they continued to purposely burn items. On 5/3/22 OT documented that that there were scorch marks noted on the resident's gloves over their bandaged fingers and on 5/5/22 new gloves were provided. During an observation on 5/19/22 at 8:20 a.m., Resident #150 exited the facility via the main entrance in a motorized wheelchair, proceeded down a driveway and around the corner to a paved area approximately 60 feet from the facility building and was then observed smoking a cigarette. Resident #150 was wearing a gray blanket (noted to have a burn hole in it) over the lap and a mesh glove (also noted with holes in it) on their right hand. During an immediate interview, Resident #150 stated that they had burned the blanket to see if it was fire retardant. The resident stated they would not wear the blanket when it was 90 degrees out and when asked where they disposed of cigarette butts, Resident #150 stated they had their own ash tray in the cup holder which they emptied in the garbage can by the main entrance or in their room. Observations of the main entrance garbage can on 5/19/22 at approximately 8:20 a.m. and Resident #150's room garbage can on 5/19/22 at 10:10 a.m., revealed neither garbage cans were fire retardant receptacles. 2.Resident #152 was admitted to the facility 12/31/20 with diagnoses that included depression and osteoarthritis. The MDS assessment dated [DATE], documented the resident was cognitively intact. The current CCP and CNA Care Card documented that Resident #152 was noncompliant with the facility smoking policy. Interventions included smoking assessments completed, that the resident may go outside with family/friends to smoke, must wear a smoking blanket/apron, use a bean bag ash tray and that the resident may keep their own smoking materials. During an interview on 5/18/22 at 3:12 p.m. Licensed Practical Nurse (LPN) #1 stated there were several residents on the unit, including Resident #150 and #152 (roommates) who smoked. LPN#1 stated the residents typically let them know when they were leaving the unit and any protective equipment should be on their care plans which staff should ensure the residents utilizes. LPN #1 stated that residents must ask for smoking materials which are kept in the medication room. When interviewed on 5/18/22 at 3:17 p.m. The Registered Nurse (RN)/Clinical Lead stated Residents #150 and #152 were alert and oriented and had smoking assessments completed quarterly or if any changes. The RN/Clinical Lead stated some residents are allowed to keep their own smoking materials and go out to smoke independently but are supposed to sign out. The RN/Clinical Lead stated Resident #150 had a noncompliant care plan and all they can do was encourage the use of safety equipment. The RN also stated Resident #150 and #152 both had locked drawers in their room for their smoking materials. During an observation on 5/19/22 at 10:28 a.m. Resident #152 entered the resident unit in a motorized wheelchair. The resident had a smoking blanket across their lap and bean bag ash tray sitting on it that contained multiple cigarette butts burned to the filters and one with fresh ashes on it. During an immediate interview, Resident #152 stated that they were unable to extinguish their cigarettes without burning their fingers. The resident stated they have staff empty the ash tray in the garbage can in their room. Resident #152 stated they use to turn in their smoking materials to staff but then found out that other residents were allowed to keep their smoking materials, so they informed staff they were now keeping theirs. In an observation on 5/19/22 at 10:10 a.m., of Resident #150 and #152's room, no locked drawers were present. During an interview on 5/18/22 at 3:33 p.m., with the Director of Nursing (DON) and the Administrator and again on 5/23/22 at 8:04 a.m., with the DON, the DON stated that all staff are responsible for ensuring that resident's CCPs are followed. Regarding Resident #150, the DON stated that the resident has had smoking assessments completed by nursing and therapy and had been educated on the risk. Resident #150 was deemed competent and aware of the risks and staff encourage the resident to follow the recommendations (cigarette holder, apron, blanket, gloves). The DON stated that if a resident passed a smoking assessment, they were allowed to keep their own smoking materials and added that they did not have a policy related to the smoking assessment. The Administrator stated that the facility has taken many measures to ensure resident safety and is unsure what more could be done without violating the resident's rights. During an interview on 5/19/22 at 8:33 a.m., with the Administrator, [NAME] President (VP) of Operations, and the Medical Director, the VP of Operations stated that the facility encourages residents to sign out and provide supervision as possible however residents make some decisions on their own. The VP of Operations stated the facility is a nonsmoking facility, but they do provide containers outside for used smoking materials. The VP of Operations stated the residents are reminded and encouraged to follow their plan of care however they have a right to refuse. The VP stated residents have a right to keep personal property including smoking materials. The Administer, the VP of Operations and the Medical Director stated they were all unaware of where residents disposed of cigarette butts/ashes. The Medical Director stated if a resident can understand the risks and are competent it is their right to smoke and refuse treatment. On 5/19/22 at 6:30p.m. the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: a. Beginning 5/19/22, the facility will provide staff supervision for all residents who smoke. The facility provided buckets of sand outdoors for cigarette butt disposal and the social work department educated staff and all the residents who smoke regarding the use of the buckets. b. The policy and procedure for smoking assessments will be reviewed and revised and staff provided education. 10NYCRR 415.12(h)(1)(2)