**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 (NY00276844), completed on 7/15/21, 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 one of two residents reviewed. Specifically, Resident #243 was assessed for safe smoking on 11/30/20, 3/8/21 and again 5/28/21 and determined to be unsafe to smoke unattended. On 4/23/21 Resident #243 went outside unsupervised, obtained cigarettes from another resident, asked another resident to help light the cigarette and Resident #243's hair caught on fire. The fire was put out by another resident and Resident #243 sustained a partial thickness burn to the forehead. There was no Comprehensive Care Plan (CCP) related to smoking or burns due to smoking. There were no documented interventions following the 4/23/21 incident. On 7/13/21 survey staff observed Resident #243 smoking outside unsupervised at approximately 10:30 a.m. Both hands had significant hand tremors while holding the cigarette. There was no staff present. During interview the unit Certified Nursing Assistant (CNA) said the resident is allowed to smoke. The Licensed Practical Nurse (LPN) said the resident can leave the unit unsupervised but is not allowed to smoke and they check on the resident as frequently as they can. This resulted in Immediate Jeopardy and Substandard Quality of Care with the potential for serious harm to Resident #243's health and safety. Findings include: The facility policy Smoking, dated 3/3/20, revealed all new admissions shall have a Smoking Safety Assessment completed on admission, annually and as the interdisciplinary team (IDT) feels necessary. The use of cigars, e-cigarettes, pipes and or vaping devices are strictly prohibited in the outdoor smoking enclosure or on facility grounds. Resident #243 was admitted to the facility 10/7/20 with diagnosis that included progressive multiple sclerosis, epilepsy, and bipolar disorder. The Minimum Data Set Assessment, dated 3/9/21, revealed the resident was cognitively intact, required supervision for locomotion on and off the unit and was a current tobacco user. The CCP, dated effective 5/24/21 to present, included to provide a safe environment and constantly assess possible intent to harm. Goals for behavioral health and trauma included that Resident #243 had a history of smoking cigarettes and opioid dependence. Interventions included to provide direction as needed for inappropriate behavior, to refer to counseling and/or psychotherapy as needed and to provide assistance as needed. The CCP did not include any interventions related to the resident's wishes to smoke or plans to provide safe smoking or smoking cessation. The current Resident Care Summary (care plan used by the Certified Nursing Assistants to direct daily care) documented that the resident required staff assist for locomotion off the unit using a manual wheelchair and under smoking, it documented 'no'. An Occupational Therapy (OT) evaluation, dated 11/30/20, documented that Resident #243 was not safe to go outside independently and did not demonstrate safety or independence with aspects required to have smoking privileges. A Physical Therapy (PT) evaluation, dated 3/2/21, documented the resident was unable to safely propel outside or over any thresholds independently. An Incident/Accident (I/A) report, dated 3/3/21, documented that Resident #243 was found outside near the smoking [NAME], alone and on the ground. The resident fell out of their wheelchair. The I/A report summary included that the Resident #243 struggled with uneven surfaces, was unable to safely propel outside and was not following safety recommendations. An OT evaluation, dated 3/8/21, documented that Resident #243 was found outside by therapy, requiring assistance to re-enter the building. The resident had been smoking. Resident #243 reported to the therapist that they had received assistance by other residents to light, smoke and ash their cigarettes. This was confirmed by other residents. A Smoking Safety Assessment, dated 3/9/21 and signed by the Registered Nurse (RN), documented that Resident #243 stated they were smoking. The Assessment included that the resident could not safely simulate smoking, including but not limited to, accessing smoking materials, lighting a cigarette, disposal of ashes or the cigarette in an appropriate receptacle. The Assessment did not include any interventions or plans to assist the resident with safe smoking. An I/A report, dated 4/23/21 at 10:19 p.m., documented the CNA #1 saw Resident #243 in the smoking [NAME] falling asleep. Multiple cigarette burns were observed on the resident's clothing with holes in their pants and jacket and a red area noted on the resident's forehead. The report included that Resident #243's hair caught on fire when they requested a 2nd resident to assist in lighting their cigarette. The fire was put out by the 2nd resident. The red area noted on the resident's forehead was not reported to medical until 4/26/21. A Medical provider note, dated 4/26/21 and signed by the Nurse Practitioner (NP) documented that Resident #243 had sustained a superficial partial thickness burn to the forehead while smoking outside in the smoke [NAME]. The NP documented the resident's hair was noted to be singed and that the resident had been deemed an unsafe candidate for smoking without staff assistance and had been preciously educated on this. A physician note, dated 5/27/21, documented that Resident #243 had progressive multiple sclerosis with associated muscle spasm and was being seen for an evaluation of capacity after setting off the smoke alarm in their room due to vaping. Resident #243 was evaluated by physical therapy who again deemed the resident to be unsafe to navigate to the smoking [NAME]. Two physicians determined the resident continued to hold adequate decision-making capacity and was able to understand the risk of smoking to their health and the potential safety to the facility. Resident #243 declined a nicotine patch and was informed of the New York State Smoker's Quit Hotline. In a nursing progress note, dated 5/27/21, the RN#1 documented that Resident #243 was informed that their smoking privileges were denied (cigarettes outside and vaping in their room). The Investigation Summary, dated 6/2/21, related to the 4/23/21 incident included that Resident #243 had a history of unsafe smoking behaviors at other facilities and that a behavioral plan would be initiated and the facility would monitor the resident's smoking habits and behaviors through the medical record. The conclusion included that the Interdisciplinary Team met on 5/27/21 and determined that Resident #243 was no longer safe to smoke and smoking privileges were denied. A Wellness Plan document, dated 6/3/21, included a statement signed by Resident #243 that they acknowledged they had been evaluated by therapies to be unsafe to go outside and smoke, and was not allowed to smoke or vape in their room or anywhere on the facility campus. A nursing progress note dated, 6/4/21, documented the resident was found vaping in their room. There was no documented evidence that an investigation was completed or that the CCP was changed or updated following this incident. A nursing progress note, dated 6/13/21, documented the resident was found outside the building unsupervised. There was no documentation that the CCP was updated following this incident. During an observation on 7/9/21 at 10:56 a.m., Resident #243 was observed by surveyor outside the building, propelling their wheelchair towards the smoking [NAME] with a lit cigarette in their hand. During an observation on 7/13/21 at 10:35 a.m., Resident #243 was sitting in a wheelchair in front of the smoking [NAME] holding a cigarette in their hand smoking. Significant tremors were visible to both of the resident's hands. A 2nd resident wheeled up next to Resident #243 and handed Resident #243 a cigarette. Resident #243 proceeded to smoke the second cigarette. There were no staff in sight. During an interview on 7/13/21 at 11:12 a.m. the Unit Clerk stated that the residents do not need to sign out when leaving the unit. The Unit Clerk stated they thought that Resident #243 was allowed to smoke. During an interview on 7/13/21 at 12:02 p.m., Resident #243 stated that they like to go outside and that they do smoke occasionally. Resident #243 stated, in order to go out, they would just wait by the outside door for another resident to go in and out of the building. Resident #243 added they had not burned themselves smoking. During as interview on 7/13/21 at 2:09 p.m. the Unit Aide stated they did not know who was able to smoke or who was able to leave the unit independently. During an interview on 7/13/21 at 2:12 p.m. CNA#2 stated that Resident #243 was able to smoke. CNA#2 stated that they did not know which residents were able to leave the unit independently. CNA #2 stated that Resident #243 did not let staff know when the resident was leaving the unit. During an interview on 7/13/21 at 2:16 p.m. LPN#1 stated after therapy evaluated a resident for smoking it would be documented in the resident's care plan. LPN#1 said if a resident was not able to leave the facility unassisted, they would have a wander guard bracelet on and if they were approved to smoke, they would wear a lanyard indicating that. LPN#1 stated Resident #243 was not allowed to smoke but the resident does leave the unit unassisted and staff try to check on the residents as often as they can. During an interview on 7/13/21 at 5:30 p.m. LPN #2 stated there were three residents on the unit who smoked including Resident #243. LPN #2 stated those residents should have lanyards or passes to access in and out of the building. During an interview on 7/13/21 at 5:48 p.m., CNA #3 stated that they were unaware of the residents who smoked and that there was no list of smokers that CNA#3 was aware of. During an interview on 7/13/21 06:14 p.m., the Administrator stated that Resident #243's care plan should have been revised following the burn if indicated. During an interview on 7/13/21 at 6:27 p.m. the Assistant Director of Nursing (ADON) stated Resident #243 was aware that they were not allowed to go outside and smoke. The ADON stated the resident vaped. The ADON stated the resident was not allowed to go out of the building by themself as they need assistance. On 7/13/21 at 8:49 p.m., the survey team declared that the IJ was removed based on the following corrective actions taken by the facility. On 7/13/21 the facility provided 1:1 supervision to Resident #243 to prevent the resident from leaving the unit unattended and smoking unsupervised. The facility's security department was provided an updated list of residents who had been assessed and approved for smoking independently. Security will monitor the designated smoking location effective immediately for all residents who have access to the smoking area to verify that they are on the approved smoking list. All unit staff were educated on the updated smoking list and the procedures to follow for each resident. On 7/14/21 Resident #243 agreed to wear a wander guard bracelet on their wheelchair. Resident #243 was provided re-education on the unit sign in and sign out procedures and agreed to this. 10 NYCRR 415.12(h)(1)(2)