**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #97 (R97), the facility staff failed to provide supervision for safe LOA (leave of absence). On 7/9/24 at 10:08 a.m., R97 was interviewed. He stated that he leaves the premises and walks across the street to the store about once a week by himself. He also stated that he lets the front desk, and the nurses know before leaving, but staff do not supervise his trips. He stated that he should be using his cane to walk, but he does not. On 7/9/24 at 5:50 PM, R97 was observed walking over to Walgreens without a cane. He looked both ways on his way to Walgreens while crossing Sunset Lane. He was observed crossing 4 lanes of traffic across the street with no staff supervision. He walked with a shuffling gait. Upon his return to the facility, he was observed crossing the same 4 lanes of traffic with no staff supervision and did not look for oncoming traffic. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/17/24, R97 was admitted to the facility 4/11/24. R97 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). The resident was coded as having a walker and wheelchair and not attempting to walk 150 feet due to medical condition or safety concern. A review of R97's clinical record revealed the resident signed out once to leave the facility on 3/10/24. A review of physical therapy recommendations for 5/29/24- 6/25/24 revealed, in part: Pt (Patient) was re-educated as to the potential benefits of using an amb. (ambulation) device (vs. no device) - as well as to wear shoes with all standing/amb. Activity to minimize fall risk (in light of recent fall). A review of R97's physical therapy discharge summary for 5/29/24- 6/25/ revealed, in part: Ambulation .Walking 10 feet on uneven surfaces= supervision or touching assistance. 1 step (curb) = Supervision or touching assistance. A review of R67's care plan revealed, wheeled walker for ambulation and transfers. On 7/9/24 at 3:42 p.m., LPN (licensed practical nurse) #3 was interviewed. She stated that, to know if a resident is safe to leave, they look at their BIMS score, and it has to be above a 10. She also stated, with the BIMS score anything below 8 staff the resident is cognitively impaired. She stated that MDS does the BIMS coding on the residents, so if nursing staff disagree with a BIMS of someone trying to leave, nursing staff will look at safety. LPN #3 stated that in the past, staff had to assess people who wanted to leave and that somebody would go with them and see if they knew how to cross the street. She stated that as a floor nurse if someone wants to leave, she has to check if the resident is their own responsible party and if they are not, have them sign out in the sign out book. LPN#3 stated if the resident cannot sign out, a X is documented in the sign out book and a staff sign beside the X. She stated that nurses try to write a note for documentation. She also stated that sign out sheets tell staff where the person is, but they will call the resident if they want to check up. On 07/09/24 at 4:03 p.m., OSM (other staff member) #20, the Rehab Manager, was interviewed. She stated that if residents wish to independently leave the facility, therapy assesses them on community outings if that was something desired at admission. She also stated that it is something that is documented in therapy's evaluations and discharge summary. OSM #20 stated that therapy makes the determination that it is safe for residents to leave after they ambulate with residents or simulate those type of environments. She stated that therapy assess for safety so things like assistance device management and awareness of surroundings would be included in that. She also stated that R97's need for a cane or walker can increase the chances of injury if not used properly. OSM #20 further stated that the therapy staff did not specifically evaluate R97 for community outings, but the resident was assessed as requiring supervision or touching assistance when walking 10 feet on uneven surfaces. OSM #20 stated supervision meant someone should have eyes on the resident. OSM #20 stated that if R97 independently ambulated in the community without a complete assessment, and without supervision, he could have a fall with an injury. The facility policy, Leave of Absence (LOA), revealed, in part: When patients leave the center for reasons other than a medical transfer initiated by the center, the patient and/or responsible party will provide signature, accepting complete responsibility of the patient and absolving the management, personnel, and the attending physician of responsibility for any deterioration in condition or accident that may happen while the patient is away. On 7/9/24 at 5:42 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, and ASM #4, the regional vice president of clinical services, were notified of Immediate Jeopardy (IJ). The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 7/9/24 at 7:32pm. No further information was provided prior to exit. 5. The facility failed to provide a safe environment for Resident #136 while on LOA (leave of absence) On 7/9/24 at 7:53 AM, Resident #136 was observed ambulating independently with a rollator walker off facility property. Resident #136 was observed crossing the street at two points of a major intersection using the pedestrian walkways. Resident #136's gait was shuffling and show. He turned into the facility driveway and walked down the center of the driveway where cars were entering and exiting, rather than using the facility sidewalk. He was wearing a red and yellow safety vest. Resident #136 stated he goes to the local gas station each morning, then returns to the facility to eat breakfast. He stated after breakfast each day, he leaves the facility to go off the property to a local wellness center. Resident #136 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ASCVD (atherosclerotic cardiovascular disease), atrial fibrillation and Poly osteoarthritis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/21/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being independent for bed mobility, transfer, dressing and eating; supervision for hygiene and bathing. A review of the comprehensive care plan dated 9/13/23 revealed, FOCUS: The resident requires assistance with ADLS (activities of daily living). INTERVENTIONS: Resident frequently signs self out LOA, have provided safety vest to wear as tolerated. Remind resident to use walker for ambulation and transfers. A review of Resident #136's Elopement Risk Assessment dated 6/19/24, scored the resident as a '3'= low risk. There was no evidence of an assessment to determine the resident's safety to leave the facility independently on leave of absence. A review of Resident #136's sign-out sheet, revealed the last time he signed out was 12/23. On 7/9/24, the facility receptionist was interviewed. She stated the resident leaves the facility each morning, and that he is supposed to sign out on his unit. An interview was conducted on 7/9/24 at 3:45 PM with LPN (licensed practical nurse) #3. When asked what is your role when a resident wants to leave the facility, LPN #3 stated, we check if they are their own RP (responsible party), their BIMS, sign them out in the sign out book and write a note in the sheet, what time they went out. If they are gone a long time, we call the resident's cell phone, 'just checking on you, when are you coming back'. If they are their own RP they must sign out, if they are not their own RP, we call the RP and get permission and then 2 nurses' sign. If the resident cannot sign their name, we have them do an X and then 2 nurses' witness. I am assuming Resident #136 has been assessed because he has a safety vest as on my days off, I have seen him at the pharmacy and the grocery store. On 7/11/24 at 9:10 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and ASM #4, the vice president of operations was made aware of the finding. The facility's LOA (Leave of Absence) policy revealed the following, When patients leave the center for reasons other than a medical transfer, the patient will provide signature accepting complete responsibility of the patient for any deterioration in condition or accident that may happen while the patient is away. Upon return to the facility, the patient will sign back in with date and time. No further information was provided prior to exit. Immediate Jeopardy: A. On 7/8/24 at 4:17 PM, the findings of Immediate Jeopardy and substandard quality of care were confirmed during a phone call with the State Agency, related to concerns identified for resident smoking. On 7/8/24 at 5:38 PM, ASM #1 (Administrative Staff Member) the administrator, ASM #2, the Director of Nursing, ASM #3 the Regional Director of Clinical Services, and ASM #4 the Regional [NAME] President of Operations, were informed of the Immediate Jeopardy and subsequent SQC (substandard of care) finding and the need to complete a plan of removal. The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 7/8/24 at 6:18 PM. On 7/8/24 at 9:48 PM, ASM #4 presented an acceptable plan of correction which was accepted on 7/8/24 at 9:49 PM. B. On 7/9/24 at 5:30 PM the findings of Immediate Jeopardy and substandard quality of care were confirmed during a phone call with the State Agency, related to concerns identified for LOA ( resident leave of absence.) On 7/9/24 at 5:42 PM, ASM #1, #2, #3 and #4, were informed of the Immediate Jeopardy and subsequent SQC finding and the need to complete a plan of removal. The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 7/9/24 at 7:32 PM. On 7/10/24 at 11:05 AM, ASM #4 presented an acceptable plan of correction which was accepted on 7/10/24 at 12:07 PM. The facility alleges abatement of the Immediate Jeopardy on 7/10/24 at 6:00 P.M F689 Accidents and Hazards Abatement: 1. Plan of Corrective Action for those residents found to be affected by the deficient practice: A. Resident #148 had a skin assessment performed on 7/8/24 and no burns were noted. Resident's smoking items were obtained by staff and put into a safe storage area. Resident re-educated on smoking policy and procedure, to include smoking location, smoking times, cigarette disposal, and smoking item storage. Resident had a smoking assessment completed on 7/8/24 that deemed him as safe supervised smoker without any adaptive equipment needed. A. Resident #90 had a skin assessment performed on 7/8/24 and no burns were noted. Resident's smoking items were obtained by staff and put into a safe storage area. Resident re-educated on smoking policy and procedure, to include smoking location, cigarette disposal. Resident had a smoking assessment completed on 7/8/24 that deemed him as safe independent smoker without any adaptive equipment needed. B. Resident #97 was placed on 1:1 supervision to ensure his safety and to not leave the building unattended. A therapy evaluation request was placed on 7/9/24 to conduct an assessment for the ability to leave the building independently. Resident was educated that if he were to leave the building, he needed to sign out on the sign out sheet and let the nurse know he was leaving the building. A new elopement assessment was completed on 7/9/24 and he was deemed a low elopement risk. 2. Corrective Actions taken for residents with potential to be affected by deficient practice: A. All residents who smoke have the potential to be affected by this deficient practice. The facility Interdisciplinary Team will conduct resident smoking safety assessments on 7/8/24 assessing residents for safe smoking criteria. All residents assessed to be a smoker will have all smoking materials stored by the facility to be distributed if they are deemed requiring supervision, during approved smoking times by 7/9/24. The Facility Administrator will conduct a town hall meeting on 7/9/24 at 8:30 A.M. with the residents that smoke and review facility smoking policy and consequences for non-compliance. B. All residents who leave the building have the potential to be affected by this deficient practice. The facility licensed nursing staff will conduct new elopement assessments on all residents to determine elopement risk. Identified residents that leave the building unattended will have an evaluation by therapy to determine their ability to safely leave the building unattended on a leave of absence or an approved medical leave. The Interdisciplinary Team will discuss the outcome of evaluations with a medical provider to obtain leave of absence order as indicated. 3. Systemic Changes put into place to ensure the deficient practice does not recur: A. The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the Regional Director of Clinical Services on facility smoking policy to include resident safe smoking practices, supervision with smoking, and resident non-compliance with smoking policy. Starting 7/8/24 all staff will be educated, and no staff member will be permitted to return to work until they have completed the mandatory education on facility smoking policy, safe smoking and supervision, and non-compliance with smoking policy. Smokers that require supervision will be monitored by Activities staff or Nursing staff or by another appropriate person. A list of smokers will be provided to the monitor to include those who require supervision and adaptive equipment needed. The monitor will distribute smoking materials to those who require supervision and ensure materials are collected once smoking is completed. This education will be provided to all new employees as part of new hire orientation to include agency staff. B. The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the Regional Director of Clinical Services on the Leave of Absence Policy to include ensuring residents sign out when leaving and returning to the building, any resident that desires to be independent in the community will require a interdisciplinary evaluation from Therapy/Nursing and the physician prior to being deemed safe to leave independently, what to do if a resident refuses to sign out, the nursing staff must write a note that the resident refused and verbalized they were leaving the building; and that all residents must exit via the front door only. The medical providers will be educated by the Director of Nursing on the process of evaluation for residents who desire to leave the building independently. Starting 7/10/24 all staff will be educated by the Director of Nursing/designee, and no staff member will be permitted to return to work until they have completed the mandatory education on facility Leave of Absence Policy and above. A list of those residents that leave the facility and have been deemed safe to be in the community unattended will be posted at the nurse's station and front desk. The list will be maintained and updated by the nursing department as changes occur. Any new or existing residents that have not been deemed safe to be independent will not be allowed to leave the building without being accompanied by a family member or staff member. New or re-admitted residents that are admitted to the facility and have a desire to leave the facility independently will have an evaluation performed by the therapy department for safety and independence in consultation with the medical provider to approve the leave of absence. The Interdisciplinary Team will review the approved list weekly during the risk meeting for any changes needed. Resident sign out books will be located at each nursing unit, this will be maintained by the medical records department when a resident admits, discharges or room changes occurs. The nursing staff, receptionist or an employee that assists with any exits or after-hours exits out of the building will ensure residents are signed out prior to leaving. Residents are only permitted to leave through the front door. Residents will be tracked for Leave of Absence's through the sign-out books at each nursing station. This education will be provided to all new employees as part of the new hire orientation to include agency staff. On 7/10/24 Residents will be educated during Resident Council on the new process for Leave of Absence policy for those that wish to leave the facility independently. Resident Family Members will be educated by Social Services or designee on the new process of evaluation for independently leaving the building, signing in and out of the building for a leave of absence. A. The Administrator to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 7/9/24 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, Medical Director and Unit Managers. B. The Administrator to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 7/10/24 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, Medical Director and Unit Managers. 4. A. Facility will monitor residents for change in condition to determine if a new smoking assessment is needed or will be done quarterly per policy. If a resident is observed by a smoking monitor with unsafe smoking practices, the resident will be stopped from smoking and have a new assessment completed to determine any changes to ensure safe smoking ability. The Administrator or designee will do random audits three times weekly x 4 weeks, then weekly x 4 weeks then monthly x 2 months to ensure residents that require supervision during smoking are supervised during the approved smoke time, staff are maintaining smoking materials for those residents during nonsmoking times and that all residents are smoking in the designated area. B. Facility will monitor residents for changes in condition to see if a new therapy evaluation will be needed to reassess safety. The Administrator or designee will audit the sign out sheets three times weekly x 4 weeks, then weekly x 4 weeks then monthly x 2 months to ensure that residents are signing out and if a resident refuses to sign out, there is a nurses note present in the medical record. 5. The facility alleges abatement of the Immediate Jeopardy on 7/10/24 at 6:00 PM. Monitoring of corrective action to ensure the deficient practice does not recurA. On 7/9/24, the plan of removal for smoking concerns was verified by the surveyors onsite. The education completed by the administration regarding the facility's smoking policy and procedures was verified. Interviews were conducted with the staff of each department. All staff interviewed properly stated the smoking policy and procedures. A list of residents who smoke and their status as being independent or requiring supervision was posted at each nurse's station and the front desk. Observation was made of the designated smoking area on 7/9/24 at 11:20 AM. Residents identified as smokers were observed with staff supervision of all residents during smoking and all safety measures were in place, including a new fire extinguisher cabinet on the wall outside the door in the courtyard, with a new fire extinguisher in it. In addition, a smoking blanket was observed on the wall next to the fire extinguisher. This was in addition to the one just inside the door to the courtyard. The Immediate Jeopardy was abated on 7/9/24 at 1:46 PM, the IJ for part A (smoking) was removed B. On 7/11/24, the plan of removal for leave of absence was verified by the surveyors onsite. The education completed by the administration regarding the facility's leave of absence policy and procedures was verified. Resident assessments were being completed to determine which residents were safe for independent leave of absence and which residents required supervision. Interviews were conducted with staff from each department. All staff interviewed properly stated the leave of absence policy and procedures. A review of the sign out book revealed the book was updated, and one was available at each nurse's station. A list of residents allowed to leave the facility independently was posted at the front desk and nurse's stations. On 7/11/24 at 10:32 AM, the IJ for the LOA (leave of absence) was removed. 4. For Resident #120, the facility staff failed to implement a LOA (leave of absence) process for resident safety to ensure the facility had knowledge of Resident #120's whereabouts at all times. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #120 was coded as moderately impaired in ability to make daily life decisions, scoring a 12 out of a possible 15 on the BIMS (Brief Interview for Mental Status exam). A review of the physical therapy notes revealed the following: On 3/21/23 was documented, Gait training over indoor/outdoor surfaces for distance of 1033 (feet) without AD (assistive device) over concrete/carpet/grass/tile .focusing on directional changes and obstacle negotiation. On 3/27/23 was documented, Pt (patient) ambulated around building on uneven and even surfaces. Patient performed gait training showing ability to maneuver through environment and crouch when needed without LOB (loss of balance) over lvl (level) and unlevl (unleveled) surfaces (grass/concrete) . On 3/30/23 was documented, Pt performed gait training on level and unlevel surfaces both inside and outside for over 1000ft (feet). Also demonstrated ability to ascend and descend stairs to test balance and coordination . On 4/1/23 was documented, Gait training throughout facility over 1000 (feet) .focusing on directional changes and obstacle negotiation . On 4/3/23 was documented, Gait training over indoor/outdoor surfaces (I) (independently) without AD (assistive device) focusing on directional changes and obstacle negotiation with no LOB (loss of balance) noted. The above reflected the resident's ability to safely ambulate over various level and unlevel surfaces for an extensive distance in 2023. Further review of the clinical record revealed that Resident #120 has not had any falls in the calendar year of 2024 from 1/1/24 through this survey of 7/11/24. A nurse's note dated 4/9/24 documented, He went to (name of drugstore across the street) . A review of the sign out sheet for Resident #120 revealed the last time he actually signed out to go anywhere was on 10/18/23. There was no sign out for a leave of absence since 10/18/23 up through this survey of 7/11/24. On 7/9/24 at 9:20 AM, Resident #120 states he goes out about three times a week across the street to the local drug store. He stated that he does not tell anyone and does not sign out. He stated that he has no issues with walking, has had no falls, and does not need the assistance of a walker or wheelchair. He stated that he looks out for traffic and is careful about crossing the street. On 7/9/24 at 3:44 PM, an interview was conducted with LPN #3 (Licensed Practical Nurse). She stated that Resident #120 signs himself out frequently, goes to (local drug store across the street). She stated that she has not actually seen him cross the road, but that he is aware of his surroundings, is steady on feet, requires no assistive devices, has no disability with ambulation, but is hard of hearing. She stated that if a resident wants to leave the facility independently, that staff should check to see if the resident is their own RP (responsible party), check their BIMS, make sure they have their cell phone available, and have them sign out in the sign out book. She stated that everyone has to sign out when they leave. She stated that if possible, find out what they want and see if someone can go get it for them, so they do not have to go out if it is a really hot or cold day. She stated that risks would include heat stroke, passing out, getting hit by a car. When asked about the likelihood of these things happening, she stated that it could happen to anyone. She stated that a resident with a physical impairment or need for assistive devices increases the likelihood of something happening. She stated that therapy can help assess a resident to see if they are safe to leave independently. On 7/10/24 at 2:22 PM an interview was conducted with LPN #8. She stated that she always see him in the building, never seen him go out. He has never notified me he was going out. A review of the comprehensive care plan failed to reveal any interventions for the resident to go on leave of absence independently. The facility policy, Leave of Absence documented, When patients leave the center for reasons other than a medical transfer initiated by the center, the patient and/or responsible party will provide signature, accepting complete responsibility of the patient and absolving the management, personnel, and the attending physician of responsibility for any deterioration in condition or accident that may happen while the patient is away. 1. Before a patient leaves the premises for any reason other than a medical transfer initiated by the center, the patient and/or responsible party must notify a licensed nurse on the unit. 2. A licensed nurse ensures that medical approval of the leave has been provided by the patient's provider. This can be in the form of a provider's order. 3. The Release of Responsibility for Leave of Absence (LOA) Form is filled out prior to leaving the center, the date, time, and signature of the person accepting responsibility is filled in. 4. The estimated time of return is provided to a licensed nurse. 5. A licensed nurse will make arrangements with the pharmacy for any necessary medications to be sent with the patient, if applicable. 6. If the patient will not be returning to the center on the same day as the beginning of the leave, the patient and/or responsible party must also notify nursing, Admissions Director, Business Office Manager, or the Administrator prior to or at the time of departure to initiate a Voluntary Bed Retention Agreement, if applicable. 7. A licensed nurse will note the LOA in the medical record. 8. Upon return to the center, the patient or responsible party will sign back in with date and time on the LOA form and a center staff will sign the form accepting responsibility of the patient at that time. 9. A licensed nurse will note return in the medical record, including the condition of the patient or any issues experienced during the LOA expressed by the patient or responsible party (fall, bruise, skin tear, change in condition, etc.). 10. Notify the provider, if necessary, and document in the medical record. No further information was provided prior to exit. Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide adequate supervision for residents smoking and leaving the building, for five of 50 residents in the survey sample; Residents #148, #90, #97, #120, and #136. 1. For Resident #148, the facility staff failed to provide resident supervision and safety for smoking. Resident #148 was assessed on the Smoking Safety Screen dated 3/8/24 and 6/8/24 as requiring supervision for smoking. On 7/8/24 at 3:00 PM, Resident #148 was observed smoking in an outdoor garden area with raised plant beds. There was no staff supervision present, no safe cigarette disposal receptacle, no fire blanket and no fire extinguisher in the immediate area. 2. For Resident #90 (R90), the facility staff failed to provide supervision for safety. 3. For Resident #97 (R97), the facility staff failed to provide supervision for safe leave of absence. On 7/9/24 at 5:50 PM, R97 was observed walking over to Walgreens without a cane. This resulted in Immediate Jeopardy (IJ) and SQC (substandard quality of care), which was identified in the area of Quality of Care on 7/8/24 at 4:17 PM for concerns related to smoking and on 7/9/24 at 5:30 PM for concerns related to unsupervised leave of absences. The plan of removal for the immediacy related to smoking concerns was accepted on 7/8/24 at 9:49 PM and as related to leave of absence concerns on 7/9/24 at 6:09 PM. The IJ was removed on 7/9/24 at 1:46 PM related to smoking concerns and on 7/11/24 at 10:32 AM related to the leave of absence issues, with the Scope and Severity lowered to a Level 2, Pattern. 4. For Resident #120, the facility staff failed to evidence staff were aware of the resident leaving the facility to ambulate unsupervised across the street to the local drug store. On 7/9/24 at 9:20 AM, Resident #120 stated that he leaves the facility two to three times a week to go across the street to the local drug store and does not sign out and does not notify staff that he is leaving. 5. The facility failed to provide a safe environment for Resident #136 On 7/9/24 at 7:53 AM, Resident #136 was observed ambulating independently with a rollator walker off facility property. Resident #136 was observed crossing the street at two points of a major intersection using the pedestrian walkways. Resident #136's gait was shuffling and show. He turned into the facility driveway and walked down the center of the driveway where cars were entering and exiting, rather than using the facility sidewalk. He was wearing a red and yellow safety vest. The findings include: 1. For Resident #148, the facility staff failed to prevent the resident from smoking unsupervised, in an unapproved area devoid of any safety requirements (staff supervision, safe disposal of cigarette butts, smoking blanket and fire extinguisher) on 7/8/24 at 3:00 PM. Resident #148 was admitted to the facility on [DATE] and was coded on the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], as being cognitively intact in ability to make daily life decisions, scoring a 14 out of a possible 15 on the BIMS (Brief Interview for Mental Status exam). On 7/8/24 at 3:00 PM, Resident #148 was observed self-propelling his wheelchair down the main front sidewalk of the facility towards the wooded area. He then turned right onto another sidewalk and entered through a gate into a facility garden area with raised plant beds. He then was observed obtaining a cigarette and lighter from his person and lighting it. At this time he was interviewed and stated that he goes to this area to smoke and he keeps his smoking materials on his person. He was observed to throw his cigarette butt on the ground. On 7/8/24 at 3:24 PM, Resident #148 was still observed to be smoking in garden area. There was no staff present for supervision, no devices for the[TRUNCATED]