**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R299 was admitted to the facility on [DATE] with diagnoses that included spina bifida and paraplegia. R299's Care Plan, dated [DATE] revealed a focus area related to the resident smoking. A goal was that the resident would not suffer injury from unsafe smoking/vaping practices. Interventions included helping to and from the designated smoking area. R299's medical record did not contain any smoking assessments since their admission or readmission to the facility. R299's MDS, dated [DATE] revealed R299 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. During an observation on [DATE] at 5:10 PM, 2 Surveyors, who were in the conference room on the south side of the building, approximately 100 feet from the south door, heard someone banging and yelling at the south door of the building. This door led to the designated resident smoking area, and the door was locked. R299 was the resident banging on the door and yelling. Surveyors noted that the door swung outward towards the smoking area. R299 was seated in his wheelchair with his legs extended out on the pedals. In order for R299 to re-enter the building independently, he would have to put the code in to unlock the door, and then try to re-position his wheelchair so that he could open the door before the code expired. At 5:25 PM, R299 was noted to still outside of the south door and was banging and yelling to come in. Surveyors summoned the Activity Coordinator to come and help him in the building. She went and opened the door at 5:35 pm. R299 had to be instructed to move out of the way as the Activity Coordinator was unable to open the door. The Activity Coordinator brought R299 inside the building at 5:36 pm. He had a blanket around his shoulders. R299 had been attempting to re-enter the building for 26 minutes. Per weather.com, it was 50 degrees outside at 5:36 PM. During an interview on [DATE] at 5:38 PM, R299 was asked if someone had helped him get outside to the smoking area. R299 did not respond to the question. During an interview on [DATE] at 6:00 PM, CNA M (Certified Nursing Assistant) stated he had helped R299 out at 5:24 PM, and someone had brought R299 in at 5:38 pm. CNA M was informed of the surveyors' observations. CNA M maintained his statement that he took R299 out at 5:24 PM. During an observation on [DATE] at 11:00 AM, R299 was outside of the door that led to the smoking area. He was unable to get back in and was observed knocking on the door. A staff member assisted him in getting back into the building. He again had to move away from the door for the staff to help him in the building. He had a blanket draped around his shoulders. R299 was speaking in a loud voice and swearing at the staff. The temperature was 55 degrees Fahrenheit (F), and the wind speed was 11 MPH with gusts to 20 MPH from the WSW per weather.com. The wind chill temperature was noted to be 46 degrees. During an interview on [DATE] at 1:25 PM, DON B confirmed R299 should have been monitored and asked how long he wanted to stay outside. She confirmed he was unable to go out and come back into the building without assistance. Failure to ensure residents were provided needed supervision while smoking or vaping created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The jeopardy was removed on [DATE] when the facility completed the following. 1. The facility updated their policy and procedure to address safety in using e-cigarettes including their use only in designated smoking areas. 2. Assessments were reviewed and updated for all residents known to smoke/vape. 3. Based on the findings of the assessments, care plans were reviewed and updated for all residents known to smoke/vape. Appropriate interventions were put into place to ensure resident safety. 4. All staff were trained on the updated policy and procedure and location of the smoking area prior to beginning their next scheduled shift. The deficient practice continues at a scope/severity of G (actual harm/isolated) for R199 related to transfer and at severity level 2 (potential for more than minimal harm) for the following examples also related to smoking/vaping. 4. During an observation on [DATE] at 9:45 AM, when the survey team arrived at the facility, a plastic outdoor cigarette disposal container was found in the parking lot, approximately 15 feet from the south door of the building. No fire extinguishers, smoking aprons, or fire-proof containers were available. There was no staff supervision. There were signs on the building by the door that read, No Smoking within fifteen feet of the building. Further observations on [DATE] at 1:10 PM, 3:17 PM, 5:10 PM, and 9:15 PM, revealed residents exiting the south door without supervision. The residents would stand by the door and smoke, and others would go out to the cigarette disposal container in the parking lot. R3, R36, R299, R38, R34, and R18 were observed smoking in this area. 5. R14 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus with diabetic neuropathy, cerebral infarction due to unspecified occlusion or stenosis of basilar artery, and peripheral vascular disease (PVD). Review of R14's facility provided Smoking Evaluation (Comprehensive), dated [DATE], indicated, .R14 alert, oriented .exhibits safe smoking/vaping awareness .e-cigarette/vape .disposable .use a wheelchair .able to move about or remove lit material if it falls on them: yes, does the resident exhibit adequate fine motor skills to safely hold a lighted cigarette? Yes .Is resident free of smoking/e-cigarette/vaping related incidents? Yes .Planning and Interventions .Intervention: The resident can smoke unsupervised . Further review revealed no evidence of another quarterly smoking assessment completed after this assessment in [DATE]. Review of R14's clinical record and facility provided documents revealed no further smoking evaluations for the resident. During an observation and interview on [DATE] at 7:39 PM, R14 stated that they vaped outside; however, a rechargeable e-cigarette was observed on her bed. During an interview on [DATE] at 4:55 PM, DON B confirmed that R14's quarterly smoking assessment was late and should have been completed in [DATE]. During an interview on [DATE] at 8:50 AM, NHA A stated that vaping had not been a concern at the facility, but since the summer of 2024, there had been an increase in vaping at the facility. NHA A stated that this had always been a smoking building, and vaping was a new concern due to the younger population that the facility was admitting. 6. R37 was admitted on [DATE] with diagnoses that included chronic lymphocytic leukemia, chronic pain syndrome, adult failure to thrive, muscle spasm, and bipolar disorder. R37 had a Smoking Evaluation completed on [DATE] and [DATE]. The evaluations showed he was alert and oriented, had clear speech, and he used a disposable vaping device. The resident had been free of smoking/e-cigarette/vaping related incidents. Smoking Evaluations had not been completed for the first and second quarters of 2024. A smoking evaluation had not been completed until [DATE], after the beginning of the survey. R37's quarterly MDS, dated [DATE] revealed R37 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. During an observation and interview on [DATE] at 3:39 PM, R37 was observed in his room. R37 stated he uses a vaping device and kept it in his room with him. He stated he was instructed by NHA A that he should vape in his room rather than outside, as it would be easier for him due to his muscle spasms. He stated he usually only got out of bed in the afternoon. His vaping device was not in sight during the observation. During an interview on [DATE] at 8:30 PM, R37 stated his vaping device was rechargeable and could be disposed of when the nicotine liquid was gone. He stated staff did not supervise him when he used the vaping device, and he had no incidents from using the vaping device in his room. 7. R34 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, anxiety, and post-traumatic stress disorder (PTSD). Smoking Evaluations had been completed for R34 on [DATE], [DATE], and [DATE]. There was no documented evidence of a smoking evaluation for the fourth quarter of 2023 or the second quarter of 2024. It was revealed it had been greater than three months since the last smoking evaluation was completed for R34. R34's Care Plan, revised [DATE] and located under the Care Plan tab of the EMR revealed a focus of R34 being a smoker. It was recorded that the resident was independent with smoking and could smoke independently. During observations on [DATE], [DATE], [DATE], and [DATE], R34 was observed to go outside independently to smoke. He was observed to smoke independently, without supervision. 8. R32 was admitted to the facility on [DATE] with diagnoses that included anxiety and depression. Review of R32's Smoking Assessments, revealed only one smoking assessment, dated [DATE], had been completed for the resident. Review of R32's Care Plan, revealed a smoking focus had not been added to the resident's care plan until [DATE], even though they were admitted on [DATE]. The care plan interventions included instructing the resident about smoking/vaping risks and hazards and about smoking cessation aids that were available, the facility's policy on smoking/vaping, and to notify the charge nurse immediately if it was suspected the resident had violated the facility smoking policy. It was recorded that the resident could smoke unsupervised. R32 was observed smoking on [DATE] at 4:00 PM in the smoking area. 14. R43 was admitted to the facility on [DATE] with diagnoses that included syncope and nicotine dependence. R43's quarterly MDS, dated [DATE] revealed R43 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, the resident was independent for all activities of daily living. Review of R43's Care Plan, dated [DATE] revealed, The resident is a smoker. The Care Plan revealed a goal of Resident will not suffer injury from smoking/vaping practices through the review date. Interventions included instructing the resident about smoking and the facility policy. Interventions included, .The resident is able to manage his own smoking materials and smoke unsupervised . Review of R43's Smoking Evaluation, located in the EMR under the Focus tab and dated [DATE], 12 days after admission, revealed R43 did not require supervision for smoking. There was no evidence an evaluation had been completed since that time. On [DATE], during the survey, a Smoking Evaluation was completed for R43 which indicated R43 did not require supervision for smoking. 15. R36 was admitted to the facility on [DATE] with diagnoses that included alcoholic cirrhosis of liver with ascites. Review of R36's Smoking Evaluation, dated [DATE], revealed R36 did not require supervision for smoking. This was the only Smoking Evaluation located in R36's EMR. R36's annual MDS, dated [DATE] revealed R36 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, the resident was independent for all activities of daily living. Review of R36's Care Plan located in the EMR under the Care Plan tab, revealed no care plan related to smoking had been developed for the resident until [DATE], after the beginning of the survey. TRANSFERS R199 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction and vascular dementia. R199's quarterly MDS, dated [DATE] indicated R199 had a BIMS of 13 out of 15, which indicated the resident was cognitively intact. The MDS recorded the resident was dependent on staff for all activities of daily living (ADLs). R199's Care Plan, dated [DATE], indicated, .Transfer: The resident requires Hoyer (mechanical) lift with assist of 2 staff . Review of an investigative file for R199 revealed: A hospital Progress Note, dated [DATE], recorded, .Closed fracture of left distal femur Date Noted: [DATE] Assessment: Patient was accidentally dropped from Hoyer (Mechanical) lift when she suffered subsequent left distal femur fracture .Oblique fracture of proximal right femoral shaft . A document detailing a phone interview with CNA K, dated [DATE], stated, I had a normal regular day [sic] [DATE] nothing happened out of the ordinary. I washed R199 up at 10:30 AM and then proceeded to transfer her with a full body sling. I transferred her by myself. The resident never fell. I took her to the day room. She ate lunch that I fed her about 1:30 PM. She asked me to lay her down. I took her to her room and laid her down by myself. An undated interview with LPN L recorded, [R199] was stating she was dropped by a black CNA. At that time R199 did not state from [Mechanical Lift]. I assessed ROM (range of motion) but could not complete, c/o (complaints of) pain with movement. Could not visualize any swelling or bruising. MD (Medical Doctor) updated STAT [immediate] Xray ordered. Res (resident) refused Tylenol when asked. Administrator updated immediately. Xray was completed STAT which was within four hours and as soon as results popped up Res sent to ER (emergency room) and MD, POA (power of attorney) updated, POA did not answer. POA called again with no answer. POA called back and info provided. An investigation summary recorded, R199 sustained fractures of bilateral lower extremities that were discovered on [DATE] when she complained of acute left lower extremity pain. R199 is a . female with h/o (history of) CVA (cerebrovascular accident) with right sided hemiplegia, vascular dementia, epilepsy and osteoarthritis. She has a BIMs of 7 with a legal guardian .She has lived at (facility name) since [DATE]. She has been non-weight bearing since prior to her admission. She has not sustained any previous falls while a resident in this facility. R199 reports that she was dropped onto the floor during a full mechanical transfer. There was no reported fall or incident on [DATE] or any day previous to this. Her roommate has provided varying statements that include R199 herself attempting to stand then collapsing and R199 being dropped from the lift during a transfer. Staff interviews have resulted in no conclusive evidence of what event actually occurred. Based on the nature and severity of R199's injuries it is reasonable to assume that something happened during the day shift of [DATE] as the soft tissue swelling and abrupt pain onset are indicative of an acute injury. The nursing assistant who worked with R199 on [DATE] during the day shift was deceptive and dishonest during interviews. She did admit to completing a full mechanical lift without a second person present, violating our resident handling policy .Given R199's history of osteoporosis with previous fractures and hardware infection in left hip and long-standing history of non-weight bearing she was at high risk for fractures involving minimal trauma .The facility took action to identify any other residents who had the potential to be affected by this practice. There is no evidence that any other residents have had injuries as result of this deficient practice. Policies and procedures were reviewed. Education was initiated. Audits of full mechanical lifts have been initiated. The results of this investigation and the subsequent action plan will be reviewed at QAPI (Quality Assurance Performance Improvement). On [DATE] at 2:39 PM, an attempt to contact CNA K was made, and a message was left with no return phone call by the end of the survey. During an interview on [DATE] at 11:47 PM, CMT C stated she was in R199's room the day before the incident and watched CNA K transfer R199 by herself. She stated she did not help CNA K with the transfer. She stated she thought she did not need to assist with the transfer if she was in the room. CMT C stated she received mechanical lift transfer training after the incident. During an interview on [DATE] at 6:53 PM, DON B stated after the incident they started mechanical lift training immediately. DON B stated she could not confirm 100% of their staff were trained after the event. DON B stated, We were very specific during the training and told staff if you do not follow the resident's care plan or the facility policy during cares, that would be considered neglect. The facility was asked to provide the facility's mechanical lift policy and procedure 3 times. It was not provided before the end of the survey. 9. R22 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis, multiple sclerosis, and cerebral infarction. R22's Smoking Assessment, was last completed [DATE]. The most recent assessment was not completed timely. Review of R22's annual MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. R22's Care Plan, last revised [DATE], documented that the resident is a smoker/vaper. The interventions identified the resident as a safe vaper and instructed the resident about the facility policy on smoking/vaping, the locations, times, and safety concerns. During an interview on [DATE] at 7:12 PM, R22 stated that she vaped in her room when she had the money to have staff purchase a vape device for her. She stated she has not had one for a while, since she has not had the money to purchase one. 10. R31 was admitted on [DATE] with diagnoses including diabetes mellitus two, venous insufficiency, and epilepsy. Review of R31's Smoking Quarterly Review, revealed the last assessment was completed [DATE]. R31 was assessed as a safe smoker. The most recent quarterly smoking assessment was not completed timely. Review of R31's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. Review of R31's Care Plan, documented that the resident is a smoker. The interventions indicated the resident could smoke unsupervised. A new intervention, initiated [DATE] during the survey, stated to conduct a smoking safety assessment as necessary and to provide appropriate smoking management in accordance with the assessment. 11. R150 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus two, peripheral vascular disease, and hypertension. She was assessed as alert upon admission. R150's Smoking Evaluation, was completed [DATE]. R150 was assessed as a smoker, but not identified as safe or unsafe. Review of R150's Care Plan, was initiated on [DATE] as demonstrates compliance with safe smoking regulations. A baseline care plan was not developed timely. 12. R38 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypokalemia, and adult failure to thrive. R38's Care Plan, initiated [DATE], documented that the resident is a smoker. The interventions indicated the resident could smoke unsupervised, to instruct the resident about the facility policy on smoking/vaping locations, times, and safety concerns. The care plan did not identify the resident was a safe smoker until [DATE]. R38's Smoking Quarterly Review the last assessment was completed [DATE]. R38 was assessed as a safe smoker. The most recent quarterly smoking assessment was not completed timely. A delayed smoking assessment was completed [DATE] during the survey. Review of R38's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. 13. R149 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition, hypertension, and epilepsy. R149's Care Plan, initiated [DATE], documented that the resident is a smoker. The interventions documented to conduct a smoking safety assessment as necessary and to provide appropriate smoking management in accordance with the assessment. It did not document if the resident was a safe or unsafe smoker. R149's Smoking Assessment, revealed the first assessment was completed [DATE]. R149's admission MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. Based on observations, interviews, and record review, the facility did not ensure that 13 of 13 residents reviewed for smoking and/or vaping (R2, R3, R299, R36, R299, R14, R37, R34, R31, R32, R22, R31, R150, R38, R149, R43, and R36) and one resident reviewed for transfers (R199) were provided with an environment that was free of accident hazards and/or provided with appropriate supervision. R2 was allowed to vape (use an electronic cigarette) while using oxygen in her room instead of being restricted to designated smoking areas away from oxygen. In addition, the facility allowed charging of the e-cigarette in the resident's room. R3 is severely cognitively impaired. R3 was allowed to smoke without supervision and was allowed to smoke outside of the designated area. There was no safety equipment in the area where R3 was observed smoking. R299 smokes unsupervised. When R299 goes outside, R299 is unable to re-enter the building independently; he must wait for staff to come and let him back inside. Facility failure to ensure residents were provided with appropriate supervision and safety devices while smoking or vaping created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator), DON B (Director of Nursing), Regional Director of Operations, and Regional Clinical Consultant were notified of the finding on [DATE] at 12:49 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of G (actual harm/isolated) for R199 who was transferred in a Hoyer lift without a second person assisting in the transfer, resulting in a right and left proximal femoral fracture and at severity level 2 (potential for more than minimal harm) for the following examples related to smoking/vaping. R36, R299, R38, R34, and R18 smoke unsupervised and did not smoke in a designated smoking area. The area where the residents smoked did not have safety equipment (aprons, fire extinguisher, and/or fire blanket). Theses failures had the potential to cause serious adverse outcomes including serious injury, serious harm, serious impairment, up to and including death. R299 and R150 did not have an initial smoking assessment completed. R2, R3, R43, R31, R36, R38, R22, R14, R32, and R34 did not have quarterly smoking assessments completed. R150, R38, R2, and R22 did not have care plans developed related to smoking/vaping. R199 was to be transferred using a full body (Hoyer) lift and 2 staff assistance. On [DATE], CNA K (Certified Nursing Assistant) transferred R199 without a second staff person assisting. R199 fell and sustained a right and left proximal femoral fracture. Findings include: SMOKING/VAPING Review of the facility's policy titled, Vaping Safety Policy and Procedure, and dated [DATE], indicated, .To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Procedures: 1. Vaping is allowed in facility. 2. A smoking/vaping safety assessment will be completed to determine the level of assistance and supervision needed during vaping, the ability to carry and store vaping materials, in her/his own room. The plan of care shall reflect the results of this assessment. The assessment will be completed upon admission, quarterly and with significant change . Review of the facility's policy titled, Smoking Guidelines, dated 11/2023, indicated, .1. Prior to, or upon admission, residents who smoke shall be informed about any limitations on smoking, including designated smoking areas and the extent to which the facility can accommodate their smoking preferences. 2. Smoking restrictions shall be strictly enforced in all nonsmoking areas . According to Public Safety Network (Agency for Healthcare Quality and Research), .the use of any ignition source in the presence of oxygen is potentially hazardous. This issue was addressed specifically by the British Compressed Gases Association, which stated, Electronic cigarettes are . a potential ignition source and, in the context of oxygen-rich environments, have the same fire risks as traditional cigarettes.(11) This opinion was supported by the Electronic Cigarettes Industry Trade Association, which agreed that in the context of oxygen use, it would be appropriate to describe electronic cigarette use as similarly hazardous to smoking.(11) Furthermore they suggest that if a patient needs oxygen, a nonheated source of nicotine such as NRT be considered . https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room 1. R2 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure. R2's Smoking Evaluation, dated [DATE] and provided by the facility, indicated, R2 is alert, exhibits safe smoking/vaping awareness .e-cigarette/vape .preferred type: disposable .Oxygen Usage: Is the resident able to remove all oxygen equipment before entering designated smoking areas? Not applicable. Review of R2's clinical record and facility provided documents revealed no further smoking evaluations for the resident. Review of R2's Physician Order, dated [DATE] and located under the Orders tab of the EMR, indicated, .Oxygen (two-four) liters/minute as needed PRN (as needed) for hypoxia . R2's quarterly 'Minimum Data Set (MDS) dated [DATE], indicated R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R2 was cognitively intact. R2's Care Plan, revised [DATE] indicated, .The resident is a smoker/vapes .Interventions: Assist with transportation to/from smoking area, Instruct resident about smoking/vaping risks and hazards and about smoking cessation aids that are available; Monitor oral hygiene; Notify charge nurse immediately if it is suspected resident has violated facility smoking policy; and The resident can vape unsupervised. There was no documented evidence that the resident's care plan had been revised to include oxygen usage and vaping in her room. During observations on [DATE] at 11:00 AM, 5:00 PM, and 5:45 PM, a No smoking, oxygen in use sign was noted on the resident's door in the right upper corner. R2 was noted to have oxygen being administered via nasal cannula. During an interview on [DATE] at 5:45 PM, R2 stated that she vaped in her bedroom several times a day while wearing oxygen. R2 stated that she kept her e-cigarette in her room. During the interview, the surveyor observed R2 bring her white e-cigarette from under the covers in her left hand while she had oxygen going via nasal cannula. R2 stated that she had never had any burn incidents, and she had been vaping for the past two years. During an interview on [DATE] at 7:39 PM, R2 stated that the e-cigarette was rechargeable, and she charged it with her phone cord. E-cigarettes contain a heating element. Any heat source can cause oxygen to ignite, placing the resident at risk for burns. During an interview on [DATE] at 8:24 PM, DON B (Director of Nursing) stated it was the resident's right to vape in her room because it was important to maintain a homelike environment. During the interview, the surveyor and DON B observed R2 lying in bed, wearing her oxygen nasal cannula. R2 confirmed that she was receiving oxygen. DON B asked R2 if she wore her oxygen while she vaped, and R2 stated, Yes. During an interview on [DATE] at 8:35 PM, DON B stated she educated R2 about vaping with oxygen. DON B stated that she told R2 that she would need to have blood oxygen level taken after her oxygen was removed, and if they determined it was within normal limits, she could proceed with vaping. During an interview on [DATE] at 10:30 AM, DON B stated that R2 did not have oxygen anymore, and her blood oxygen levels were monitored every two hours to make sure they maintained normal levels. DON B stated R2 was allowed to continue to vape in her room and keep her own e-cigarette. DON B stated that if R2 needed her oxygen, then R2 would give her e-cigarette to staff. R2's Care Plan, located under the Care Plan tab of the EMR, revealed no documented evidence R2's care plan was revised to include vaping and oxygen usage. The DON confirmed the care plan had not been revised. During the interview on [DATE] at 11:55 AM, the DON stated that the smoking evaluation should be completed quarterly. She confirmed that there were no aprons, fire blankets, and/or fire extinguishers in the smoking area. The DON stated the electronic medical record was set up so that if you answered a question on the smoking evaluation, then the option for a smoking apron will come up, but the system would not allow a person to further elaborate. The DON stated that there was a fire extinguisher in the front of the building/reception area. During an observation on [DATE] at 12:00 PM, R2 was observed in her room with her vape; however, there was no oxygen in her room. 2. R3 was re-admitted to the facility on [DATE] with diagnoses that included dementia. R3's Smoking Quarterly Review, dated [DATE] and provided by the facility, indicated, .No change to comprehensive smoking evaluation. Quarterly Planning and Interventions .instruct resident about the facility policy on smoking: locations, times, safety concerns .The resident can smoke unsupervised . Review of R2's clinical record and facility provided documents revealed no further smoking evaluations for the resident. Review of R3's quarterly MDS, dated [DATE] indicated R3 had a BIMS score of four out of 15, which indicated R3 was severely cognitively impaired. During an observation on [DATE] at 10:15 AM, R3 was observed sitting on the bench on the front porch. There was a sign posted in front of him that read, This is Not a Designated Smoking Area. R3's four-wheeled walker was positioned in front of him, and there were no staff members present. R3 was smoking a cigarette that had only one-half inch left to the filter line. Another cigarette, with approximately three quarters inch left, was under his left thigh. R3 removed the cigarette under his left thigh. Surveyor observed that the cigarette had been lit at some point. No burn marks were observed on R3's pants. The unlit cigarette fell to the ground in front of R3 while he still had the lit cigarette in his hand. R3 bent down to get the unlit cigarette, and the lit cigarette was observed to be close to R3's face. R3 placed the unlit cigarette in the storage seat of his walker and continued to smoke the lit cigarette which was close to the filter area. R3 was not wearing a smoking apron. There was no fire blanket, no fire extinguisher,