**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 19 sampled residents to self-administer medications. (Resident #67) The findings include: An observation of Resident #67 was conducted on 02/17/25 at 10:35 AM. A medicine cup with 4 pills was observed sitting on the over bed table. When asked about this, the resident stated, If a nurse is in a hurry, then they leave the medication at the bedside, but they never watch me take my medications. A telephone interview was conducted with Employee C (a Licensed Practical Nurse) on 02/19/25 at 2:01 pm. She stated that she normally doesn't work on Resident #67's hall. She stated that she doesn't remember leaving the medications with the resident but, if she did, then it was an error on her part. She did not watch the resident take the medications. She is not sure if the resident is evaluated to self-administer her medications. A review of the resident's electronic medical record revealed no documentation discussing self-administration of medications. A review of the admission minimum data set with an assessment reference date of 12/24/24 revealed the resident had a BIMS (brief interview of mental status) of 15 indicating she is cognitively intact. A review of the policy Self-Administration of Medication, dated [DATE], states the following, A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to ensure the minimum data set (MDS) accurately reflected the resident's status for 1 of 1 sampled residents reviewed for pressure ulcers (Resident #57) and 1 of 1 sampled residents reviewed for hospitalization. (Resident #83) The findings include: Resident #57 A review of Resident #57's electronic record revealed the Medicare 5-day MDS with an assessment reference date (ARD) of 2/3/25 indicated in section M that the resident had two stage 2 pressure ulcers present upon admission or re-entry. A review of the weekly wound documentation dated 1/31/25 revealed the right heel and sacral area had stage 2 pressure wounds that were facility acquired. An interview was conducted with Employee A (MDS Coordinator Registered Nurse) on 2/19/25 at 1:32 PM. Employee A reviewed the MDS dated [DATE] and the wound records dated 1/31/25 and confirmed the stage 2 pressure wounds on the right heel and sacrum should have been coded as facility acquired on the MDS. Resident #83 A review of Resident #83's electronic record revealed a discharge MDS with an ARD of 1/20/25 that indicated in section A that the resident was discharged to a short-term general hospital. A review of the record revealed the resident was actually discharged to hospice. The record did not indicate the resident was ever hospitalized . An interview was conducted with Employee B (Registered Nurse Risk Manager) on 2/19/25 at 9:11 AM. Employee B stated the MDS was not correct, and the resident went home on 1/20/25 with hospice care. Review of the facility policy for Certifying Accuracy of the Resident Assessment (dated October 2010) revealed all personnel who complete any portion of the Resident Assessment must sign and certify the accuracy of that portion of the assessment.

Based on observation, staff interviews, and record review, the facility failed to adequately assess 1 of 1 residents reviewed for smoking to ensure adequate supervision to prevent accidents while smoking. (Resident #45) The findings include: On 11/8/23, an observation was made of Resident #45 in the designated smoking area without supervision while smoking tobacco products. No burn marks were noted on her clothing. A review of Resident #45's electronic medical record revealed no care plan for safe smoking. Further review of the electronic medical record revealed there was no safe smoker evaluation conducted by the facility for Resident #45. A review of Resident #45's admission nursing evaluation, dated 9/12/23, revealed that the resident was not a smoker at that time. On 11/8/23 at approximately 12:01 PM, an interview was conducted with the Administrator in Training (AIT) and the Regional Nurse Consultant concerning Resident #45's smoking evaluation and care plan. The AIT stated that Resident #45 did not smoke when she was first admitted to the facility, but she decided to start smoking again a few weeks later. The Regional Nurse Consultant confirmed that there was no safe smoker evaluation or a smoking care plan for Resident #45. The Regional Nurse Consultant stated that it was her expectation that, when a resident starts smoking, that the nurse on that assignment would perform the safe smoking evaluation for that resident at that time or notify the medical records nurse to complete the evaluation and for the resident's care plan to be updated for smoking. On 11/9/23 at approximately 9:30 AM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that there was no care plan for Resident #45 for smoking and stated that she would get that updated right away. The DON went on to state that all residents at the facility required supervision for smoking.