**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.a. For Resident #15 (R15), the facility staff failed to assess the resident to determine if the resident could safely spend time unsupervised on the courtyard patio and failed to provide supervision and a safe environment on the courtyard patio. R15 was unsupervised and fell on the courtyard patio. The resident sustained a head injury that required hospitalization, two staples for a laceration, and a C2 (second cervical) vertebral fracture. R15's diagnoses included but were not limited to congestive heart failure, muscle wasting and atrophy, paranoid personality disorder, auditory hallucinations, and dementia. R15's comprehensive care plan dated 7/19/23 failed to document information regarding the resident spending time outside on the courtyard patio. A review of R15's clinical record revealed the resident sustained falls on 1/9/25, 2/25/25, 3/23/25, and 3/27/25. R15's Morse fall scale assessments dated 1/9/25, 2/25/25, 3/23/25, and 3/27/25 documented the resident was at a high risk for falling. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/21/25, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. An activities note dated 1/31/25 documented, Resident at 11:30 today, the housekeeping director noticed that resident was trying to access the outside looking for a 'cat'. The director went outside for him to check and confirmed there was no cat. He then explains that every nursing home has a cat. Residents' cognitive health seems to be altered. Continues to try to leave to the patio in inappropriate clothing for the weather. A physical therapy progress note dated 4/27/25 documented, Remaining Impairments: strength impairments, decreased dynamic balance, balance deficits and decreased functional capacity. A nurse's note dated 4/30/25 documented, Resident Observed laying on ground outside in Paddio [sic]/Back yard. Upon skin assessment noted blood on head 0.5cm (centimeter) x 0.01cm to scalp. assisted resident off the ground with 3 persons to assist. and back to the room. Assessed resident no other injury noted. Physician notified with new order to send resident to ED (Emergency Department) for evaluation secondary to resident currently on Eliquis (a blood thinning medication). Scanty blood noted to scalp. Family POA (Power of Attorney) notified (name). Hospital documentation dated 4/30/25 revealed R15 sustained a fractured second cervical vertebra and a head laceration to the scalp that required two staples. R15 was re-admitted to the facility on [DATE]. Further review of R15's clinical record (including physical therapy documentation, nursing assessments, physician/nurse practitioner notes, and nurses' notes for 1/31/25 through 5/11/25) failed to reveal the facility staff assessed R15 to determine if the resident could safely spend time unsupervised on the courtyard patio and failed to reveal the facility staff implemented interventions to ensure the resident was supervised while going outside. On 5/13/25 at 4:17 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the physical therapy staff complete assessments to determine if residents can safely go out to the patio unsupervised and there was no nursing assessment. LPN #2 stated R15 resides on the second floor and has a wander guard device so if the resident attempted to get on the elevator and go to the first floor, an alarm would sound when he attempted to get on the elevator. On 5/13/25 at 5:15 p.m., an observation of R15 was conducted. No wander guard was observed on the resident's body or wheelchair. Also, a review of R15's clinical record failed to reveal documentation regarding a wander guard. On 5/13/25 at 5:02 p.m., an interview was conducted with OSM (other staff member) #4 (a physical therapist who treated R15). OSM #4 stated R15's cognition and safety awareness was poor. OSM #4 stated she educated R15 that he needed to wait for someone to help him with transfers and obtaining items from the ground and he would not wait. OSM #4 stated R15 does not listen to staff education and is going to do what he wants to do. OSM #4 stated R15 has got to lift his bottom up when transferring or will fall, the resident has a history of falling, and the resident scoots out of the wheelchair. OSM #4 stated residents are not routinely assessed by therapy staff to determine if they can safely spend time on the courtyard patio unsupervised unless a resident says he or she wants to go outside or going outside aligns with their rehab goals. OSM #4 stated she did not think R15 was assessed to determine if he was safe while outside and unsupervised. On 5/14/25 at 7:53 a.m., an observation of R15 was conducted. No wander guard was observed on the resident's body or wheelchair. On 5/14/25 at 8:15 a.m., an observation of the courtyard patio was conducted. The patio was located on the first floor approximately 12 feet from the elevator. The patio door was unalarmed and accessible by opening the door. The following was observed on the patio: -pebbled pavers -multiple tables, chairs, benches, and wooden garden beds -a covered swing -a rectangular metal propane grill with two 20-pound propane tanks -a triangular corner waterfall rock pond (approximately 16 feet [base] by seven feet [corner] by seven feet [corner]); a rail was observed spanning across the base edge of the pond but there was open space (approximately three feet) between the rail and the ground. On 5/14/25 at 8:20 a.m., ASM (administrative staff member) #1 (the administrator) provided a list that documented R15 (and another resident) independently used the courtyard. ASM #1 stated this list was generated based on talking with staff. On 5/14/25 at 8:31 a.m., an interview was conducted with OSM (other staff member) #12 (an anonymous staff member). OSM #12 stated R15 used to go outside to the courtyard patio almost daily and stated the resident said he was leaving food for cats and dogs. OSM #12 stated that at times, the resident was supervised during activities but at other times, the resident was unsupervised. On 5/14/25 at 8:47 a.m., another interview was conducted with OSM #4. OSM #4 stated R15 was non-compliant with rehab recommendations and education. OSM #4 stated she was not aware R15 had been going outside on the courtyard patio and had not been evaluated. On 5/14/25 at 9:07 a.m., an interview was conducted with LPN #4. LPN #4 stated R15 is, always all over the place and always sneaks around. LPN #4 stated sometimes R15 went outside on the patio and sometimes R15 went outside the front entrance but the last time she was aware of the resident going outside was when the resident fell on the patio. LPN #4 stated R15 was currently physically capable of wheeling himself outside to the patio. On 5/14/25 at 11:25 a.m., another interview was conducted with LPN #2. LPN #2 stated she mistakenly spoke when she said R15 had a wander guard, and the resident did not have a wander guard. LPN #2 stated she was the nurse caring for R15 on 4/30/25. LPN #2 stated that on that date, another nurse brought R15 upstairs and said the resident had fallen on the courtyard patio and hit his head on the grill. LPN #2 stated she assessed R15, and the resident was alert and moving all extremities but there was blood coming from his head. LPN #2 stated the nurse practitioner ordered for R15 to be transferred to the hospital because the resident was prescribed a blood thinning medication. On 5/14/25 at 12:37 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were notified of IJ (Immediate Jeopardy). The facility presented the following IJ removal plan which was accepted on 5/14/25 at 9:31 p.m. 1. Director of Nursing will instruct resident that he is unable to access the courtyard alone as of 5/14/25. Resident #15 is currently on therapy caseload for improving strength, functional mobility, transfers, gait, endurance, utilizing a reacher & self care. He is currently independent in his wheelchair. Morse Fall Scale and BIMs was completed 5/14/25. Nursing staff that work that unit have been educated to not allow resident to use courtyard without supervision on 5/14/25. A staff member will be posted at the door of the patio 24 hours a day until a locking system can be installed on the courtyard door. 2. Other residents using the courtyard independently could be affected by this practice. List of residents using courtyard independently has been generated as of 5/14/25. 3. The Director of Nursing or designee will educate all staff that resident is unable to access the courtyard alone as of 5/14/25. All staff are being re-educated on ensuring residents requesting to use courtyard without supervision have been assessed by therapy for independence outdoors and will not be allowed to work until re-educated. If therapy is unable to assess a resident who desires to go into the courtyard, the resident will not be able to enter the courtyard alone until the assessment is complete. This assessment will be completed within 3 business days. Should the therapy assessment deem a resident unsafe in the courtyard, the resident will not be allowed to be in the courtyard unsupervised and this will be reflected on their plan of care and in a progress note. Facility staff or family/visitor for that resident will provide supervision. 4. Therapy will screen all new admissions for their ability to go outside independently for the next 6 weeks. Current residents will be screened quarterly for their ability to go outside independently. A list of residents who require supervision to be in the courtyard will be placed on each unit and the receptionist desk. Any resident attempting to enter the courtyard without supervision will be redirected. 5. AOC: 5/14/25 Time: 11:59pm On 5/14/25 at 7:45 p.m., an interview was conducted with OSM #3 (a physical therapist who treated R15). OSM #3 stated residents who present with a fall risk and decreased safety awareness are not safe when unsupervised outside because there is more of a chance for falls and risk of hospitalization. OSM #3 stated R15 had not been assessed for being outside in the courtyard patio unsupervised because staff knows the resident is not safe out there. OSM #3 stated there is a downhill slope at the entrance to the patio and now construction is being completed. OSM #3 stated R15 is safe as long as he doesn't transfer himself without assistance, but the resident does. On 5/15/25 at 9:52 a.m., an interview was conducted with OSM #2 (an occupational therapist). OSM #2 stated there are many components to determine if a resident can safely go out into the courtyard such as managing the door, inclines, declines, coordinating around the area, and cognition. On 5/15/25 the survey team, through observations, interviews, and documentation review, verified the removal plan had been fully implemented by the facility. On 5/15/25 at 12:39 p.m., ASM #1 was informed that the abatement plan was verified. On 5/16/25 at 8:55 a.m., ASM #1 was informed the IJ had been abated. On 5/20/25 at 9:43 a.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who observed R15 on the ground in the courtyard patio on 4/30/25). LPN #3 stated that on 4/30/25, he was inside the building on the first floor and a family member came to him and asked him to go to the courtyard patio. LPN #3 stated he went out to the patio and found R15 laying in front of his wheelchair with his right elbow and legs on the ground, and his head facing the grill. LPN #3 stated that by looking at R15's position and the injury on the resident's head, it looked like R15 hit his head on the grill. LPN #3 stated R15 had two bananas and a shovel, and the resident stated he wanted to plant the bananas in the ground. On 5/20/25 at 11:25 a.m., an interview was conducted with ASM #1. ASM #1 stated a comprehensive assessment including residents' functional and cognitive abilities should be completed to determine if a resident can safely go out on the courtyard patio unsupervised. On 5/20/25 at 1:58 p.m., ASM #1 presented a form titled, Outdoor Safety Screening Tool that was developed after Immediate Jeopardy. The form documented, Trigger Questions: BIMs score (BIMs to be completed same day as screen). If BIMs score is 12 or below, resident is supervised outdoors and remainder of tool does not need to be completed. The facility policy titled, Accidents and Supervision documented, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary .1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources may include, but are not limited to: i. Quality assessment and assurance (QAA) activities. ii. Environmental rounds. iii. MDS/CAA (minimum data set/care area assessment) data. iv. Medical history. v. Physical exam. iv. Facility assessment. vii. Individual observation. e. This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff. b. Assigning responsibility. c. Providing training as needed. d. Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident). e. Ensuring that the interventions are put into action. f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. h. Facility-based interventions may include, but are not limited to: i. Educating staff. ii. Repairing the device/equipment. iii. Developing or revising policies and procedures. i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care. ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions. 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed. d. Evaluating the effectiveness of new interventions. 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment. 2.b. For Resident #15 (R15), the facility staff failed to maintain a safe environment in the resident's bedroom. A can of Krylon [NAME] aerosol varnish spray was observed in the resident's room. On 5/14/25 at 10:00 a.m., a can of Krylon [NAME] aerosol varnish spray was observed on a table in R15's room. The material safety data sheet for Krylon [NAME] dated 3/13/15 documented, OSHA/HCS status: This material is considered hazardous by the OSHA Hazard Communication Standard. Signal word Hazard statements: Danger Extremely flammable aerosol. Contains gas under pressure; may explode if heated. Causes skin and eye irritation. Suspected of causing cancer. May be fatal if swallowed and enters airways. May cause respiratory irritation. May cause drowsiness and dizziness. On 5/19/25 at 3:49 p.m., the Krylon [NAME] material safety data sheet was reviewed with LPN (licensed practical nurse) #8. LPN #8 stated the substance was flammable, hazardous and carcinogenic and with those properties, the substance should not be in a resident room because the resident may use it. LPN #8 stated she notifies a supervisor or manager if she finds an unsafe substance in a resident's room. On 5/20/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Accidents and Supervision documented, The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. No further information was presented prior to exit. Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide a safe environment for a census of 97 residents on 12/21/24 and failed to provide supervision to prevent accidents for 2 of 31 residents in the survey sample, Resident #23 and #15. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 3, isolated. The findings include: 1. The facility staff failed to A) provide a safe environment for a census of 97 residents on 12/21/24 and B) notify the fire department of a fire that occurred in the enclosed patio area at the facility on 12/21/24. On 12/21/24, Resident #23 (R23), a resident with known history of unsupervised smoking, threw a lit cigarette into the trash can in the enclosed patio area resulting in a fire which cracked the glass on the patio entrance door. A) On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/17/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On the quarterly MDS assessment with an ARD of 11/17/24, the resident scored 13 out of 15 on the BIMS assessment, indicating the resident was cognitively intact for making daily decisions. On 5/14/25 at 9:52 a.m., an interview was conducted with R23 in their room. When asked about smoking, R23 stated that they were a current smoker and smoked 1-2 times a day outside of the facility and had last smoked on 5/13/25. R23 stated that the facility did not allow smoking on the property, but he was allowed to go off the property and smoke and described taking the elevator downstairs to the basement, going out the loading dock doors and outside to a cigarette disposal receptacle located off the property. R23 stated that they kept their cigarettes and lighter in the closet where their clothes were, but an unknown nurse had taken them away on 5/13/25 and did not tell him why. When asked about the fire on 12/21/24, R23 stated that he remembered the incident. R23 stated that someone did not put out a cigarette and had put it in the trash can which caught fire on the patio. When asked about the wander guard monitor, R23 stated that staff had placed a monitor on him a while ago but he had taken it off and thrown it away. No wander guard monitor was observed on R23's person or on R23's wheelchair. The progress notes for R23 documented in part, - Effective Date: 10/08/2024 19:54 (7:54 p.m.) Type: Medical Visit . History: 40 pack history of tobacco use; currently smokes 1/4 ppd (pack per day). H/o (history of) of ETOH (alcohol) abuse in the past . Current Tobacco Use. -40 pack year history, - Cont (continue) Nicoderm, -Counsel on cessation . - 11/24/2024 03:22 (3:22 a.m.) Note Text: Nicoderm CQ Transdermal Patch 24 Hour (Nicotine) Apply 1 patch transdermally one time a day for tobacco abuse and remove per schedule. Pharmacy. Active: 10/8/2024 08:00. Resident who wears a transdermal nicotine patch has been going downstairs to the first floor and outdoors smoking. The supervisor told the resident several times that smoking isn't allowed on the premises and that he shouldn't be smoking. Writer re-enforced the information regarding smoking to the resident. - 12/21/2024 21:54 Note Text: Resident went to the patio to smoke even though he knows that the facility is a smoke free area. Resident put the lighter [sic] cigarette in the trash can and the trash can caught on fire. Fire extenguisher [sic] used to put the fire out. The glass door at the enterance [sic] of the patio is craked [sic] due to the heat from the fire. The resident admitted to putting the lighted cigarette in the trash can. Resident talked to about the dangers of smoking. 1 pack of cigarette [sic] and 2 lighters were taken from the resident for safe keeping. Will monitor closely. A sigh [sic] was placed on the door to prevent people from using the door. The nursing admission assessment for R23 dated 10/7/24 documented the resident being a current smoker, smoking 1-2 cigarettes per day. The assessment documented R23 requiring supervision when smoking and documented, Resident is smoker last time was before his admission to the hospital on [DATE] . The assessment further documented R23 was not an elopement risk. A smoking assessment for R23 dated 12/21/24 documented the resident being a current smoker, smoking 5-10 cigarettes per day. The assessment documented, .The resident is not safe to smoke. This is a smoke-free facility; [Name of R23] has disregarded our non-smoking policy. He put his cigarette in the patio trash can while it was still lit. The trash can caught fire. Luckily, staff was able to extinguish the fire swiftly. Resident is not able to smoke unsupervised. Our facility remains smoke free . The physician orders documented in part, Order Date: 4/3/2025. Special equipment: wander guard on at all times. Check placement and function every shift for monitoring right ankle. An elopement risk assessment dated [DATE] documented R23 being at risk to wander with a previous history of wandering and history of elopement. The comprehensive care plan for R23 documented in part, MD order for wander guard. Date Initiated: 04/03/2025 . The care plan failed to evidence documentation regarding R23's smoking status or smoking non-compliance. The clinical record failed to evidence documentation regarding rationale for the wander guard placement on 4/3/25, or checks of the wander guard from 4/3/25 to the present. The clinical record failed to evidence interventions put into place to prevent hazards from unsupervised smoking for the resident after they were first aware of the resident smoking at the facility. On 5/14/25 at 10:11 a.m., an observation was made of the facility loading dock area and parking lot area. Double doors opened to the loading dock area with a ramp area that opened to the parking lot. Approximately 100 yards across the paved parking lot a standing smoking receptacle was observed at the edge of the adjoining hospital property parking lot. On 5/14/25 at 9:58 a.m., an interview was conducted with CNA (certified nursing assistant) #8 who stated that staff had taken R23's smoking materials last year and they were kept at the nurse's station. On 5/14/25 at 10:05 a.m., an interview was conducted with LPN (licensed practical nurse) #2. When asked where R23's smoking materials were kept, LPN #2 stated that they were kept in a cabinet behind the desk at the nurse's station. When asked to see the location that they were stored, LPN #2 went to a cabinet located inside of the nurse's station and stated that they were not there. She stated that someone must have removed them because that was where they were. When asked about the smoking process at the facility, LPN #2 stated that they did not allow smoking and R23 was not allowed to smoke. She stated that last year was the last time she knew he was smoking as far as she knew. On 5/14/25 at 11:13 a.m., a follow up interview was conducted with LPN #2 who stated that last year R23's family had brought him cigarettes and a lighter and he had been caught smoking on the patio. She stated that time, the manager had called the family and told them that smoking was not allowed and not to give him any smoking materials. LPN #2 stated that R23 had been receiving a nicotine patch daily since coming to the facility to help him not smoke and he was not supposed to leave their floor but there were times when he tried to leave, and they redirected him. LPN #2 stated that R23 could leave the unit if they did not watch him, and they did not allow him to leave the unit because the last time he went outside he almost burned the place, and they did not know who brought the things to him. She stated that R23 was reliable, and she thought he knew if something happened but may have some short-term memory loss. When asked what staff did to keep R23 from going off the unit to smoke, LPN #2 stated that they provided snacks and drinks and explained to R23 about why he should not leave the unit. She stated that she explained to him about the Nicoderm patch and encouraged him and then he was fine. LPN #2 stated that she did not remove any smoking materials from R23 yesterday and it may have been another nurse. She stated that R23's wander guard was placed when they caught him smoking outside and the monitor would beep when he got near the elevator. She stated that R23 had tried to take the wander guard off the wheelchair in the past or left the wheelchair and tried to walk down without any assistance. She stated that when she worked with him she saw patterns and knew what he was trying to do so she would intervene. LPN #2 stated that R23 would say he was going to use the bathroom by the elevator because his was locked and they would have to stop him because he wanted to smoke. She stated that she did not have eyes on him for the entire shift, but the other staff watched him also and they relied on the wander guard to alert them if R23 was attempting to leave the unit. On 5/14/25 at 1:15 p.m., an interview was conducted with OSM #14, anonymous staff member, who stated that staff observed R23 outside smoking in the patio area about a week before the fire on 12/21/24 and it was reported to the former director of nursing in the stand-up meeting. OSM #14 stated that staff were watching R23 more closely now, but it was possible for him to go out because there were not always staff in the basement area to monitor who was coming down there, the doors were normally not locked, and the cameras down there had not worked for a long time. On 5/14/25 at 1:21 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that she was in front of the elevator on the first floor when she saw a bright light and turned and saw the fire in a trash can in the interior patio area. She stated that she ran out and moved R23 inside and got another staff member to get the fire extinguisher. She stated that the staff member put the fire out and she assessed R23, took the cigarettes and lighter and locked them in the medication cart. RN #1 stated that R23 told her that he did not know that the cigarette was still lit when he threw it in the trash can in the courtyard. She stated that she told R23 that it was a non-smoking facility, and the fire was out but could have been something else. RN #1 stated that she had seen R23 about 10 minutes prior to the incident when he told her that he was going to the bathroom downstairs. She stated that she had reported the fire to the former director of nursing who stated that she did not need to call the fire department because they had extinguished the fire. On 5/14/25 at 1:40 p.m., an interview was conducted with OSM #11, social worker. OSM #11 stated that when R23 was caught smoking and had caused the fire she was asked to speak with him about smoking. She stated that she talked to him and his family who felt that he should be able to smoke. OSM #11 stated that she had started looking for another facility that allowed smoking, but they had not been able to find any placement as of now but were still actively looking. She stated that R23's family had mentioned their dad had seen employees smoking and she had explained that they could not control hospital employees off their property and their dad should not be out far enough to see them. She stated that staff were aware that at one point he was going outside to the hospital property to smoke prior to the incident and it was probably in November 2024. She stated that since 12/24 she was not aware of him going out and she thought that he may have had stuff hidden in his room but was not aware of anyone removing anything yesterday. OSM #11 stated that she believed the daughters were bringing him the smoking materials but was not sure, as one daughter had admitted it in the past but not currently. She stated that R23 did not leave the unit that she knew of because her office was by the elevator. OSM #11 stated that when she was in her office she saw him go to the bathroom in the sunroom and he had a wander guard on and the elevator alarm would have sounded if he had gone on the elevator. She stated that she has never smelled smoke in the bathroom. OSM #11 stated that she recalled nursing reporting R23 had been caught out in the back of the facility smoking in morning stand up meeting, but nothing had happened. She stated that they always knew R23 was smoking, and the report was probably mid November 2024. OSM #11 stated that this was based on her emails with the family that discuss his care plan. She stated that she remembered that one of the night nurses had caught him outside smoking, and she thought that it was the former unit manager who had reported it in the meeting. On 5/14/25 at 5:49 p.m., an interview was conducted with OSM #16, former director of nursing. OSM #16 stated that R23 started sneaking out of the building soon after admission to smoke and they had spoken with him and his family about it being a non-smoking facility. She stated that they had attempted to find R23 a smoking facility and he had agreed not to smoke until he moved but they had reports that his family still took him out to smoke. On 5/16/25 at 9:30 a.m., an interview was conducted with OSM #11, anonymous staff member. OSM #11 stated that they had never witn[TRUNCATED]