Health inspection·December 16, 2021

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to support one (Resident 120) of 12 sampled residents in the development of a person-centered care plan which incorporated his cultural preferences when the facility failed to honor Resident 120's request for a male certified nursing assistant (CNA) to help him with his personal hygiene in accordance with his religious beliefs. This failure resulted in Resident 120 not receiving a shower for three weeks which made him feel angry and frustrated. Findings: A review of Resident 120's Face Sheet, undated, indicated Resident 120 was admitted with a diagnosis of generalized muscle weakness. A review of Resident 120's MDS dated [DATE] indicated Resident 120 felt it was very important for him to be able to choose his type of bathing: a tub bath, shower, bed bath, or sponge bath. A review of Resident 120's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 11/13/21, indicated Resident 120 had a score of 15 on the Brief Interview for Mental Status exam. (BIMS is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 15 was totally dependent on one person for assistance with bathing and required extensive physical assistance from one person for personal hygiene (shaving, combing hair, washing/drying face, and hands, brushing teeth). A review of the facility's shower schedule on 12/16/21 at 1:00 p.m., indicated Resident 120 was scheduled for a shower on the evening shift on Monday and Thursday. During an observation and concurrent interview on 12/15/21 at 9:00 a.m., Resident 120 lay awake in bed, with the head of the bed elevated. Resident 120 was unshaven and had flaky skin on his face and arms. Resident 120 stated he had asked multiple times for a male CNA so he could shower. Resident 120 stated he had refused showers in the past because a male CNA was not available to help him. Resident 120 stated his religious beliefs prohibited him from having someone of the opposite sex assist him with showering. Resident 120 stated he had last showered on 11/11/21, three weeks ago, and his skin was now itchy. Resident 120 stated it was frustrating to not have the assistance of a male CNA so that he could shower. Page 1 of 14 056422 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 120's Point of Care History for 11/1/21 to 12/14/21 indicated Resident 120 received only one shower on 11/11/21. During an interview on 12/15/21 at 3:53 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she had taken care of Resident 120 many times. CNA 2 stated Resident 120 did not allow her to wash or powder his groin. CNA 2 stated when she offered a shower, Resident 120 would sometimes accept initially, but would then refuse before transport to the shower room. CNA 2 stated Resident 120 had expressed his preference for a male CNA for his personal care, and CNA 2 had told the licensed nurses of Resident 120's preference. CNA 2 stated she had noticed Resident 120's frustration when he could not have male CNAs for his personal care. During an interview and concurrent record review on 12/15/21 at 12:25 p.m., with the Unit Manager (UM), Resident 120's care plans were reviewed. The UM stated Resident 120 did not have a care plan which incorporated his preference for a male CNA for showers. The UM stated she was unaware of Resident 120 had a preference for a male CNA for shower assistance because of his religious beliefs. 056422 Page 2 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to provide a functional bathroom sink for the use of one (Resident 8) of 12 sampled residents. Residents Affected - Some This failure resulted in Resident 8 being unable to maximize her independent performance of activities of daily living (ADL, activities such as eating, dressing, personal hygiene, locomotion). Findings: A review of Resident 8's Minimum Data Set (MDS, an assessment tool used to guide care) dated 10/5/2021, indicated Resident 8 was able to make herself understood and could understand others. The MDS indicated needed limited assistance from one person for personal hygiene (brushing teeth, washing/drying face and hands). The MDS indicated Resident 8 was able to walk in her room with a walker or wheelchair, with only supervision and setup help needed. During an observation on 12/13/2021, at 12:38 p.m., in Resident 8's shared bathroom, the bathroom sink contained a piece of brown paper on top of a pile linen. The words, Do not use were written on the brown paper. During an interview on 12/14/2021, at 10:00 a.m., in Resident 8's room, Resident 8 stated her bathroom sink had been broken for two to three days, so she had not been able to use the sink as usual. Resident 8 stated she had to brush her teeth at the bedside, and spit into a cup. Resident 8 stated she had not been able to wash her hands but had to clean her hands with a moist towelette. Resident 8 stated it had bothered her when the sink was out of order. During an observation on 12/14/2021, at 11:35 a.m., Resident 8 used a walker (an assistive device for locomotion) in her room. During an interview and concurrent record review on 12/14/2021, at 11:40 a.m., with the Maintenance Director, the Maintenance Log was reviewed. MD stated the maintenance log did not reflect Resident 8's sink had been inoperable. MD stated maintenance issues were either written in the maintenance log or relayed verbally. MD stated he did not know who had repaired the sink or when the sink was repaired. During an interview on 12/15/2021, at 12:05 PM, with the Administrator (ADM), the ADM stated the malfunctioning sink had been noticed on the morning of 12/13/2021, and repaired on the afternoon of 12/13/2021. The ADM was unable to provide documentation for how long the sink had been out of order. 056422 Page 3 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and document review, the facility failed to transmit the completed annual assessments for three residents (Residents 21, 25, and 26), and failed to transmit the quarterly assessments for 19 residents of 26 residents (Residents 6, 16, 11, 7, 17, 14, 29, 19, 8, 18, 28, 13, 9, 15, 23, 24, 10, 22, 12) within required timeframes. Residents Affected - Some This failure resulted in lack of monitoring of quality measures and resident status with a potential for inadequate care plan revision and care provision. Findings: A review of the facility Resident Assessment task, received 12/16/21 from Licensed Vocational Nurse 2 (LVN 2), indicated 23 residents (Residents 21, 25, 26, 6, 16, 11, 7, 20, 17, 14, 29, 19, 8, 18, 28, 13, 9, 15, 23, 24, 10, 22, 12) had the transmission of Minimum Data Set (MDS, an assessment used to plan care) information overdue for more than 35 days from the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all responses to MDS coding items) when: Resident 6 had an ARD of 9/26/21, with an MDS transmitted date of 12/14/21. Resident 16 had an ARD of 10/6/21, with no MDS transmitted date. Resident 11 had an ARD of 10/5/21, with an MDS transmitted date of 12/14/21. Resident 7 had an ARD of 9/29/21, with an MDS transmitted date of 12/14/21. Resident 17 had an ARD of 10/27/21, with no MDS transmitted date. Resident 14 had an ARD of 10/5/21, with no MDS transmitted date. Resident 29 had an ARD of 10/24/21, with no MDS transmitted date. Resident 19 had an ARD of 10/17/21, no MDS transmitted date. Resident 8 had an ARD of 10/5/21, with an MDS transmitted date of 12/14/21. Resident 21 had an ARD of 10/25/21, with an MDS transmitted date of 12/15/21. Resident 18 had an ARD of 10/12/21, with no MDS transmitted date. Resident 28 had an ARD of 10/20/21, with no MDS transmitted date. Resident 26 had an ARD of 10/15/21, with an MDS transmitted date of 12/15/21. Resident 13 had an ARD of 10/5/21, with no MDS transmitted date. Resident 9 had an ARD of 9/23/21, with an MDS transmitted date of 12/14/21. 056422 Page 4 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0640 Resident 15 had an ARD of 10/6/21, with no MDS transmitted date. Level of Harm - Minimal harm or potential for actual harm Resident 23 had an ARD of 10/26/21, with no MDS transmitted date. Resident 25 had an ARD of 10/15/21, with an MDS transmitted date of 12/14/21. Residents Affected - Some Resident 24 had an ARD of 10/28/21, with no MDS transmitted date. Resident 10 had an ARD of 10/5/21, with no MDS transmitted date. Resident 22 had an ARD of 10/25/21, with no MDS transmitted date. Resident 12 had an ARD of 10/5/21, with no MDS transmitted date. During an interview on 12/15/2021 at 2:10 p.m., with the Administrator (ADM), the ADM stated the facility was currently looking for an MDS Coordinator, as the facility had not had a full-time MDS coordinator since September 2020. The ADM stated the facility had been relying on nursing staff to assist with the MDS assessments, and the prior MDS coordinator (RN 1/MDSC), who worked one or two days a week, to transmit the completed MDS assessments. During an interview on 12/15/21, at 2:10 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated he had started assisting the facility with completion of MDS assessments yesterday. LVN 2 stated there was a backlog of assessments since the MDS coordinator had stopped working full time in September. LVN 2 stated he did not have the qualifications to verify the completion and transmission of the MDS assessments. During an interview on 12/15/21 at 3:30 p.m., with the Director of Nursing (DON), the DON stated RN 1/MDSC was the only person in the facility trained to do transmission of completed MDS assessments. A review of the document titled, RAI-OBRA (Resident Assessment Instrument-Omnibus Budget Reconciliation Act) Required Assessment Summary, dated 10/2019, the document indicated a facility had 14 calendar days to complete the Annual and Quarterly MDS assessments from the assessment reference dates. A review of the CMS RAI Version 3.0 Manual, the OBRA-required comprehensive assessment, dated (submitted and accepted into the QIES ASAP system) electronically no later than 14 calendar days after 056422 Page 5 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice to assess and treat itchy rashes on the feet of one (Resident 13) of 12 sampled residents. Residents Affected - Few This failure resulted in Resident 13 having physical and mental discomfort from intense itching and scratching her feet to the point of causing breaks in the skin and had the potential to result in a foot infection due to Resident 13's increased risk of foot infection from having diabetes mellitus. (Diabetes mellitus is a chronic condition resulting in increased blood sugar levels.) Findings: A review of Resident 13's Face Sheet, undated, indicated Resident 13 was re-admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A review of Resident 13's Physician Order Report dated 11/16/21 - 12/16/21, indicated an order to update weekly skin sheets on Thursday's, with a start date of 12/8/21. During an observation and concurrent interview on 12/13/21 at 12:37 p.m., with Licensed Vocational Nurse 1 (LVN), in Resident 13's room, Resident 13 had pink, clustered rashes on the top part of both feet and in between her toes. Resident 13's feet also had scratch marks, some red, some scabbed. LVN 1 stated Resident 13 had returned from the hospital on [DATE] with rashes and multiple scratches and scabs on both legs and her feet. LVN 1 stated Resident 13 had been scratching her legs and feet, so staff had applied A & D ointment to the areas. During an interview and concurrent record review with Unit Manager (UM) on 12/16/21 at 9:56 a.m., Resident 13's 12/2/21 re-admission records, weekly skin sheets, and physician orders were reviewed. UM stated there was no documentation of Resident 13's of the rashes on Resident 13's feet in the re-admission records. UM stated there were no orders to monitor the rashes on Resident 13's feet, no treatments ordered for the rashes, and no weekly skin assessments. During an observation and concurrent interview with UM and Resident 13 on 12/16/21 at 10:08 a.m., UM stated she was aware of the scratches and scabs on Resident 13's legs but had not known about the rashes and scratches on Resident 13's feet. Resident 13 stated the itch was intense and felt like flea bites. UM stated Resident 13 had not received any medication for treatment of the itchiness. During an interview on 12/16/21 at 10:13 a.m., with Treatment Nurse (TN), TN stated he had not known Resident 13 had rashes on her feet but would call the physician to request a treatment order for the rashes. A review of the Center for Disease Control and Prevention article, Diabetes and your Feet, dated 5/7/21, indicated, About half of all people with diabetes have some kind of nerve damage. You can have nerve damage in any part of your body, but nerves in your feet and legs are most often affected. Nerve damage can cause you to lose feeling in your feet. Nerve damage, along with poor blood flow-another diabetes complication-puts you at risk for developing a foot ulcer (a sore or wound) that could get infected and not heal well. If an infection doesn't get better with treatment, your toe, foot, or part of your leg may need to be amputated (removed by surgery) to prevent the infection from spreading and to save your life. When you check your feet every day, you can catch problems early and get 056422 Page 6 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0687 them treated right away. Early treatment greatly reduces your risk of amputation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056422 Page 7 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to keep the environment free from accident hazards when: Residents Affected - Some 1. The facility hallways' flooring from room [ROOM NUMBER] to room [ROOM NUMBER] was warped and had adhesive tape applied to the warped flooring. This failure created a tripping hazard for 29 of 29 residents who could ambulate. 2. One (Resident 119) of two sampled residents who smoked, stored smoking materials (cigarettes and lighter) on his person. This failure had the potential to result in physical injury to Resident 119 or other residents. Findings: 1. A review of the facility, Resident Census and Conditions of Residents, dated 12/13/21, indicated the facility had one resident who was independently ambulatory, and 28 residents who were ambulatory with assistance or the aid of an assistive device. During an observation on 12/13/21, at 12:30 p.m., in the hallways from room [ROOM NUMBER] to room [ROOM NUMBER], the flooring was warped and uplifted. The uplifted sections of flooring had red tape applied to the surfaces. During a concurrent observation and interview on 12/15/21, at 1:30 p.m., with Maintenance Director (MD), of the flooring in the hallway of rooms 31 to 38, MD stated the flooring was warped, and the red tape was used to keep the flooring from any more uplifting. MD stated the red tape was a tripping hazard. During an observation on 12/16/21, at 10:25 a.m., Resident 237 walked in the hallway from the direction of room [ROOM NUMBER] toward room [ROOM NUMBER], using a walker (a device used to stabilize persons with poor balance or mobility) with the assistance of Occupational Therapist (OT). Resident 237 looked down at the floor, hesitated, and muttered to himself, as he started to step onto an area with red tape on the floor. During an interview on 12/16/21, at 11:14 p.m., with OT, OT stated the flooring between room [ROOM NUMBER] to room [ROOM NUMBER] had been warped and taped down for several months. OT stated the uneven flooring required the residents to lift their legs higher when they walked, and if they were not able to do so, they could only walk in the physical therapy room. During an interview on 12/16/21, at 11:45 p.m., with Resident 127, Resident 127 stated he had been doing physical therapy in the hallway with his walker and had almost tripped on the flooring and red tape in the hallway. A review of the facility Safety Committee Minutes dated 8/26/21, indicated, Regional Project Manager Notified of floor issues in the hallway . 2. A review of Resident 119's Face Sheet, undated, indicated Resident 119 was admitted to the facility in November 2021 with difficulty walking. 056422 Page 8 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 119's Safe Smoking Assessment/Evaluation dated 11/3/21, indicated Resident 119 was a safe smoker who needed supervision to smoke independently. A review of Resident 119's Independent Smoker Contract dated 11/3/21, indicated, I will store my lighting materials per the facility policy and the IDT's [Interdisciplinary Team] decision (at the nurse's station). The Contract was signed with Resident 119's name in the area labeled Resident Signature, with a date of 11/3/21. During an interview on 12/14/21 at 11:17 a.m., inside the facility, with Resident 119, Resident 119 stated he kept his cigarettes and lighter in his pocket. During an observation and concurrent interview on 12/14/21 at 11:28 a.m., with Unit Manager (UM), UM stated all smoking materials were supposed to be kept at the nurses' station or inside the medication cart. UM left the interview for a few minutes, and then returned and stated she had spoken with Resident 119 and verified Resident 119 had his lighter and cigarettes on his person. Review of the facility's policy titled, Smoking, revised May 2020, indicated, A Safe Smoking Assessment is going to be completed to ensure safety of residents who may smoke and residents other than smokers. The purpose of the smoking safety assessment is to: identify risk factors indicating the resident's ability to smoke safely, develop a plan of care that promotes safety for the resident who smokes Residents, regardless of Safe Smoking Assessment result, will need to keep smoking materials in the nurses' station. 056422 Page 9 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post daily staffing information in a prominent place readily accessible to residents and visitors. Residents Affected - Some This failure had the potential to result in the lack of information for residents and family about facility's staffing. Findings: During an observation and concurrent interview with Director of Staff Development (DSD) on 12/16/21 at 11:21 a.m., DSD stated staffing information was recorded and kept in a binder at the nurses station. DSD went to the nurses station and took a binder from an overhead cabinet inside the nurses' station, and stated this was the binder for the staffing information. 056422 Page 10 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when: Residents Affected - Some 1. Refrigerator #1 had: a. An opened bag of English muffins and an opened bottle of soy sauce were not labeled with opened-on dates. b. An open tub on the top shelf, collected water leaking from a rusted evaporator. c. The bottom shelf had a box of raw, unwashed cabbage. On top of the box of cabbage was a tray of ready-to-serve sliced pies. Adjacent to the box of cabbage and stacked sliced pies was an opened carton of thawing, raw, chicken leg quarters. 2. Refrigerator# 5 had: a. Rusty interior walls. b. An opened bottle of soy sauce was not labeled with an opened-on date. 3. Multiple plate covers and bases (a two-piece container of a cover and base designed to enclose a meal plate during transportation to and from a resident) had peeling layers of a surface film. 4. The ice machine air filter had a thick build-up of grayish white fluffy substances. The interior of the ice machine drain pan had a white slimy substance and scattered brownish grime. These failures had the potential to result in food-borne illness for residents. Findings: During an initial kitchen observation on 12/13/21 at 11:19 a.m., with Director of Food and Nutrition Services (DFNS) and Registered Dietary Nutritionist (RDN) the following was observed: 1. Inside refrigerator/freezer #1: a. An opened bag of English muffins was not labeled with an opened-on date. During a concurrent interview, DFNS could not say when the bag of English muffins had been opened. b. There was an open tub on the top shelf, collecting water leaking from a rusted evaporator. During an interview with Dietary Aide (DA) on 12/13/21 at 11:35 a.m., DA stated Refrigerator/freezer #1 had been leaking for two weeks. and the Maintenance Director (MD) had been informed of the leak. c. The bottom shelf had a box of raw, unwashed cabbage. On top of the box of cabbage was a tray of 056422 Page 11 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ready-to-serve sliced pies. Adjacent to the box of cabbage and stacked sliced pies was an opened carton of thawing, raw, chicken leg quarters. During a concurrent interview on 12/13/21 at 11:19 a.m., with DA, DA stated the box of chicken leg quarters was delivered on 12/9/21, and had been placed into the refrigerator, in its original carton packaging, directly from the delivery truck. A review of the facility's Safe Refrigerator Storage, undated, posted on the refrigerators indicated raw poultry such as chicken, turkey, and duck, should be stored on the bottom shelf, and ready-to-eat, fully cooked food items should be stored on the top shelf. A review of the facility's, Food Service Policy and Procedures Manual, Sanitation and Infection Control, Refrigerated Storage, 2018, indicated, Fresh fruits and vegetables should be washed and stored in designated bins or containers in a designated area of the refrigerator Leftover food or unused portions of packaged foods should be covered, labeled and dated to assure they will be used first All frozen uncooked meat, poultry and fish should be placed on the bottom shelf for proper thawing, with pull by date and used by date. All meat and perishable food, e.g. pudding, milkshakes, juices, etc. placed in the refrigerator for thawing must be labeled and re-dated with the date the item was transferred to the refrigerator, with pull by date and used by date. 2. Inside Refrigerator# 5: a. The interior walls were rusty. b. An opened bottle of soy sauce was not labeled with an opened-on date. 3. During an observation and concurrent interview on 12/15/21 at 11:21 a.m., with DFNS in the kitchen, multiple plate serving covers and bases had peeling layers of a surface film. DFNS stated she did not know if the sanitizing level of the plate covers were affected by the peeling layer. During an observation and concurrent interview on 12/13/21 at 11:48 a.m., with DA, DA stated the facility used chlorine sanitizer for dishwashing and that both dishware and plate bases should be sanitized. A review of the U.S. Food and Drug Administration, Food Code 2017, indicated, 4-101.11 Characteristics. Materials that are used in the construction of utensils and foodcontact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: P (A) Safe; P (B) Durable, corrosion-resistant and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated 113 warewashing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition .4-101.19 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. 4. During an observation and concurrent interview with Maintenance Director (MD) on 12/14/21 at 12:38 p.m., MD stated, there was only one ice machine in the facility and was located outside the kitchen hallway. MD confirmed the ice machine's drip pan contained white slimy substances and scattered brownish grime. 056422 Page 12 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0812 Level of Harm - Minimal harm or potential for actual harm A review of the U.S. Food and Drug Administration, Food Code 2017, indicated, 4-204.120 Equipment Compartments, Drainage. Equipment compartments that are subject to accumulation of moisture due to conditions such as condensation, food or beverage drip, or water from melting ice shall be sloped to an outlet that allows complete draining. Residents Affected - Some 056422 Page 13 of 14 056422 12/16/2021 Fremont Healthcare Center 39022 Presidio Way Fremont, CA 94538

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for one (Resident 119) of two residents who smoked, the facility failed to complete a smoking care plan. Residents Affected - Few This failure had the potential to result in unsafe smoking practices which resulted in injury to residents or property. Findings: A review of Resident 119's Face Sheet, undated, indicated Resident 119 was admitted to the facility in November 2021 with difficulty walking. A review of Resident 119's Safe Smoking Assessment/Evaluation dated 11/3/21, indicated Resident 119 was a safe smoker who needed supervision to smoke independently. The assessment indicated Resident 119 would have a care plan to indicate what degree of supervision was needed, what protective devices were needed, and where smoking materials would be stored. During an interview and concurrent record review on 12/14/21 at 11:30 a.m., with Director of Nursing (DON), Resident 119's care plans were reviewed. DON was unable to provide a care plan for Resident 119's smoking. DON stated the facility policy was for smokers to have a care plan for smoking. A review of the facility's policy titled, Smoking, revised May 2020, indicated, A Safe Smoking Assessment is going to be completed to ensure safety of residents who may smoke and residents other than smokers. The purpose of the smoking safety assessment is to: identify risk factors indicating the resident's ability to smoke safely, develop a plan of care that promotes safety for the resident who smokes All residents that desire to exercise the privilege to smoke will be assessed to determine their smoking safety awareness.Care plans will be then be developed based on the assessment and findings . 056422 Page 14 of 14