Broadway Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for the front lobby and utility hallway for 1 of 1 facility reviewed for accident hazards. 1. The women's restroom in the front lobby, which was open and accessible to residents, did not have grab bars, a means to call for assistance, the locking mechanism was a latch on the inside of the door, and the door was difficult to open from the inside. 2. The men's restroom in the front lobby, which was open and accessible to residents, did not have grab bars or a means to call for assistance. These deficient practices could result in physical harm to residents. Observation on 04/16/2026 at 3:35 p.m. revealed the women's restroom in the front lobby was open, unlocked, and accessible by residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 5 residents (Resident #74) reviewed for call light. Resident #74's call light was not placed within reach of her . This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 residents (Resident #7) reviewed for resident rights, in that: CNAs D and E did not completely close Resident #7's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents who received incontinent care at-risk of loss of dignity, embarrassment, and a decline in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that PRN (as needed) orders for psychotropic medications were limited to fourteen days for 1 (Resident #5) of 25 residents reviewed, in that: Resident #5's PRN order for ABH gel (Ativan/Benadryl/Haldol) was not limited to fourteen days. This deficient practice could result in residents who receive PRN psychotropic medications being administered such medications for staff convenience rather than resident need.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 of 2 residents (Resident #87) reviewed for new admissions. The facility failed to develop a baseline care plan within 48 hours of admission for Resident #87. This failure could lead to residents not receiving necessary care and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan with the participation of the resident and the resident's representative within seven days after completion of the comprehensive assessment for 1 (Resident #30) of 25 residents reviewed, in that: Resident #30's care plan conference meeting was held twenty-five days after completion of comprehensive assessment. This deficient practice could result in the needs and/or concerns of residents and their representatives being unheard and unaddressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Residents #7) reviewed for incontinent care and catheter care, in that: While providing incontinent care for Resident #7, CNA D used a back-and-forth motion to clean Resident #7. These deficient practices could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #83) reviewed for medication storage, in that: The facility failed to ensure medication Vick's (nasal decongestant) was not left on Resident #83's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 residents' refrigerators (Resident #29) reviewed. The personal refrigerator in Resident #29's room contained food items that were unlabeled and undated. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #7) reviewed for infection control, in that: 1. The facility failed to ensure CNA D changed her gloves and sanitized her hands after cleaning Resident #7 and before touching the clean brief and pad. 2. The facility failed to ensure CNAs D and E wore a gown while providing catheter care for Resident #7 who was on enhanced barrier precaution. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to ensure were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter for 4 of 7 Residents (Resident #2, Resident #3, Resident #4, Resident #5) reviewed for physician visits. The facility failed to ensure Resident #2's, Resident #3's, Resident #4's and Resident #5's were visited by their physician at least every 60 days after their 90-day admission period. This deficient practice could place residents at risk for not having an MD assessing their health status.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 7 residents (Resident #1) whose records were reviewed. LVN A failed to notify Resident 1, Resident 1's physician or NP and Resident 1's emergency contact when LVN A received a critical CO2 lab result (A CO2 blood test measures the amount of carbon dioxide in your blood, primarily in the form of bicarbonate (HCO3). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse for 1 of 7 Residents (Resident #2) whose records were reviewed for abuse. The ADM failed to report an allegation of abuse when Resident #2 threw a plastic cup at Resident #3 causing a skin tear over his left eyebrow within two hours after the allegation was made. This deficient practice could place residents at risk of further abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 7 Residents (Resident #1) whose records were reviewed. LVN A and LVN B failed to document what they did in response to Resident #1's critical lab, CO2 for value of 42, This deficient practice could place residents at risk of not having their medical records reflecting the care and services the residents received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 2 of 4 residents (Residents #1 and #2) reviewed for accidents and hazards. 1. The facility failed to ensure the environment was free of hazards to Resident #1 after the resident was hospitalized for suicidal ideation on 05/14/2025 and then on 08/14/2025 the resident attempted to self-infict an injury to her wrist with a razor. Resident #1 was discovered with a bleeding right wrist and a shaving razor on her bed on 08/14/2025 at 5:00 PM. 2. The facility failed to ensure Resident #1 was provide supervision the resident after being hospitalized for a suicidal ideation on 05/14/2025, resulting in the resident's attempt at self-injury on 08/14/2025.3. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 2 of 14 residents (Resident #8 and # 1) reviewed for care plan revisions. 1. The facility failed to ensure Resident #1's care plan was comprehensive and reflected Resident #1's history of hospitalization for suicidal ideation on 05/14/2025 and had attempted to injure herself on 08/14/2025.2. The facility failed to ensure Resident #8's care plan was comprehensive and updated to reflect Resident #8 used a geriatric chair (a large, padded chair with wheeled bases, designed to assist seniors with limited mobility) as a fall prevention. [...]

Inspectors wroteBased on interview and record review, the facility failed to convey within 30 days the resident's funds upon discharge for 1 of 3 residents (Resident #9) reviewed for personal funds. The facility failed to ensure Resident #9's personal funds were conveyed within 30 days of the resident's self-initiated discharge from the facility. This failure could result in loss of personal funds or decreased quality life to residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one resident (Resident #1) of 8 residents reviewed for abuse and neglect. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for 2 (Residents #29 and #68) of 4 D-Hall residents reviewed for dignity. The facility failed to ensure MA B and LVN C treated Residents #29 and #68 with dignity and respect when they referred to the residents' as feeders. This failure could place residents at risk for psychosocial harm due to diminished self-esteem and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment for 2 (Residents #38 and #20) of 14 residents reviewed for informed consent, in that: 1. The facility failed to ensure Resident #38's right to informed consent for treatment with the psychotropic medication Sertraline was provided. 2. The facility failed to ensure Resident #20's right to informed consent for treatment with the psychotropic medication Sertraline was provided. These failures could place residents at-risk of receiving treatment without having been informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he or she prefers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. Boxes of food were stored on the floor in the dry goods pantry. 2. Frost and ice accumulated on two boxes of food in the freezer. 3. An open container of jelly, labeled refrigerate after opening, was left out of the refrigerator. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Residents #45 and #23) reviewed for infection control, in that: 1. LVN A did not wear a gown and gloves while performing an accu-check (process of testing blood glucose level using a lancet to prick a finger to draw blood and analyze with a glucometer), and administering medication to Resident #45 who had been placed on contact isolation precaution. 2. LVN A did not wear gloves while performing an accu-check on Resident #23. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in that: The lobby area of the secure unit smelled strongly of urine. This deficient practice could result in residents living in, staff working in, and the public visiting in an unpleasant environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 1 (Resident #54) of 14 residents reviewed for advance directives. The facility failed to ensure Resident #54's desire to formulate an advance directive OOH DNR was completed and part of the record. This failure could place residents at-risk of having their end of life wishes dishonored and of having treatments that go against their personal preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 2 medication rooms (A-Hall medication room) reviewed for storage, in that: Controlled medications were not kept in a separate, permanently affixed compartment in the medication room. This deficient practice could place residents at risk of misappropriation of medications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 4 residents (Resident #4) reviewed for administration. 1. The facility failed to ensure Resident #4's EMR reflected unwitnessed falls on (2) occasions. 2. The facility failed to ensure Resident #4's EMR reflected behaviors requiring PRN medication on (2) occasions. These failures could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #1) reviewed for care plans, in that: The facility failed to develop and implement a care plan related to monitoring for side effects of Resident #1's use of Aspirin (antiplatelet/blood thinner) and Ticagrelor (anti-platelet/blood thinner). This failure could place the residents at risk for delayed interventions and decline in health.

Inspectors wroteBased on record review, interview, and observation, the facility failed to assure that menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. The facility had no existing method to inform residents of substitutions to the menu. This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 2 of 6 residents reviewed for call light (Residents #13 and #19) reviewed for reasonable accommodations, in that: 1. Resident #16's call light was behind the headboard of the resident's bed and not within the resident's reach on 02/21/2024. 2. Resident #17's call light was on the floor on the resident's room and not within the resident's reach on 02/21/2024. This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on record review and interview, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 2 of 6 staff (LVN A and CNA B) reviewed for employee misconduct screenings, in that: The facility had failed to complete an annual Employee Misconduct Registry search for LVN A and CNA B. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment, to include maintenance services necessary to maintain comfortable and safe temperature levels, for 1 of 1 facility reviewed for a safe, clean, comfortable, and homelike environment, in that: The facility presented with 2 Heating Ventilation and Air Conditioning systems [HVAC], of which 1 HVAC was not functioning causing cold interiors during the winter season. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 07:04 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the residents' environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 facility and 18 of 18 residents (Resident #1, #4 , #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67) reviewed for accident hazards and supervision, in that: 1. Residents (Resident # 1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67) were residents who resided on the facility's memory care unit and needed supervision and safety monitoring due to their diagnoses of dementia and wander / elopement risks and were without staff care and or supervision, without secured entry exit doors, and without secured windows on 11/17/2023. 2. [...]

Inspectors wroteBased on observations, interviews and record review failed to ensure facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 8 (Resident #39) residents and 1 of 1 facility, in that: 1. The facility failed to maintain and or repair the 1 of 2 Heating Ventilation Air Conditioner systems [HVAC]. 2. The facility failed to maintain and or repair the call light system. 3. The facility failed to communicate and coordinate between nursing and dietary staff which resulted in Resident #39's physician ordered House supplement was not available. 4. The facility failed to maintain and or repair the ceilings. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities, for 1 of 1 facility's reviewed for a functioning call light system for 4 of the facility's 4 halls (Halls A, B, C, and D) reviewed for resident call system, in that: The facility failed to have a functioning call light system for the census of 69 residents who resided on the facility's 4 halls, Halls A, B, C, and D. This failure could place residents at risk for injuries or neglect.

Inspectors wroteBased on interview, and record review, the facility failed to make prompt efforts to resolve any grievances the residents may have for 11 of 30 grievances reviewed in that: The facility did not provide a response or written description of any action taken after receiving written grievances. This failure could affect residents who reside in the facility for unresolved grievances in a prompt manner.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, for 2 of 20 residents (Residents #12 and 47) reviewed for injuries of unknown source, and for 1 of 1 facility HVAC system not operating in that: 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 18 of 18 residents reviewed for memory care (Residents #1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67) reviewed for memory care and nursing services, in that: 1. CNA F failed to wait her her relief, CNA U, and left her assignment resulting in the 18 residents on the memory care unit being left unattended for one hour on the morning of 11/17/2023. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. The facility error was 11.11% based on 3 errors out of 27 opportunities for 3 of 7 residents (Resident #13, #39, and #44) reviewed for medication administration: 1. LVN H administered expired insulin to Resident #39. 2. RN AW administered late medication for Resident #44. The medication was scheduled for administration any time between 08:00 AM and 10:00 AM. The medication was administered at 10:49 AM. 3. RN AW administered late medications for Resident #13. The medication was scheduled for administration any time between 08:00 AM and 10:00 AM. The medication was administered at 11:06 AM. These deficient practices placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to Maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility in that: 1. Kitchen faucets had running water that could not be turned off by kitchen staff and caused a drip of water to be on floor on one of sinks in the kitchen. 2. There were ceiling lights with missing covers, broken, and missing lights in the kitchen and in the main dining room. 3. In the Laundry Room, there were 2 out of 3 washers and 3 out of 6 dryers were not working. These failures could affect residents and could result in residents not having clothes and light.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents could request and formulate advance directives, for 1 of 8 (Resident #59) residents reviewed for formulation of advanced directives in that: Resident #59's medical record reflected conflicting physicians' orders for Resident #59's wishes for an advance directive. This failure could result in residents not having their end-of-life choices respected.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 8 (Resident #49) residents reviewed for comprehensive care plans, in that: Resident #49's comprehensive care plan did not address the resident's use of a Trapeze bar for bed mobility or the use of a seatbelt on the resident's electric wheelchair. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #65) reviewed for comprehensive care plans, in that: Resident #65's care plan was not revised to indicate significant weight loss after their Dietician Comprehensive Assessment in accordance with minimum standards. This failure could place residents at risk for not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 8 (Residents #50 and #59) residents reviewed for quality of care, in that: 1. The facility provided hospice services for Resident #50 without a physicians' order. 2. The facility supported and facilitated dialysis services for Resident #59 without a physicians' order. These failures could affect all residents with contracted services and could result with inappropriate care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 1 medication aide medication cart, reviewed for security, in that, The Medication Aide J's medication cart was unattended and unlocked. This failure placed residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observations, interviews, and record reviews the must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for safe, functional, sanitary and comfortable environment in that: The facility failed to maintain ceilings in the facility. This deficient practice placed residents at risk for harm by diminished health status and diminished self esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the availability of the most recent survey results for 1 of 1 facility reviewed for rights to survey results in that: The facility failed to place survey results in a readily accessible location where individuals wishing to examine survey results without having to ask to review them. This failure could affect residents who reside in the facility and could result in a lack of awareness for visitors, family, and residents regarding the survey results and the plan of correction submitted by the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident's had the right to be free from abuse, neglect, misappropriation of resident's property, or exploitation, for 3 of 5 residents (Residents #2, #6, and #7) reviewed for abuse, in that: 1. The facility failed to ensure CNA A did not verbally abuse Resident #2 during interactions on 9/7/2023. 2. The facility failed to ensure Resident #7 was not hit by Resident #6 while sleeping, was not sent to hospital for an MRI afterward due to headaches, hearing and vision issues. Nurse assessment and progress notes did not indicate any issues with headaches or injuries from the incident. The incident was not reported to HHSC. This failure placed the resident at risk of decreased self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #4) reviewed for misappropriation of resident property. The facility failed to ensure Resident #4 was not subject to financial misappropriation of property by CNA G. CNA G misappropriated funds using the residents debit card totaling $477.54. This failure could place residents at risk for loss of money, possessions, and the feeling of loss.

Inspectors wroteBased on observations, interview and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 2 (# 6) residents in that: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 1 of 1 facility reviewed for smoking, in that: The facility failed to ensure unknown staff or unknown residents were not smoking in a non-smoking designated area. This failure could place residents at risk for smoking-related injuries and fires in the facility.