Valley Center

Inspectors wroteBased on observation and staff interview, the facility failed to store and dispose of garbage and refuse properly. One (1) of the three (3) dumpsters located outside of the facility had one sliding door that was open. During two different observations of the kitchen during the survey process, the lid for the trash can located in the dining room was not on, and was sitting on the floor. This was a random opportunity for discovery that has the potential to affect every resident at the facility. Facility census: 122.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure a dignified experience with toileting for Resident #3, catheter care for Resident #29 and dining for Resident #17. This was true for three (3) of 39 residents reviewed during the survey process. Resident Identifiers: #3, #29, and #17. Facility Census: 122. Findings Include: a) Resident #3 An initial interview was held with Resident #3 on 03/31/2026 at 11:14 AM. Resident #3 stated, They won't take me to the bathroom .they said if I fall, I'll sue them .if someone will help me I can use the wheelchair and the bars in the bathroom .they tell me to use the brief or bed pan .I cannot have a bowel movement in a brief. One or two of the girls will take me, the rest will not. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure Resident #81, Resident #49, and Resident #51's medical power of attorney (MPOA) were contacted in a timely manner when these residents experienced a change in their condition. This was true for three (3) of three (3) residents sampled for notification of changes during the Long-Term Care Survey Process. Census: 122 Resident identifier: #81, #49, #51c) Resident #51 On 04/02/26 at 9:00 AM, an investigation into a complaint was completed. The record review for Resident #51 found a change of condition dated 03/24/26. The resident did not have medical decision-making capacity. However, upon further review the resident was notified, but the Health Care Surrogate (HCS) was not. The resident was noted with worsening lower back pain. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 17 of 71 resident rooms observed during the long-term care survey process. Rooms 119, 120, 121, 124, 125, 126, 201, 204, 205, 206, 207, 209, 210, 212, 213, and 305. Facility Census: 122.

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to develop and/or implement the care plan for Resident #3 and #29's transfer status, #7's fall precautions, #31's fractures, #96 and #87's shower preference and #46's gradual dose reduction (GDR) of psychotropic drugs. This was true for seven (7) of 39 residents reviewed during the survey process. Resident Identifiers: #3, #29, #7, #31, #96, #87, and #46. Facility Census: 122.

Inspectors wroteBased on record review, and staff interview the facility failed to ensure resident received the care and services to help them maintain and or attain their highest practicable physical, mental and psychosocial well being. For Resident #14 there was a delay in starting an ordered antibiotic. The facility did not notify the physician when the residents blood sugar was over 400 for Resident #12. For Resident #48 the facility failed to provide prompt wound evaluation and treatment. Finally for Resident #87 the facility failed to ensure basic hygiene tasks were performed to keep the resident from scratching his own skin. This was true for four (4) of 39 sampled residents. Resident Identifiers: #14, #12, #48, and #87. Facility Census: 122. b) Resident #12 On 03/06/2026 at 12:00 PM, a blood glucose fingerstick reading of 413 mg/dL was obtained. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible This was true for The Transitional Care Unit dining and 6 out of 12 sampled residents. Resident identifiers: #135, #136, #7, #17, #3, and #29. Facility Census:122 a) Resident #77 On 03/31/2026 at 3:50 PM, observation of the resident's room revealed a container of bleach cleaning wipes (Micro-Kill), identified as a white bottle with a blue lid, left unattended at the resident's bedside. The container was observed to be within reach and accessible to the resident, indicating it was not stored in a secure or supervised location. The presence of a chemical cleaning agent at the bedside created the potential for accidental exposure, ingestion, or misuse, which could result in harm to the resident. [...]

Inspectors wroteBased on food tray temperatures, resident interviews and staff interviews, the facility failed to serve food that was attractive, palatable and at a safe and appetizing temperature to prevent foodborne illness. The facility failed to ensure hot foods were served hot. This failed practice was true for three (3) of three (3) meal trays tested throughout the survey process. Residents identified: #99 and #60. Facility census: 122.

Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. The facility also failed to ensure that all employees that enter the kitchen have their hair properly restrained. This practice had the potential to affect more than a limited number of residents. Facility census: 122.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an infection control program to prevent communicable diseases during clean linen transport, during catheter care for Resident #29, North and South shower rooms, soiled linen throughout the facility, Resident #9, #42, and #46's wheelchairs as well as the facility wheelchairs and Geri-chairs throughout the facility, and an unclean and unsanitary room for Resident #7. These were random opportunities for discovery. Resident Identifiers: #29, #9, #42, #46, #39, #25 and #7. Facility Census: 122. a) Resident #7 On 03/31/2026 at approximately 2:57 PM, observation of Resident #7's room revealed two full urinals placed on the floor at the bedside. Additionally, a brown-like substance was observed on the floor in multiple locations, including near the bedside commode. [...]

Inspectors wroteBased on record view and staff interview, the facility failed to ensure informed consent was obtained for psychotropic medications. This was found true for two (2) of five (5) residents reviewed. Resident #12 and Resident #46. Facility census: 122. a) Resident #12 A record review for Resident #12 revealed a physician order for Buspirone HCl 5 mg (milligram), to be administered as one (1) tablet by mouth. Further review of the clinical record revealed no documented evidence of informed consent for the use of Buspirone. Documentation indicated the medication was initiated on 03/01/26; however, there was no evidence that informed consent had been obtained prior to initiation of the medication. This finding was confirmed with the Director of Nursing (DON) on 04/01/26 at approximately 3:45 PM.

Inspectors wroteBased on record review, staff interview and observation, the facility failed to ensure call lights were within reach for dependent residents. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #19 and #47. Facility Census: 125.

Inspectors wroteBased on record review and interview, the facility failed to honor Resident #49's bathing choices from 03/23/26 to 03/31/26. This was true of one (1) of five (5) residents sampled for choices during the Long-Term Care Survey Process. Census: 122 Resident identifier: #49Findings include: a) Resident #49 Resident #49's care plan from 02/03/26 stated the resident prefered to take a shower. The bathing task for the month of March shows Resident #49 had a shower twice per week by Nurse Aide (CNA) #15 from 03/01/26 through 03/22/26. After that date, Resident #49 only had bed baths. Further, the bathing tasks showed there were no refusals of showers during that time frame. In an interview with Resident #49 and her son on 03/31/26 at 10:02 AM, she stated she only gets showers when NA #15 is working. She further stated she had not been asked if she wanted a shower since 03/22/26. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. This was true for one (1) of five (5) residents reviewed under the Unnecessary Medications Pathway throughout the Long-Term Care Survey Process. Resident identifier: #46. Facility Census:

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the residents' current condition. This was true for two (2) of 39 residents sampled for accuracy of assessments during the Long-Term Care Survey Process. Census: 122 Resident identifier: #31, #57Findings included: A) Resident #31 A1) Section GGThe significant change Minimum Data Ser (MDS) dated [DATE] section GG, shows resident is ambulating 10 feet with supervision. A physical therapy Discharge summary dated [DATE] reveals Resident #31 was able to stand without moving in the parallel bars, but unable to take steps at that time. In an interview with Physical Therapist Assistant (PTA) #122 on 04/06/26 at 3:04PM, he stated Resident #31 has not been able to walk since the fractures occurred. [...]

Inspectors wroteBased on record review and staff interview the facility failed to coordinate with the appropriate State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs when completing/revising a Pre-admission Screening and Resident Review (PASARR). This was true for 1 of 30 residents sampled. Resident Identifier: #66. Facility census: 122. Findings Included:a) Resident #66On 04/01/26 at 11:00 AM record review found Resident #66 had the following medical diagnosis:Psychoactive Substance AbuseReview of the PASARR dated 04/01/26 found that this diagnosis was not identified on the PASARR.The above information was confirmed with The Social Worker on 04/02/26 at 10:00AM, who agreed that the additional medical diagnosis should have been on the PASARR.

Inspectors wroteBased on record review, staff interview and resident interview, the facility failed to develop a baseline care plan for a resident ordered oxygen therapy by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #29. Facility Census: 125.

Inspectors wroteBased on resident interview, staff intervew and record review, the facility failed to revise a care plan to indicate Resident #24's preference for night time care. This was true for one (1) of 39 residents reviewed during the survey process. Resident Identifier: #24. Facility Census: 122. Findings Include: a) Resident #24 On 04/06/2026 at 2:00 PM, a record review was completed for Resident #24. Also, a review of a facility-reported incident (FRI) dated 12/08/25 was reviewed. The allegation of neglect was noted in the FRI for Resident #24 regarding incontinence care at night time. The resident was interviewed on 04/06/26 at approximately 3:00 PM regarding the allegation of neglect. The resident stated, you know how it is .I don't remember that but I'm sure if I said it .it must have happened. An interview was held with the Social Services Director (SSD) on 04/06/26 at 3:00 PM. [...]

Inspectors wroteBased on observation, staff interview, and family interview, the facility failed to ensure necessary activities of daily living (ADL) care, including personal hygiene and grooming, for two (2) of eight (8) of sampled residents. This was found true for Resident #87 and Resident #96. Facility census 122.a) Resident #87 On 03/31/2026 at approximately 2:24 PM, an interview was conducted with the resident's wife, who reported observing the resident with a dirty face, neck, and hands, as well as soiled bedding. She further stated that the resident's fingernails were long and untrimmed and reported observing scratches behind the resident's right ear, which she attributed to the resident scratching. The resident's wife indicated she personally trimmed the resident's fingernails, cleaned his face and neck, and requested staff assistance to change the resident's shirt and bedding. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure access to fluids at bedside for one (1) resident, placing the resident at risk for inadequate hydration. This was found at a random opportunity for discovery. This was found true for one (1) resident. Resident identifier: #77. Facility census: 122. a) Resident #77On 03/31/2026 at 3:07 PM, observation of the resident's room revealed no water present at the bedside. At approximately 3:15 PM, the observation was reviewed with LPN #16, who confirmed that no water was present at the bedside at the time of observation. There was no evidence to indicate that fluids had been recently offered or were readily accessible to the resident. Water was subsequently provided to the resident following surveyor intervention.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an ongoing assessment of Resident #17's condition before, during and after dialysis treatment. This was true for one (1) of one (1) residents sampled for dialysis. Census: 122 Resident Identifier: #17Findings include: a) Resident #17 A policy titled Dialysis: Hemodialysis (HD)-Communication and Documentation, states following completion of the HD, the dialysis facility should complete and return the form and/or other communication to the Center with the patient. Upon return of the patient to the Center, a licensed nurse will:-Review the certified dialysis facility communication;-Evaluate/observe the patient; [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that the resident was served foods consistent with the prescribed diet order, placing the resident at risk for choking and aspiration. This was found true of two (2) of two (2) residents reviewed. Resident #110 and Resident #114. a) Resident #114During dining observation, on 3/31/26 at approximately 12:30 PM it was noted that Resident #114, who was ordered a Dysphagia Advanced (Dys Adv) diet, was served whole grapes. The facility's diet guidelines indicate that foods should be provided in an appropriate consistency for a Dysphagia Advanced diet, such as applesauce or other modified textures, to reduce the risk of choking. Through surveyor intervention, whole grapes were removed from resident access and applesauce was substituted. [...]

Inspectors wroteBased on policy, observation, and resident and staff interviews, the facility failed to provide services to ensure Resident #49's physical needs were met by failing to provide lunch to Resident #49. This was true for one (1) of 13 residents sampled for abuse during the Long-Term Care Survey Process. Census: 122 Resident Identifier: #49Findings include: A policy titled Resident Rights Under Federal Law, states Patients/Residents (hereinafter resident) have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. At 12:43PM on 04/07/26, State Surveyor went in to Resident #49's room to observe lunch. Resident #49's son was present and stated that no one had been in the room yet to offer lunch to Resident #49. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure accurate pain assessment, timely reassessment, administration of medications in accordance with physician orders, and maintenance of an accurate medical record for one (1) of four (4) resident reviewed (Resident #48). Facility census: 122. a) Resident #48On 03/31/26 at approximately 10:30 PM, surveyors observed Resident #48 in his room. During this observation, the resident verbalized, I am in pain and My legs are hurting, A review of the clinical record revealed that Nurse #13 administered Tylenol 325 mg orally at 10:24 PM. Documentation further indicated that Nurse #13 completed a pain assessment at 10:24 PM, with the resident's pain level recorded as zero (0) at that time. This documented pain level is not consistent with the resident's subsequent verbal reports of pain observed at 10:30 PM. [...]

Inspectors wroteBased on family interview, record review and staff interview, the facility failed to notify the resident's representative of two (2) significant changes for Resident #123. This was true for one (1) of one (1) residents reviewed during the survey process. Resident identifier: #123. Facility Census: 122. Findings Include: a) Resident #123 On 05/14/25 at 10:39 AM, an interview was held with Resident #123's representative. The representative stated, They (the facility) didn't call me when two (2) different incidents happened to (Resident #123). I was very upset and felt someone should have called me. On 05/14/25 at 11:35 AM, a record review was completed. The review found a physician determination of capacity dated 05/27/23, which indicated the resident lacked capacity due to Alzheimer's disease. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate MDS assessment in the area of discharge destination. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of hospitalization. Resident identifier: #117. Facility census: 124.

Inspectors wroteBased on record review and staff interview the facility failed to identify Bipolar Disorder on one (1) of three (3) Preadmission Screening and Resident Review (PASARR) reviewed during the Long Term Care Survey Process. Resident identifier: #48. Facility Census: 123. Findings Include: a) Resident #48 During record review, on 10/08/24 09:10 AM, a review of Resident #48's medical diagnoses revealed the following: - UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE -DELUSIONAL DISORDERS -BIPOLAR DISORDER, CURRENT EPISODE MIXED, MODERATE -ANXIETY DISORDER, UNSPECIFIED -MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED -UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH AGITATION Further review of Resident #48's medical record showed the PASARR completed on 08/20/24 did not identify Bipolar Disorder. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan regarding the discontinuation of an anticoagulant. This was true for one (1) of three (3) residents reviewed under the care area of hospitalizations. Resident Identifier: #74. Facility Census: 124. Findings Include: a) Resident #74 On 10/09/24 at 9:30 AM, a record review was completed for Resident #74. The review found a focus area on the care plan noted as Resident is at risk for injury or complications related to the use of anticoagulation therapy lovenox. Upon further review, the anticoagulation medication (Lovenox) was discontinued on 09/29/24. The care plan had not been revised to indicate the Lovenox had been discontinued. On 10/09/24 at 10:50 AM, the Director of Nursing (DON) confirmed the medication had been discontinued and the care plan had not been revised.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to document the refrigerator and room temperatures in the South medication room. This was a random opportunity for discovery. Facility Census: 124. Findings Include: a) South Medication Room On 10/08/24 at 10:05 AM, a tour of the South medication room was completed. During the tour, the medication refrigerator and room temperatures were not documented for the following dates: --10/01/24 AM room temperature --10/03/24 PM refrigerator temperature --10/07/24 PM room temperature --10/08/24 AM room temperature On 10/08/24 at 10:22 AM, the Director of Nursing (DON) was notified and confirmed the refrigerator and room temperatures should be documented.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain accurate and complete medical records for Resident #222. This is true for one (1) of 27 residents reviewed under the care area of advance directives. Resident identifier: #222. Facility Census: 124. Findings Include: a) Resident #222 On 10/08/24 at 8:30 AM, a record review was completed for Resident #222. The review found that the Physician's Order for Scope of Treatment (POST) was not complete. The signature of the Medical Power of Attorney (MPOA) was not dated. On 10/08/24 at 8:58 AM, the Director of Nursing (DON) was notified and confirmed the POST form was missing the date of the MPOA's signature.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program for blood glucose monitoring. This was a random opportunity for discovery. Facility Census: 124.

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure the environment was free of accident hazards. Medicated items were identified to be left out accessible to wandering residents during a complaint survey. This was determined for more than an isolated number of residents identified to be at risk for wandering in the facility. Twenty-five (25) residents were identified to have wandering tendencies. had wandergards. Census: 121.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents received treatemt and care in accordance with professional standards of pratcie, the comprehensive care plan and resident choices. Resident #49's medication was not available. Resident #33 did not receive insulin as ordree for elevated blood sugar. For Resident #125 the facility failed to ensure the residents wishes according to the Physician Orders for Scope of Treatment (POST) forms orders that were followed. The facility failed to ensure Resident #26's physician orders were followed for skin integrity and fracture stability. Advanced Directive orders did not match the POST for Resident #71 and Resident #44. Insulin administration was not documented for Resident #33. These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: [...]

Inspectors wroteBased on observation, and staff facility failed to ensure the environment was free of accident hazards. Resident #41's medication was left unattended in Resident room. A treatment cart and mediation cart were found unlocked and unattended. This failed practice was a random opportunity for discovery and had the potential affect more than a limited number of residents. Resident identifier: #41. Facility census: 129.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident Identifiers: #28 and #19. Facility census:

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure that all alleged violations involving verbal abuse were reported to the appropriate state agencies. This was true for one (1) of five (5) residents reviewed under the abuse pathway in the Long-Term Care Survey Process. Resident identifier: 95. Facility census: 129.

Inspectors wrotec) Resident 116 An observation on 04/08/24 at 1:18 PM, of Resident #116's lunch tray in front of her showed Resident #16 had not taken a bite of her food. During A record review on 04/08/24 at 3:00 PM, of Resident #116's medical record revealed the following weights: 04/5/24 8:39 AM, 80.6 P pounds (Lbs) with Mechanical Lift (ML) 03/27/24 4:18 PM, 80.8 Lbs with Wheelchair (WC) 03/20/24 5:37 PM, 82.4 Lbs with WC. 03/13/24 5:26 PM, 85.4 Lbs with WC. 03/6/24 9:06 PM, 84.4 Lbs with WC. 02/29/24 9:22 PM, 82.4 Lbs with WC. 02/19/24 3:44 PM, 84.4 Lbs with WC. 02/13/24 9:58 AM, 86.4 Lbs with WC. 01/18/24 8:29 AM, 90.0 Lbs with WC. 01/12/24 8:18 AM, 92.4 Lbs with WC. 01/3/24 9:24 AM, 94.8 Lbs with WC. 12/29/23 7:39 PM, 89.9 Lbs with ML. 12/21/23 10:49 PM, 92.4 Lbs with ML. 12/20/23 6:59 AM 92.4 Lbs admission weight. The weights equaled a 12.5% weight loss in 3.5 months. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with newly evident or a possible serious mental disorder. This was true for three (3) out of seven (7) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifiers: #49, #44, and #81. Facility census: 129.

Inspectors wroteBased on record review and staff interview the facility failed to revise the care plans for two (2) of 38 residents when their needs changed. Resident #71's care plan was not revised to reflect pain management. Additionally, the facility failed to include Resident #44's delusional disorder diagnosis in her care plan. Resident identifiers: #71 and #44. Facility census: 129.

Inspectors wroteBased on record review and staff, the facility failed to effectively evaluate pain level and effectiveness for pain medication given for two (2) of five (5) residents reviewed for pain. This failed practice had the potential to affect more than a limited number of residents. Facility census: 129 Resident identifiers: #71 and #81.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure monthly Medication Regimen Reviews (MRR) were being reviewed/signed by the attending physician. This was true for one (1) of five (5) residents reviewed in the unnecessary medication review pathway during the Long-Term Care Survey Process. Facility Census: 129. Resident identifier:

Inspectors wroteBased on resident interview, staff interview, and record review the facility failed to obtain routine and/or emergency dental services for Resident #75. This failed practice was found true for (1) one of (4) four residents during the Long-Term Care Survey Process. Resident identifier #75. Facility Census 129. Findings Include: a) Resident #75 During an interview on 04/08/24 at 2:00 PM, Resident # 75 indicated to the surveyor that she had a loose tooth. A record review on 04/10/24 at 2:08 PM revealed that Resident # 75 has an active order dated 02/07/24 for a dental referral for loose cap to upper front tooth Further record review showed no referral to the dentist had been made. During an interview on 04/10/24 at 9:30 AM, the Interim Director of Nursing (IDON) stated, I'm not going to lie to you, there is not a dental referral in (Resident #75 name's) chart. [...]

Inspectors wroteBased on observation, and staff interview the facility failed to maintain appropriate infection control procedures during medication pass for Resident #49. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #49. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan for Resident #126. This is true for one (1) of six (6) residents reviewed during the survey process. Resident Identifier: #126. Facility Census: 125. Finding Included: a) Resident #126 On 09/26/23 at 11:30 AM, a record review was completed for Resident #126. The record review found the care plan had not been developed and implemented for Resident #126. Resident #126 was admitted on [DATE] and had been sent to the emergency department on 09/07/23. The care plan had incomplete focus areas, interventions and goals in the areas of at risk for decreased ability to perform ADL(s), risk for falls, may not smoke per smoking evaluation and exhibits or is at risk for alterations in comfort. The care plan was void of any information. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure one (1) of five (5) residents had a care plan revised when a resident's advanced directive had changed. Resident identifier: #28. Facility census: 125.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure they developed an ongoing program to support residents in their choice of individual activities for (1) resident. Resident #87 was reviewed at random for activities. Resident identifier: #87. Facility census: 125.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #126's smoking status and 15 minute observations for Resident #86. This was true for two (2) of six (6) residents reviewed during the survey process. Resident Identifiers: #126 and #86. Facility Census: 125. Findings Included: a) Resident #126 On 09/26/23 at 1:45 PM, a record review was completed for Resident #126. The review found a smoking evaluation dated 08/31/23. The smoking evaluation indicated the resident was not allowed to smoke. Upon reviewing the hospital records prior to the admission to the facility, the documentation stated the resident had never smoked. The admission Minimum Data Set (MDS) dated [DATE] section J, indicated the resident did not use tobacco. [...]