Health inspection·November 29, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, interview and record review, the facility failed to maintain an environment free from accident hazards for three of three sampled residents (Resident 1, Resident 3 and Resident 4) when Residents were not educated on oxygen safety precautions. This failure resulted in Resident 1 being burned from when her oxygen tubing caught fire and had potential for Resident 3 and 4 being burnt. Findings: During a record review of Resident 1's admission Record (AR-a document with personal identifiable and medical information), dated October 11, 2023, the AR indicated Resident 1 was admitted to the facility on [DATE] diagnoses which included chronic kidney disease (condition in which kidneys are damaged and cannot filter blood as well as they should), heart failure (condition that develops when the heart does not pump enough blood for the body's needs), and chronic ulcer (an open sore) of lower leg. Resident 1 required staff assistance for activities of daily living. During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs identify cognitive (mental processes) and physical functional level assessment), dated 7/26/23, indicated, .Resident 1 ' s Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, and (13-15) cognitively intact) . During a review of Resident 1 ' s Nursing – Clinical admission Evaluation , dated 7/22/23, indicated, . Does the resident express a desire to smoke/utilize tobacco products? [NO was marked] . During an observation and concurrent interview on 10/11/23, at 10:00 a.m., with Resident 1, in her room, Resident 1 stated, fire had just started and Resident 1 denied smoking. Resident 1 stated, she did not remember what happened but saw sparks and swiped plastic from her face when she was in the bathroom. Resident 1 stated she has used oxygen for seven years. Resident 1 stated the facility did not provide education on smoking while using oxygen. Resident 1 stated, she has not seen anyone smoking at the facility. Resident 1 observed resting in bed, and short of breath while talking and wearing oxygen. Resident 1 was observed with a transparent dressing to left side of cheek and left thigh. During a record review of the fire department's investigation, titled Incident type: 111 – Building Fire, . Incident #: 2023-592 , dated 10/10/2023, the report indicated, Origin: Burn patterns Page 1 of 2 055047 055047 11/29/2023 Palms Care Center 1010 Ventura Avenue Chowchilla, CA 93610

F 0689 Level of Harm - Minimal harm or potential for actual harm are consistent with the witness statements of the origin being in the bathroom. Cause: The origin room had no obvious heat source. Nothing was plugged in to the outlet and no other electrical equipment found, however, a partially burnt material (possible joint) typically used for smoking was found in the toilet. That evidence, with the location of the burns to the resident, indicates smoking while using an oxygen supplied nasal cannula. Residents Affected - Some During an interview on 10/11/23, at 9:53 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, the facility was a no smoking facility. CNA 1 stated, if we saw smoking material, we let the nurse know and confiscate the smoking material. CNA 1 stated, if residents are new and smoking materials are in the inventory, we tell the nurse and report it immediately. During a concurrent interview and record review on 10/11/23, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 1, the records of Resident 1, Resident 3 and Resident 4 were reviewed. LVN 1 stated, the facility was a no smoking facility and Resident 1 had been in noncompliance at times. LVN 1 stated, Resident 1 had vape (a device used for inhaling) pens that had to be taken away. LVN 1 stated he could not find a record for education of not smoking/flames with oxygen use on Res 1, Res 3, and Res 4 who all used oxygen and smoke. LVN 1 stated the facility did not provide education on smoking with oxygen use. During an observation and concurrent interview on 10/11/23, at 10:31 a.m., with Resident 3, Resident 3 stated, she was shaken up by fire but feels safe now. Resident 3 stated, she had not been educated on smoking or having flames next to oxygen. Signage observed outside Resident's room indicates oxygen in use. Resident 3 observed in bed with clean clothes and no odors. During an observation and concurrent interview on 10/11/23, at 10:40 a.m., with Resident 4, Resident 4 stated, she had not been educated by the staff about safety precautions while using oxygen. Signage observed outside Resident's room indicates oxygen in use. During an interview on 10/11/23, at 10:44 a.m., with CNA 2, CNA 2 stated, when residents were using oxygen, they could not smoke as oxygen is flammable and could ignite. CNA 2 stated, no smoking was allowed at the facility and we will tell the nurse if resident was smoking. During an interview on 10/11/23, at 11:00 a.m., with the Administrator (ADM) and the Director of Nursing (DON), the ADM stated, residents who were using oxygen should be educated about the safety precautions of using oxygen and smoking. The DON stated, residents should be educated about oxygen safety precautions and if it was not charted it was not done. ADM stated, the policy indicates residents should be educated and the education documented in the chart on safety precautions of using oxygen and not smoking. The ADM and DON stated the facility did not provide education on safety precautions of using oxygen and smoking at the same time to Resident 1, 3 and 4. During a review of the facility's policy and procedure (P&P) titled Oxygen Safety, dated 2023, the P&P indicated .Staff, residents, and families will be educated on oxygen safety precautions in accordance with their roles and responsibilities related to the use and storage of oxygen . 055047 Page 2 of 2