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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055047 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palms Care Center 1010 Ventura Avenue Chowchilla, CA 93610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)