Health inspection·June 27, 2025

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. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents while smoking for one of four sampled residents (Resident 2). Residents Affected - Few This failure had the potential for residents to suffer significant injuries. During an observation on 5/30/25 at 8:35 a.m. while walking up to the front entrance of the facility, Resident 2 was observed lying in the street after sustaining a fall from his wheelchair after going off the curb of the sidewalk while alone in the front of the facility to smoke a cigarette. The surveyor walked into the facility to look for staff to get assistance but was unable to locate any staff members. The surveyor walked down the hall to the nurse's station and alerted Charge Nurse (CN) of Resident 2 lying in the street next to his wheelchair. Observed multiple staff running out of the facility to assist the resident back into his wheelchair and assess Resident 2 for injuries. Followed staff outside to the front of the facility to observe. Resident 2 was yelling at staff to leave him alone and not to call an ambulance as Resident 2 stated, I am not going to the hospital. Resident 2 was found to have 2 packs of cigarettes and a lighter in his possession. During an interview on 5/30/25 at 8:45 a.m. with Resident 2, Resident 2 stated he went out at the front to smoke. Resident 2 stated he keeps his own cigarettes in his room and goes outside to smoke whenever he wants to. Resident 2 stated he does not use the facilities smoking area and does not wear that stupid bib. Resident 2 stated that nobody watches him when he smokes. During a review of Resident 2's Medical Record (MR), the MR indicated, Resident 2 had a past medical history of Alcohol Abuse, Unspecified Dementia, Alcoholic Cirrhosis of the Liver without Ascites (a condition where the liver is scarred due to excessive alcohol consumption, but fluid buildup in the abdomen (ascites) is not present), Bipolar Disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels), Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that cause long-term breathing problems), Malignant Neoplasm of Prostate with urinary catheter for bladder obstruction, absence of right great toe and other right toes, and difficulty in ambulation (walking). Resident 2 had a BIMS score of 8 (Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well a person is functioning cognitively at the moment. Score of 8 to 12 indicates Moderate cognitive impairment). During a concurrent interview and record review on 5/30/25 at 10:10 a.m. with Director of Nurses (DON), DON stated Resident 2 fell on 5/28/25 without sustaining any injuries. DON stated the fall was similar to the one this morning [5/30/25] where Resident 2 went out in front of the facility to smoke and fell out of his wheelchair. The DON stated the smoking assessment is done at time of admission and indicated that Resident 2 should be supervised when he smokes. Review of Interdisciplinary Team Page 1 of 2 055861 055861 06/27/2025 Ojai Health & Rehabilitation 601 North Montgomery Street Ojai, CA 93023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (IDT) meeting notes dated 5/28/25 with DON, DON stated, Resident 2 consistently refuses to wear flame retardant smoking apron. IDT meeting notes indicated, Plan of Care: Continue to supervise all smoking sessions as per facility policy. DON stated that Resident 2 should be supervised when he smokes but he has not been. During a record review of Resident 2's Smoking Observation Assessment, dated 2/5/25, the Assessment indicated, in part, Resident 2 is a smoker. Resident does not have cognitive impairment. Resident does not have visual impairment. Smoking adaptive equipment needed: smoking apron. Level of assistance: Supervision required IDT Decision: May smoke with supervision. During a review of facility's policy and procedure (P&P) titled, Smoking Policy-Residents dated October 2023, the P&P indicated in part, The resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. Residents are not allowed to keep smoking items, including cigarettes, tobacco, etc. except under direct supervision. 055861 Page 2 of 2