Health inspection·April 14, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 a safe and hazard free environment for one of 9 sampled residents (Resident 1) by failing to: 1) Implement its Policy and Procedure (P&P) titled, Smoking Policy which indicated, no cigarette/tobacco products were allowed to be kept in the possession of the residents. 2) Review, update and document a quarterly Smoking Evaluation for the resident. 3) Ensure Resident 1's smoking Care Plan had current and accurate interventions. These failures had the potential to endanger the health and safety of residents, staff and visitors. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included nicotine dependence (a chronic condition characterized by a compulsive and uncontrollable urge to use tobacco products containing nicotine, despite negative consequences), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and chest pain. During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool) dated 3/16/2025, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and had clear understanding. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with upper and lower body dressing and was independent with eating. During a review of Resident 1's Smoking Evaluation dated 11/05/2024, the Evaluation indicated Resident 1 liked to smoke in the morning, afternoon, evening, and smoked 6 times a day. The Smoking Evaluation indicated Resident 1 was educated on safe smoking practices and able to locate the designated smoking area. During a review of Resident 1's Medical Records, the Records did not indicate Resident 1's Smoking Evaluation was completed reviewed and updated at least quarterly. During a review of Resident 1's smoking care plan dated 3/10/2025, the care plan indicated Resident 1 has a potential for injury related to smoking. The care plan goal indicated Resident 1 would have (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: 056267 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 056267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camino Healthcare 13922 Cerise Avenue Hawthorne, CA 90250 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)