Health inspection·June 17, 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 implement smoking precaution, by not providing a smoking apron (worn while smoking to help decrease incidents of burning self), to one of four residents (Resident 1) while smoking cigarette at the facility patio. This failure had the potential for Resident 1 to sustain burn injuries while smoking a cigarette. Findings: On May 9, 2025, at 10:30 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On May 9, 2025, at 10:50 a.m., during an observation of residents smoking on the patio, the Activity Assistant (AA) was observed taking the smoking apron and placing the apron to Resident 1 who was almost done smoking his cigarette. The AA stated she forgot to put the smoking apron to the resident (Resident 1). On May 9, 2025, at 10:53 a.m., during an interview, the AA stated she was on the patio to supervise the residents smoking. The AA stated, when residents smoke, she would hand out the cigarettes and an apron to those who are required to wear them, then light their cigarettes. The AA stated the resident (Resident 1) is blind, and the resident should wear an apron to prevent burns. The AA verified Resident 1 was not wearing a smoking apron, while smoking because she forgot to hand him (Resident 1) one. On May 9, 2025, at 10:57 a.m., during an interview, Resident 1 stated he is supposed to wear an apron when smoking, and to return the apron back to the staff when done. The resident verified he was not wearing a smoking apron when he was smoking. On May 9, 2025, at 11:32 a.m., during an interview, the Activities Director (AD) stated nursing staff would complete a smoking assessment on all smokers, and from this assessment, it would be determined if a resident is required to wear a smoking apron for safety. The AD stated the activity staff would monitor smoke breaks, and ensure residents are wearing their smoking apron, prior to lighting their cigarettes. The AD stated she would expect the staff to ensure residents are wearing their smoking aprons while smoking. A review of Resident 1 ' s admission record dated, May 9, 2025, indicated the resident was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease Page 1 of 2 056428 056428 06/17/2025 California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

F 0689 (COPD-a group of lung diseases that make it difficult to breath), and legal blindness. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1 Brief Interview of Mental Status (BIMS- a cognitive assessment) indicated a score of 12, which meant moderate cognitive impairment. Residents Affected - Few A review of Resident 1 ' s, Smoking and Safety, assessment dated [DATE], indicated, . Poor vision or blindness . Care Planning: Tobacco Use; Intervention: Utilize smoking apron . A review of Resident 1 ' s, Care Plan, titled, Tobacco use, dated, February 25, 2025, indicated, . Resident needs supervision during smoking schedule with the use of apron due to total blindness . On May 9, 2025, at 3:30 p.m., during an interview, the Director of Nursing (DON) stated a staff member has to supervise residents while smoking in the patio. The DON stated Resident 1 should have a smoking apron prior to staff lighting his cigarette for safety. The DON verified that Resident 1 was not wearing the smoking apron while smoking at the patio. The DON stated the AA knew the smoking policy and that the resident (Resident 1) should have a smoking apron when smoking. A review of the facility Policy & Procedure (P&P) titled, Smoking Residents, revised, July 27, 2023, indicated, . Procedure: 2. Smoking by residents is allowed outside the facility in designated, marked smoking areas with the following safety measures readily available . d. Fire-retardant blanket (Smoking blanket) . 6. Using the Resident Smoking Assessment, the licensed Nurse will assess residents who express a desire to smoke, upon admission, quarterly, annually and upon significant change of condition, and present it to the interdisciplinary Team (IDT) for review . 056428 Page 2 of 2