Health inspection·November 13, 2025

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 provide a safe environment that allow residents who wish to smoke, the opportunity to do so with optimal safety of themselves and others for two of eight sampled residents (Residents 4 and 5) according to the facility's policy and procedure (P&P) titled, Smoking by Residents, by failing to: Ensure Activities Assistant (AA) 1 provided adequate supervision (oversight, encouragement, or cueing) while Residents 4 and 5 were smoking on 11/13/2025 at 1 pm. As a result of this failure, AA 1 did not visualize Residents 4 and 5 smoking at the smoking patio. This failure placed Residents 4 and 5's safety at risk and had the potential for the residents to sustain cigarette burns (an injury to the skin's tissues caused by heat) and being harmful to themselves, each other, and being susceptible to abuse. Findings: a. During a Review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 2/25/2025 and was readmitted on [DATE] with diagnoses including peripheral vascular disease (PVD- poor blood flow to the legs and arms because the blood vessels are narrowed or blocked and lack of coordination (uncoordinated movement due to muscle control that causes an inability to coordinate movements). During a review of Resident 4's untitled Care Plan (CP) initiated on 4/4/2025, the CP indicated Resident 4 was at risk for hazards/injury (burn) related to smoking cigarettes. The CP goal indicated Resident 4 will not experience injuries associated with smoking daily. The CP interventions indicated Resident 4 would be provided by staff with precautionary measures and supervision during smoking schedule if possible. During a review of Resident 4's Smoking and Safety- V1 Assessment (SSA) dated 6/3/2025, timed at 11:01 pm, the SSA indicated Resident 4 had balance problems while sitting or standing (during smoking). The SSA indicated Resident 5 used tobacco products. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 8/29/2025, the MDS indicated Resident 4 had intact cognition (ability to think, reason, and function). The MDS indicated Resident 4 needed setup or clean-up assistance (helper sets up or cleans up while the resident completes the activity and helper assists only prior to or following the activity) with personal hygiene and upper body dressing. During a review of Resident 4's Order Summary Report (OSR) dated 11/13/2025, the OSR indicated Resident 4 did not have an order for smoking cigarettes. b. During a Review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 6/15/2012 and was readmitted on [DATE] with diagnoses including PVD, muscle wasting and atrophy (thinning of muscle mass) and nicotine (an addictive chemical found in tobacco plants and cigarettes) dependence ( a chronic addiction driven by a drug's effect on the brain which creates feelings of satisfaction). During a review of Resident 5's untitled CP initiated on 8/18/2024, the CP indicated Resident 5 was at risk for hazards/injury (burn, device explosion) related to smoking cigarettes and vaping (e-cigarette- an electronic device that heats up a liquid and turns it into a mist when inhaled). The CP goal indicated Resident 5 would not experience injuries associated with smoking/vaping daily. The CP interventions indicated Resident 5 Page 1 of 2 056431 056431 11/13/2025 Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would be provided by staff with precautionary measures and supervision during smoking schedule if possible. During a review of Resident 5's OSR dated 12/1/2024, the OSR indicated Resident 5 may smoke at the designated area per facility protocol. During a review of Resident 5's SSA dated 8/3/2025, timed at 1:35 pm, the SSA indicated Resident 5 followed the facility's policy on location and time of smoking. The SSA indicated Resident 5 used tobacco products. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had intact cognition. The MDS indicated Resident 5 needed partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with personal hygiene, upper and lower body dressing, showering/bathing self, toileting hygiene, and putting on/taking off footwear. During a concurrent observation and interview on 11/13/2025 at 1:04 pm, with Activities Assistant (AA) 1, AA 1 was sitting next to the door of the smoking patio. AA 1 was observed sitting to the right of the door along the wall. AA 1 was not looking out the door at the residents who were smoking on the patio. AA 1 was facing the wall that was perpendicular to the door. Residents 4 and 5 were on the other side of the wall from where AA 1 was sitting, in the smoking patio. AA 1 stated Residents 4 and 5 were let out onto the patio to have a cigarette at 1 pm. AA 1 stated AA 1 was monitoring residents smoking from 1 pm to 1:30 pm. AA 1 stated AA 1 could not see the two residents (Residents 4 and 5) smoking from where AA 1 was sitting. AA 1 stated the importance of watching the residents from the doors' window was to ensure residents' safety and prevent the possibility of burning themselves or an altercation with one another. During an interview on 11/13/2025 at 3:13 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated residents were not allowed to smoke on the patio unsupervised for safety reasons. LVN 1 stated residents could burn themselves with the lighter or cigarette, potentially needing medical attention. LVN 1 stated without proper supervision, there could be altercations or abuse between residents. During an interview on 11/13/2025 at 3:58 pm with the Director of Nursing (DON), the DON stated staff must maintain visual contact with all residents during smoking activities as the residents require supervision and monitoring. The DON states, continuous monitoring was necessary to prevent situations such as altercations between residents, falls, burns, or potential fires. During a review of the facility's P&P titled, Smoking by Residents, dated 9/2018, the P&P indicated, As identified by the SSA, residents who require assistance and/ or monitoring for smoking safety are not allowed to smoke unaccompanied/unsupervised. 056431 Page 2 of 2