Other·June 14, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint conducted on 3/20/17, 5/4/17, 5/8/17, and 5/16/17. For Entity Reported Incident CA00527071 regarding Accidents, a Federal deficiency was identified (see F323). A Class "AA" citation was also issued. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 10918, Health Facilities Evaluator Nurse and 26295, District Administrator.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to provide adequate supervision to prevent an accident for one of 11 sampled residents (Resident 1) when facility staff were aware of Resident 1's unsafe behavior of smoking with oxygen in use. This failure resulted in a fire with Resident 1 sustaining extensive thermal (burn) injuries and death. Findings: Review of Resident 1's record indicated she was admitted to the facility on 11/25/11 with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that causes coughing, wheezing, shortness of breath, and other symptoms) and emphysema (condition in which the air sacs of the lungs are damaged and enlarged, causing difficult breathing). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 had a physician's order dated 11/26/16 to give oxygen two liters per minute by nasal cannula (a device used to deliver supplemental oxygen placed in the nostrils). Review of Resident 1's nursing progress notes dated 3/19/17 at 2:14 p.m. (documented a day after the incident) indicated a fire started in Resident 1's room (Room A) and Resident 1 was "caught on fire." Before the fire, a certified nursing assistant (CNA A) saw Resident 1 standing in her room, not on oxygen, and she was "fiddling with hands under the table but did not smell smoke." CNA A left the room to retrieve supplies and on the way back, a visitor and Resident 1 called for help. CNA A saw Resident 1 standing and the top of her pants was on fire. After grabbing a towel and wetting it in the bathroom, CNA A saw the resident was "already covered in flames" and she "couldn't get close to the patient." During an interview on 5/4/17 at 2:45 p.m., CNA A stated she was assigned to provide care to Resident 1 on the evening of the fire. Resident 1 used oxygen constantly, she sometimes removed it and the oxygen in her room (Room A) was never turned off. She recalled about two weeks before the fire, she smelled cigarette smoke in Resident 1's room. CNA A went out of the room to get supplies and when returning heard a male visitor yelling "she needs help." She saw two nurses run into the Room A to stop the fire. CNA A proceeded to evacuate other residents and when she did not see Resident 1 outside, she went back to a bathroom joining Room A, opened the door and saw Resident 1 standing and saying "help me, help me" in a weak voice. CNA A screamed for help, ran to restorative nurses assistant (RNA) B and told him Resident 1 was still in her room. RNA B went to Room A and took Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE out of Room A. During an interview on 5/4/17 at 3:15 p.m., RNA B described Resident 1 as forgetful, frequently asking "Where's my room." and she smoked every day. On the day of the fire, RNA B entered Room A, saw a flame on one spot of the floor and discharged the fire extinguisher and stated he did not know someone was inside the room. RNA B then went out of the room holding his breath and saw a female staff holding a fire extinguisher. RNA B took the extinguisher from the staff and used it in Room A. When he stepped inside the Room A, he heard someone moaning and saw someone standing, leaning on the bedside table, and he was "presuming" the person was Resident 1. No one else was in the room. He hooked his left arm around Resident 1 and led her out of the building. During an interview on 5/4/17 at 4:30 p.m., the Minimum Data Set coordinator (MDS-C) stated he heard there was a fire, he got a fire extinguisher and went to Room A. MDS-C saw CNA A went to the bathroom to wet a towel and Resident 1 was standing, holding onto the bedside table and her lower trunk was on fire. The fire "suddenly" traveled to the resident's body, arms and legs and he discharged the fire extinguisher. There was so much smoke he could not see anything and he stepped out to rescue residents in the hallway. During an interview on 5/8/17 at 10:30 a.m., the charge nurse (CN) stated Resident 1 was confused, needed constant reminding about smoking times and designated smoking area. Resident 1 sometimes sneaked outside and smoked and needed oxygen when she returned to her room. On the day of the fire, CN was clocking in to work at 4:03 p.m. and heard someone shouted "she needs help" and a staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE member was pointing to Room A. She saw Resident 1 in "flames" to her lower abdomen and clothing. She noticed the oxygen concentrator was running and pulled out the plug. The room was full of smoke and she could not breathe so she ran out of the room thinking someone was still with Resident 1. CN saw Resident 1 being taken out of the building by RNA B. The CN stated she did not take Resident 1 out of the room because she could not breathe and if she touched the resident she would also be on fire . During an interview on 5/8/17 at 11:10 a.m., the director of staff development (DSD, staff who oversees training programs and works directly with employees to become knowledgeable and efficient) stated the facility used the "RACE" procedure for emergency response. RACE is an acronym where R represents rescue, A - alarm, C - confining the fire, and E - extinguishing and evacuation. The DSD stated she gave staff inservice training going over the RACE procedure before the fire. The DSD stated if a person was on fire, the correct procedure was to put the person on the ground and roll. She did not know Resident 1 was left alone in the fire. Review of the "DISASTER PREPAREDNESS AND FIRE PREVENTION" a PowerPoint inservice, dated 1/16/17, indicated the first two to three minutes of a fire emergency was the most crucial. Memorizing the acronym RACE could help you remember what to do if such an emergency occurred. R was for rescuing residents and the "First priority must always be to rescue resident in immediate life threatening danger." Review of the "RESPONDING TO A PERSON IN FIRE" undated lesson plan indicated if a person catches fire, to wrap them with blanket, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE get them down on the ground and if necessary use a leg, sweep, roll them on the ground until the fire is out. Review of the Sign-In Sheet dated 1/16/17 for the Disaster Preparedness and Fire Prevention inservice showed the staff involved in Resident 1's fire incident (CNA A, RNA B, MDS-C, CN and RN) had signed the sheet indicating they had attended the inservice. During an interview on 5/8/17 at 3:40 p.m., a register nurse C (RN C) stated she attended to Resident 1 on the day of the fire. Resident 1 was always smoking and someone in the past had reported the resident smoked in her room. The oxygen in Resident 1's room was always running. On the day of the fire someone was saying "ahhh", "ahhh" and RN C ran with another female staff into Resident 1's room and saw a Resident 1 on fire and she was trying to pull down her pants. The fire to her left hip was growing fast. In another second the fire "blew" and she could not extinguish the fire and she ran out of the room to find an extinguisher. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 2/10/17, indicated she had severe impairment in memory and in daily decision-making skills. Resident 1 had a cognitive loss/dementia care plan dated 3/14/13, indicating she had changes in short and long term memory recall and was moderately impaired in daily decision making skills. Review of Resident 1's nurses progress notes dated 2/17/17 at 1:52 p.m. indicated a certified nurse assistant D (CNA D) reported Resident 1 was "observed smoking a cigarette in her room." Review of Resident 1's Nursing Quarterly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Annual - Safe Smoking Evaluation form dated 8/31/16 and 2/18/17, both indicated Resident 1 was a safe smoker. The 2/18/17 form indicated "yes" to the question, "Are there any concerns about the Resident's ability to smoke independently?" and had no explanation of the smoking concern. Review of Resident 1's social services notes dated 2/21/17 at 8:15 a.m. indicated the social services director (SSD) informed Resident 1 about the smoking policy and smoking was only allowed in the designated area (outside gazebo). It indicated Resident 1 "was in agreement and signed the smoking contract." Review of a "SMOKING CONTRACT," dated 2/17/17, indicated a verbal consent was obtained by Resident 1's responsible party (RP) on 2/17/17 and signed by the administrator on 2/20/17. It indicated Resident 1 agreed to refrain from smoking in the bedroom or in the building at any time and understood smoking was a "Clear and present danger." Review of Resident 1's quarterly interdisciplinary (IDT, team members from different departments involved in a resident's care) conference note dated 2/21/17 at 1:38 p.m. indicated there was a discussion with the RP and ombudsman (an advocate who listens to and addresses the concerns of nursing home residents) about the implementation of the smoking policy and nursing was to call the RP when Resident 1 was found with a lighter. Review of Resident 1's smoking care plan dated 12/31/15, identified problem episodes of smoking in the side patio and the entrance of the facility, non-compliance with the smoking schedule and policy. The behavioral symptoms care plan dated 4/26/14, 8/7/15, and 9/4/16 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated problem behaviors such as refusing care. The behavioral and smoking care plans were not revised in identifying Resident 1's behavior of using oxygen and smoking in her room and not informing staff when given cigarettes and lighters, despite the facility staff being aware of her non-compliance. During an interview on 57/17 at 2:15 p.m., the assistant director of nurses D (ADON D) who reviewed the record stated when Resident 1 was found in her room smoking , there should have been a care plan identifying Resident 1's behavior with new approaches developed. ADON D confirmed there was no documentation supporting Resident 1 was monitored for smoking and having smoking paraphernalia (e.g. cigarettes and lighters). During an interview on 5/4/17 at 10 a.m., the administrator (ADM) described Resident 1 as forgetful and hard to redirect. In February 2017, he saw Resident 1 with an unsafe behavior of smoking outside and "reconstructed" the smoking policy. The assistant director of nurses reassessed and "passed" Resident 1 as a safe smoker and Resident 1 continued to have unsafe smoking behavior. Residents who were unsafe could not have smoking materials on them and needed supervision. During an interview on 5/4/17 at 12:50 p.m. the social services director (SSD) stated Resident 1 was very forgetful about everything, had a two-minute attention span, and smoked 10 to 15 cigarettes a day. The SSD stated Resident 1 would slowly walk outside towards the gazebo (designated smoking area), get tired halfway and smoke near a trash can. The SSD also stated friends gave Resident 1 cigarettes even though they knew they were not supposed to, they felt sorry for her. The SSD further stated when a family member did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE laundry, she found several lighters in the pockets of her clothing. The SSD stated after the fire incident, Resident 1's smoking assessment was reviewed and determined the safe smoking conclusion was a "mistake." During an interview on 5/8/17 at 12:40 a.m., the ADON C who completed Resident 1's smoking assessment on 2/18/17 stated Resident 1 was assessed as a safe smoker. Her concern of Resident 1 smoking safely was her low BIMs score (Brief Interview for Mental Status, an MDS assessment tool to evaluate a resident's decision making skills) and stated she should have but did not document her concern on the form. ADON C stated she assumed her role in January 2017 and did not know Resident 1 had been noncompliant with smoking rules. Because the resident was assessed as a safe smoker she was allowed to smoke unsupervised. Review of an acute care hospital emergency department provider notes dated 3/18/17 at 5:34 p.m. indicated Resident 1 was brought in by ambulance as major trauma for estimated 80% burns. It documented Resident 1 was smoking cigarette and the oxygen tank flashed and caused fire at the skilled nursing facility. During transport from the skilled nursing facility to the emergency room, Residnt 1 coded (absence of pulse) and died in the emergency room. Under "SECONDARY SURVERY" section, it indicated Resident 1's head had desquamation (peeling skin) and burns across face and scalp, tympanic membranes (eardrum) with scarred EAC (external auditory canal, or outer ear), large tongue, burned labia (the inner and outer folds of the vagina), and thickened skin with burns and sloughing off (dead tissue separating from living tissue) when touched over forehead, cheeks, neck, chest, back, arms, thighs, and genitals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056082 (X3) DATE SURVEY COMPLETED 05/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the county "MEDICAL EXAMINERCORONER" report dated 4/6/17, indicated the cause of Resident 1's death was extensive thermal (burn) injuries. The undated "SMOKING POLICY," indicated smoking was not allowed inside the facility. Unsafe /dangerous behavior was defined as smoking in areas that were not designated, smoking with oxygen tank in close proximity, improper extinguishing and disposal of cigarette buds, etc. For residents who demonstrate unsafe/dangerous smoking behavior, smoking was only allowed in the Gazebo and only at the designated times under the supervision of a facility staff member. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WON711 Facility ID: CA070000023 If continuation sheet 10 of 10