Health inspection·January 10, 2025

Sunnyvale Gardens Post Acute F689 The following reflects the findings of the California Department of Public Health during an abbreviated survey. Event ID: VFGK11 Representing the Department, HFEN # 49345 State Citation A was written. REGULATORY VIOLATION(S): Code of Federal Regulations, Title 42, §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, § 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/21/24, an unannounced visit was conducted at the facility for an abbreviated survey. The facility failed: 1) To implement and inform all residents of their Smoking Policy upon admission. Census during the survey on 11/21/24, was 127. 2) To ensure a safe environment free from accidents when one (Resident 1) out of six sampled residents suffered burns from an electronic cigarette (e-cigarette, a cigarette-shaped battery-operated device that contains nicotine, flavorings, and other chemicals that create an aerosol that is inhaled into the lungs, used to simulate the experience of smoking tobacco) explosion. These failures resulted in: (1) first degree facial burns (a burn that affects the outer layer of skin); (2) intubation (inserting a tube into the patient's airway to help them breathe, administer medication, or remove blockages); and (3) hospitalization for Resident 1. This failure had the potential to result in serious injury to all the residents in the facility. On 11/22/24, at 3:27 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator (ADMIN) and Director of Nursing (DON) due to the facility's failure to implement and inform all residents of their smoking policy upon admission (Census was 127 on 11/21/24) and failure to provide a safe environment and supervise Resident 1 who used an E-Cigarette while connected to an Oxygen Concentrator via Nasal Cannula in her room, resulting in fire on Resident 1's hair and burns on her nose and face, the nasal cannula burnt open, Resident 1's face blackened, and her bottom lip bleeding. Resident 1 was sent via 911 to the hospital. On 11/22/24, at 4:32 p.m., an IJ removal plan (IJRP) with a completion date of 11/26/24, was submitted but not accepted. On 11/25/24, a revised IJRP was submitted with a completion date of 11/25/24. On 11/26/24, a visit was done to the facility to review the implementation of this revised IJ Removal Plan. The IJ was lifted on 11/26/24, at 4:08 pm. The acceptable IJRP with completion date of 11/25/24, included the following corrective actions: Resident 1 was transferred to the hospital on 11/19/2024 for further evaluation and treatment as indicated. Resident's attending physician and emergency contact were notified of the incident. The resident is still currently in the hospital. Resident 2 was provided emotional support and re-assurance of the facility staff in relation to the incident. Resident was offered psychology consult which she declined on 11/20/24. Resident 2 currently feels safe and has not brought up concerns to the facility staff. Residents 3, 4, & 5 have now been notified of the no smoking policy and a copy of the policy is available to the residents. All residents have the potential to be affected because of the use of oxygen at the facility. The facility leadership reviewed and observed all the residents on oxygen and all residents with history of smoking and found no other safety concerns such as smoking inside the room or other parts of the facility. All residents will be informed of the facility's non-smoking policy and will be educated on the complication of oxygen use and smoking (whether real cigarettes, e-cigarettes, or vapes) with signed confirmation which has been initiated and will be completed by November 25, 2024. The Director of Nursing (DON), Director of Development (DSD) or designee will in-service all staff on the facility Smoking Policy to promote resident and staff safety. The Director of Nursing (DON), Administrator or designee will in-service all Admission Department on informing new admissions of the facility's non-smoking policy including the imminent risks of smoking while using oxygen or near oxygen products. To ensure ongoing compliance, the interdisciplinary team {IDT) will conduct at least a weekly review of the removal plan on ensuring residents' safety and will verify that new admissions were informed of the facility's Non-Smoking policy and were educated on the complication of smoking while using oxygen in the weekly IDT meetings. Any concerns will be discussed by the Administrator or designee for immediate resolution. The IDT will also review daily in the IDT meeting on weekdays if there are new patients with history of smoking and/or new patients that require oxygen use and verify that proper evaluation and safety interventions have been initiated. Moreover, the Administrator, Director of Nursing (DON) or designee will audit compliance in ensuring safety of residents including informing all new patients of the Non-Smoking policy and education on the complication of smoking while using oxygen or near oxygen products. This audit will be done weekly for 4 weeks, then monthly for 6 months beginning the week of November 25, 2024, and ending the month of June 2025. Any concerns or issues will be discussed in the daily stand-up meeting for immediate resolution and/or re-assessment by the interdisciplinary team. The Administrator or DON will provide a written quality assurance report that includes evaluation of the effectiveness of the plan of correction in the quarterly QAPI meeting for 6 months using pertinent compliance audit information and resolutions from November 2024 through the end of June 2025. The corrective actions have been initiated and will be completed by November 25, 2024. An extended survey was conducted on 11/27/24. FINDINGS: During an observation and walk through in the facility on 11/21/24, at 9:00 a.m., surveyor 1. observed signs by the doors of all Residents[TU1][RY2] on oxygen stating, "No smoking Oxygen in Use." During a concurrent observation and interview on 11/21/24, at 2:57 p.m., Resident 3, who was lying on his bed with a nasal cannula connected to an oxygen concentrator (a medical device that extracts oxygen from the surrounding air), stated he was not informed that smoking is prohibited in the facility upon admission. During an interview on 11/21/24, at 2:58 p.m., Resident 4 stated he was not informed of smoking policy upon admission. During an interview on 11/22/24, at 11:45 a.m., Resident 6 stated that she was not told that smoking is not allowed in the facility upon admission. During an interview and concurrent review with the DON on 11/21/24, at 2:02 p.m., the DON stated the facility does not admit active smokers and in February 2024, when the new management took over the facility, there was only one active smoker, Resident 5, who was grandfathered (exempted individual that existed before a new policy was implemented) by the facility. The DON verified that Resident 5 had an assessment, care plan and order for smoking. The DON also stated that Resident 5 was not in the facility and was currently in the hospital since 11/20/24 for other reasons. The DON further stated residents were informed of facility's smoking policy upon admission. During this continued concurrent interview with the DON, the surveyor reviewed the Admission packet of Resident 1 with the DON, during which the DON verified there was no signed "acknowledgement of the facility's smoking policy" in Resident 1's admission packet. On 11/21/24, the Facility's Sample Admission Packet was reviewed by the surveyor, and it did not include any 'smoking policy acknowledgement form' to be signed by newly admitted residents. During an interview with the DON 11/22/24, at 3:02 p.m., the DON was asked why the 'smoking policy acknowledgement form' was not found with or included in a new resident's Admission Packet. The DON stated that the Admission Packet is based on regulations. The DON further verified there was no separate "smoking policy acknowledgement form" included in the Admission Packet. 2. The clinical records of Resident 1 were reviewed. Resident 1 was admitted on 3/22/2024, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, group of lung diseases that make it difficult to breathe and worsen over time); bronchiectasis (a condition in which the lungs' airways become damaged, making it hard to clear mucus), abnormal gait and mobility, muscle weakness, major depressive disorder (a serious mood disorder that affects how a person feels, thinks, and acts); anxiety disorder (a condition that causes excessive fear, worry, dread, and uneasiness that can interfere with daily life); and hypertension (pressure of blood in your blood vessels is consistently too high). Review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment to test a person's cognition level) dated 9/27/2024, Resident 1's score was 15, meaning she was cognitively intact [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 1's Nurse Practitioner's (NP, a nurse who has advanced clinical education and training) progress notes dated 10/23/24 indicated, "...Past Medical History...former smoker." A review of Resident 1's Physician Orders indicated an order for "Oxygen at 3 liters/minute via nasal cannula [a small flexible tube with two prongs that fit inside the nostrils]" dated 3/25/24. A review of Resident 1's "Social History Assessment" dated 9/24/24, and timed 4:42 p.m., indicated, "...Other Social History...7. Recreational Drug Use: Does the resident use of the following? ... b. Cigarettes/E-Cigarettes..." A review of Resident 1's clinical record indicated that Resident 1 had a "Smoking Observation/Assessment" dated on 3/23/24, 6/28/24, 10/31/24, and 11/4/24. All four assessments indicated, "1. Safe smoking assessment: 2. Resident denies smoking or use of all tobacco products." A review of Resident 1's Nurse's Notes dated 11/4/24, at 10:56 a.m. indicated, "Nicotine Patch 24 Hour 14 mg [milligram, unit of measurement]/ hr. [hour] Apply 1 patch transdermally [on the skin] one time a day for smoking cessation [stopping of] for 2 weeks and remove per schedule order received from MD [medical doctor] ..." During an observation upon entry to the facility on 11/21/24, the Administrator (ADM) presented "No Smoking While on Oxygen" Acknowledgement forms signed by 18 out of 19 residents who were on oxygen, and all were dated 11/20/24 (day after the accident). Resident 1 had not signed this form since she was sent out on 11/19/24 after the explosion incident. During an interview on 11/21/24, at 11:46 a.m., with Resident 1's roommate, Resident 2, Resident 2 stated that on 11/19/24, she heard an explosion and looked at Resident 1's side of the room and saw flames. Resident 2 also stated she felt scared and stressed. During an interview on 11/21/24, at 12:22 p.m., with Licensed Vocational Nurse (LVN) B, LVN B stated that Resident 1 was scheduled to be given a nicotine patch in the morning and Resident 1 liked to have it on. LVN B stated during the incident, she ran to the room, and she was instructed to call 911 (emergency number). LVN B also stated after calling 911 on 11/19/24, when she entered Resident 1's room a broken electronic cigarette was found on the floor and Resident 1 was saying she was in pain. During a concurrent interview and record review on 11/21/24, at 2:02 p.m. with the Director of Nursing (DON), the DON stated residents were informed of the facility's smoking policy upon admission and it is in the admission packet. The DON also reviewed Resident 1's admission packet, and verified there was no signed acknowledgement of the facility's smoking policy on Resident 1's admission packet. During an interview on 11/21/24, at 2:45 p.m. with the Social Services Director (SSD), SSD stated that after the explosion in Resident 1's room on 11/19/24, they saw a slim electronic cigarette in the room, and it had a black tip and a gray body. SSD also stated they should have done a search in Resident 1's room more or visited her more prior to the incident to prevent an accident. During an interview on 11/21/24, at 3:17 p.m., with LVN A, LVN A stated it was around 5:45 p.m. on 11/19/24, when she heard a loud pop in the hallway and heard Resident 1 screaming. LVN A stated she then entered Resident 1's room and saw Resident 1's hair was on fire, and she was patting her head, the nasal cannula was burst open, and Resident 1 had a spark on top of her mouth and there was a little bit of bleeding on the bottom lip. LVN A further stated she then took a towel from Resident 1's bedside, dampen it in the bathroom and put it over Resident 1's head to put out the fire and then LVN A turned off the oxygen concentrator. LVN A also stated she interviewed Resident 1 after she put out the fire. Resident 1 did not have complaints of pain, no SOB (shortness of breath) observed and LVN A further stated Resident 1 'was in shock'. LVN A also stated that the facility's Non- Smoking Policy should have been more enforced to prevent fire accidents. During an interview on 11/22/24, at 3:02 p.m. with the DON, the DON verified that facility did not have anything to the effect of a no electronic cigarette acknowledgement form and that there was no signage either prohibiting the possession or use of an electronic cigarette in the facility. Review of Resident 1's hospital records entitled "Plastic & Burn Surgery Consult H&P [history and physical]" dated 11/19/2024, 6:50 pm., indicated, "Reason for Consult: Facial burn after vape [electronic cigarette] explosion History: ...presenting after thermal [pertains to heat] burn to the face after vape explosion. Patient was vaping in her bed while on her oxygen when the vape pen exploded in her face. Was holding vape pen in L [left] hand...Intubated in the trauma bay [the area in which emergency assessment and treatment begins] for airway protection... Assessment: Preliminary Diagnoses: 1st degree burn of face w/ unclear airway involvement... Procedures: intubation - patient intubated during initial assessment w/ RSI due to concerns of developing airway edema iso burn with unknown oropharyngeal involvement. Consultations: Burn, time called: 6:45 PM. Disposition: Probable admit to: ICU." A review of the facility's policy and procedure (P&P) entitled "Smoking Policy - Residents" revised August 2022, the P&P indicated, "POLICY STATEMENT: This facility has established and maintains safe resident smoking practices. POLICY INTERPRETATION AND IMPLEMENTATION: 1. Prior to and upon admission residents are informed of the facility smoking policy. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes are permitted in designated areas only. 3. Oxygen use is prohibited in smoking areas.... 15.This facility maintains the right to confiscate smoking items found in violation of our smoking policy. 16. If the facility policy changes to one that prohibits smoking (including electronic cigarettes), residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents, while considering the health and well-being of non-smoking residents. 17. Resident admitted after "No Smoking" policy is adopted are informed of the policy on admission. ELECTRONIC CIGARETTES: 1. Electronic cigarettes (e-cigarettes) are not considered smoking devices with respect to the risk of ignition, but they are