Health inspection·April 3, 2025

The following reflects the findings of the California Department of Public Health during a Recertification Survey which resulted in Dual Enforcement, a Class B Citation (Event ID 36S411). §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; 22 CCR § 72311 Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72507 Smoking (b) The facility shall provide designated areas for smoking. Patients shall be permitted to smoke only in designated areas. The designated area shall be under the periodic observation of facility personnel or responsible adults. This does not preclude the designation of the patient rooms as smoking areas. (d) Smoking or open flames shall not be permitted in any rooms or spaces where oxygen cylinders are stored or where oxygen is in use. Such rooms or spaces shall be identified by prominently posted "No Smoking" or "No Open Flame" signs. Based on observation, interview, and record review, the facility failed to ensure the environment was free from potential serious accident hazards for patients and staff in the facility when: 1. The facility failed to assess and identify one of 10 patients (Patient 104) for smoking upon admission and failed to complete quarterly smoking assessments (an evaluation used to determine a patient's ability to smoke safely) for four of 10 patients (Patients 4, 13, 31, and 71). 2. The facility failed to ensure safety when eight of 10 patients (Patients 4, 13, 26, 32, 71, 79, 82, and 104) were observed smoking unsupervised in a non-oxygen free facility. 3. The facility failed to provide safe storage of a lighter for five of 10 patients (Patients 13, 31, 71, 82, 96), who had a physician's order for supplemental oxygen (a medical treatment delivering additional oxygen to a patient that significantly increases both the risk and intensity of fires). 4. The facility failed to ensure safety measures were followed by allowing four of 10 patients (Patients 4, 13, 96, and 104) possess lighters and were in proximity of other patients who used supplemental oxygen. 5. The facility failed to ensure the safety of all patients due to fire risk when 10 of 10 patients (Patients 4, 13, 26, 31, 32, 71, 79, 82, 96, and 104) were in possession of lighters. 6. The facility failed to update the smoking care plans (the plans showing specific interventions to provide effective and person-centered care to meet the patient's needs) for 5 of 10 sampled patients (Patients 4, 13, 26, 79, and 96) and failed to develop an individualized care plan related to smoking for one of 10 sampled patients (Patient 104), addressing safe storage, supervision, and the use of smoking materials. These failures placed patients at risk of serious harm, including fire hazards, burns, and other preventable injuries. Without proper supervision and safe storage of smoking materials, there was an increased likelihood of accidental fires, which could result in property damage, smoke inhalation, or even fatalities. Additionally, inadequate oversight could lead to patients with cognitive impairments or physical limitations mishandling smoking materials, further heightening the risk of injury to themselves and others. Findings: A. During the Entrance Conference on 3/3/25 at 8:58 a.m. with Administrator and Director of Nursing (DON), a list of patients who smoke was requested. Review of the "Smoker Worksheet" indicated there were eight patients who were smokers in the facility (Patients 4, 13, 26, 31, 32, 71, 79, and 82). The Administrator stated the list needed to be updated to reflect the current number of patients who smoked. The Administrator then provided the "Smoker Worksheet" showing nine patients who smoked (Patients 4, 13, 26, 31, 32, 71, 79, and 96). During an observation and concurrent record review on 3/4/25 at 9:58 a.m., two patients were observed smoking on the patio unsupervised (Patients 79 and 104). Patient 104 stated he had cigarettes and a lighter in possession. During an interview with Patient 104 on 3/4/25 at 10:15 a.m., Patient 104 stated he was able to smoke "whenever I feel like it." During a concurrent observation on 3/4/25 at 10:25 a.m., in Patient 104's room, a sign outside of the room indicated, "No smoking oxygen in use." The sign was also noted to have two circles with a slash over a cigarette. Inside the room where Patient 104 resided was also Patient 36 who shared the room. Patient 104's roommate, Patient 36, was observed with 2 liter (L- a unit of measurement) per minute (min) of oxygen in use via nasal cannula (NC - a small, flexible tube with two prongs, used to deliver supplemental oxygen or increased airflow to a patient through their nostrils). During a review of Patient 104's "Admission Record" (a document showing a summary of the patient's information) dated 3/5/25, indicated Patient 104 was admitted to the facility on 2/21/25. A review of Patient 104's "History and Physical (Amended)" dated 3/3/25 indicated Patient 104's diagnoses included but not limited to Chronic Obstructive Pulmonary Disorder (COPD - a group of lung diseases that makes it hard to breathe leading to damaged and inflamed airways), polysubstance abuse, schizoaffective disorder (a mental health condition where a person experiences both schizophrenia [a condition that affects how people think, feel, and behave] and a mood disorder [a condition that impacts a person's emotional state]). A review of Patient 104's "Care Plan Report" undated, indicated a comprehensive care plan was developed for the patient. However, further review of the "Care Plan Report" indicated there was no documented evidence a care plan problem was developed to address Patient 104's smoking. During a concurrent interview and record review with the DON on 3/4/25 at 11:28 a.m., the DON reviewed the clinical record for Patient 104 and verified Patient 104 did not have a care plan for smoking. During a concurrent interview and record review on 3/4/25 at 12:07 p.m. with the Activities Director (AD), Patient 104's "Activities - Initial Review" dated 2/24/25, indicated one of Patient 104's hobbies included smoking. The AD stated she completed an assessment on 3/2/25 when she saw Patient 104 smoking. During an interview and concurrent record review on 3/4/25 at 2:45 p.m. with the Minimum Data Set Nurse Assistant (MDSNA), the MDSNA verified Patient 104 was not on the current "Smoker Worksheet" provided by the facility. The MDSNA stated, she was unsure if Patient 104 was a smoker when he was admitted to the facility. A review of Patient 104's "Clinical Admission" (an evaluation conducted upon a patient's arrival or admission to a facility, focusing on gathering data to determine their health status, identify potential problems, and develop a plan of care) dated 2/24/25, indicated under Safety section number 72 for smoking, Patient 104 was marked as being "not assessed." An initial screening for smoking was not completed for Patient 104. In addition, Patient 104 was not on the list of smokers on the "Smoker Worksheet" provided by the facility. During an interview and concurrent record review with the Administrator and DON, on 3/6/25 at 11:43 a.m., the DON reviewed Patient 104's "Clinical Admission" dated 2/24/25, and verified Patient 104's smoking use was not assessed upon admission. The DON further stated that she was responsible for failing to ensure the baseline screening was completed for the smokers. B. A review of Patient 4's "Admission Record," dated 3/5/25 indicated Patient 4 was readmitted to the facility on 10/24/24. Patient 4's diagnoses included but not limited to CHF (Congestive Heart Failure - a condition that develops when the heart does not pump enough blood for the body's needs), COPD, history of CVA (Cerebral Vascular Accident - an interruption in the flow of blood to the cells in the brain) with right upper weakness, and PVD (Peripheral Vascular Disease - a condition where blood vessels outside of the heart and brain become narrowed or blocked). During a concurrent observation and interview with Patient 4 on 3/3/25 at 10:15 a.m., in his room., Patient 4 stated he smoked about 10 packs of cigarettes daily. Patient 4 displayed that he currently had two packs of cigarettes and two disposable lighters in his possession. Patient 4 further stated that he was able to smoke on the patio whenever he wanted. During an observation on 3/4/25 at 9:14 a.m., Patient 4's room was observed to be located next to a room with a sign outside that indicated, "No smoking oxygen in use." The sign was also noted to have two circles with a slash over a cigarette. During a concurrent observation and interview with Patient 4 on 3/4/25 at 9:38 a.m., Patient 4 was smoking unsupervised by staff. Patient 4 was observed in possession of and displayed two packs of cigarettes and two lighters in a bag. Patient 4 stated he kept the lighters and cigarettes with him. Review of the "Smoker Worksheet" provided by the Administrator showed Patient 4 was a smoker. Review of the "Smoking and Safety," assessment dated 11/11/24, showed Patient 4 "follows the facility's policy on location and time of smoking." During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with the MDSNA, the MDSNA stated Patient 4's smoking assessment was completed on 11/11/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly. The MDSNA stated the assessments should be up to date because there could be a change in condition where patients were no longer a safe smoker (a patient who was assessed to have appropriate cognitive, vision, communication, and physical functions and was able to verbalize understanding of the facility's smoking policies as per the facility's "Safe Smoking Assessment" form). A review of Patient 4's "Care Plan Report" undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the patient will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to "Conduct Smoking Safety Evaluation on admission and PRN [as needed] ... If a smoking facility, orient Patient to smoking times and procedures ...The patient does not require supervision while smoking." However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. C. A review of Patient 13's "Admission Record," dated 3/5/25, indicated Patient 13 was readmitted to the facility on 10/19/24. Patient 13's diagnoses included but not limited to COPD, schizoaffective disorder, bipolar type (a chronic mental health condition characterized by extreme mood swings, alternating between periods of mania [elevated mood] and depression [a persistent state of sadness and loss of interest that can significantly impact daily life]), and cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die). Review of the "Smoker Worksheet" provided by the Administrator showed Patient 13 was a smoker. During an interview with Patient 13 on 3/4/25 at 9:08 a.m., Patient 13 stated that she used a motorized wheelchair to go outside of the facility to buy cigarettes and lighters. Patient 13 further stated she stored and secured her own cigarettes and lighters. Patient 13 stated she smoked in the patio without supervision. During an observation on 3/4/25 at 9:13 a.m. Patient 13's room was observed to be located next to a room with a sign outside of the room that indicated, "No smoking oxygen in use." The sign was also noted to have two circles with a slash over a cigarette. During a concurrent observation and interview on 3/4/25 at 9:43 a.m., Patient 13 was smoking in the patio unsupervised. Patient 13 stated she was enjoying her cigarettes and kept her own cigarettes and lighters. During a review of the "Oxygen Order Listing Report," dated 3/4/25, an active physician's order for Patient 13 with a revised date of 7/1/24 indicated the use for oxygen 3 liters per min via NC PRN for shortness of breath (SOB) to maintain oxygen at greater than 90% every shift. During a concurrent interview and record review on 3/4/25 at 2:25 p.m. with the MDSNA, The MDSNA stated Patient 13's smoking assessment was completed on 11/8/24. The MDSNA further stated the assessment was not current according to the facility's policy which indicated assessments need to be done quarterly. The MDSNA stated the assessments should be up to date because there could be a change in condition where patients are no longer a safe smoker. A review of Patient 13's "Care Plan Report" undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the patient will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to "Conduct Smoking Safety Evaluation on admission and PRN ...If a smoking facility, orient Patient to smoking times and procedures ...The patient does not require supervision while smoking." However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. D. A review of Patient 26's "Admission Record" dated 3/5/25, indicated Patient 26 was readmitted to the facility on 12/26/23. Patient 26's diagnoses included but not limited to metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance) and COPD. During a concurrent observation and interview with Patient 26 on 3/3/25 at 10:30 a.m., Patient 26 was smoking in the patio area unsupervised. Patient 26 stated patients were allowed to smoke in the patio at any time without staff permission or notice. Patient 26 further stated his friends would provide cigarettes and lighters for use while he was in the facility. A review of Patient 26's "Care Plan Report" undated, indicated a care plan problem was developed for the use of tobacco. The goals indicated the patient will adhere to the facility's smoking policies and will not suffer injury from unsafe smoking practices. The interventions indicated to "Conduct Smoking Safety Evaluation on admission and PRN ...Educate Patient/Responsible Party on the facility's tobacco/smoking policy(s) ...If a smoking facility, orient Patient to smoking times and procedures ...The patient does not require supervision while smoking." However, there was no documented evidence showing the care plan was updated to reflect the most current smoking assessment and addressed safe storage, supervision, and the use of smoking materials. E. A review of Patient 31's "Admission Record," dated 3/5/25, indicated Patient 31 was readmitted to the facility on 11/06/24. Patient 31's diagnoses included but not limited to muscle weakness (generalized), acute respiratory failure with hypoxia, and COPD wit