Health inspection·December 16, 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 supervision for 2 of 6 sampled residents (Residents 2 and 3), who were assessed as requiring supervision while smoking. This failure had the potential to cause accidental burns and injuries to Residents 2 and 3. Findings:During a concurrent observation and interview on 12/16/2025 at 11:25 a.m. with the Activity Director (AD), on the patio, Resident 2 was observed smoking a cigarette without staff supervision. The AD stated Resident 2 should be supervised while smoking. The AD stated failure to supervise residents may increase the risk of residents getting burned or having accidents while smoking.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest) and generalized anxiety disorder (GAD- is a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things).During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 12/11/2025, the MDS indicated Resident 2 had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for Activities of Daily Living (ADLs) such as toileting hygiene, dressing and personal hygiene. During a review of Resident 2's Smoking Assessment, dated 12/04/2025, the Assessment indicated Resident 2 was a smoker and required staff supervision while smoking. A review of Resident 2's Care Plan titled, [Resident 2] is a cigarette smoker dated 12/16/2025, the Care Plan goal indicated Resident 2 would not smoke without supervision through the review date. The Care plan nursing interventions included instructing Resident 2 about the facility policy on smoking: locations, times, safety concerns and notifying the charge nurse immediately if it is suspected Resident 2 had violated the facility smoking policy.During a concurrent observation on 12/16/2025 at 1:15 p.m., on the patio, Resident 3 was observed smoking a cigarette without staff supervision. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including muscle weakness, dysphasia (difficulty swallowing) and right hip pain.During a review of Resident 3's MDS, dated [DATE], the MDS Resident 3 required set up or clean up assistance with toileting hygiene, personal hygiene, and upper body dressing.During a review of Resident 3's Smoking Assessment, dated 12/11/2025, the smoking assessment indicated Resident 3 was a smoker and required staff supervision while smoking. A review of Resident 3's Care Plan titled, [Resident 3] is a smoker dated 12/17/2025, the Care Plan goal indicated Resident 3 will not suffer injury from unsafe smoking practices and Resident 3 will not smoke without supervision through the review date. The Care Plan nursing interventions included instructing Resident 3 about the facility policy on smoking: locations, Page 1 of 2 555273 555273 12/16/2025 Manchester Healthcare Center 837 W. Manchester Ave. Los Angeles, CA 90044

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some times, safety and concerns, and notifying the charge nurse immediately if it is suspected Resident 3 had violated facility smoking policy.During an interview on 12/16/2025 at 2:10 p.m., with the Director of Nursing (DON), the DON stated Smoking should be supervised by the Activity Department staff or Assistant, and the lack of supervision may increase the risk of injuries or burns.During a review of the facilities policy and procedure (P/P) titled, Smoking, dated 10/1/2023, the P/P indicated the purpose of this policy is to maintain a safe healthy environment for both smokers and non-smokers. The P/P indicated smokers shall be identified at the time of admission, residents will be provided with a copy of this policy during the admission process. The P/P indicated all smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly. All smoking sessions will be supervised by Facility Staff members. 555273 Page 2 of 2