Health inspection·December 6, 2019

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the care plan for one of one sampled resident (Resident 11) to address repeated non-compliance with the facility's smoking policy. This failure had the potential to result in Resident 11 placing herself, other residents and staff at risk of injury from a possible fire. Findings: During a concurrent observation and interview on December 2, 2019, at 11:23 AM, with Resident 11, in Resident 11's room, she stated she smokes unsupervised and that she keeps her cigarettes and lighter in her room. Resident 11 revealed her cigarettes and lighter that were stored in the cup holder of her wheelchair in her room. During a review of Resident 11's smoking assessment dated [DATE], the smoking assessment indicated that 8 d. Resident is safe to smoke independently and 9. Facility to store lighter and cigarettes? 1. Yes (marked) During a concurrent observation and interview on December 2, 2019, at 3:47 PM, with a Licensed Vocational Nurse (LVN 1), Resident 11 was observed to be in her room and in possession of her cigarettes and lighter. The LVN 1 stated it is acceptable for Resident 11 to be in possession of her lighter. During a review of the facility's policy and procedure titled, {Name of facility]Smoking Policy, signed and dated August 24, 2018 by Resident 11, indicated, If a Resident is a smoker, the nurse shall insert an appropriate entry into the Resident Care Plan (RCP) outlining what steps will be implemented to ensure that Resident smoking is done safely. 2. If a Resident is deemed to be an unsafe or safe smoker, he or she shall not be permitted to retain his or her smoking materials; rather they will be maintained at the nursing desk under the supervision of the nurse. During a concurrent observation and interview on December 3, 2019, at 11:45 AM, the DON presented a plastic bag containing 4 lighters and stated that the lighters were confiscated from Resident 11 and stated the resident is non-compliant with the smoking policy. During a review of the clinical record for Resident 11 on December 4, 2019, at 2:30 PM, there was no care plan entry addressing Resident 11's non-compliance with the facility smoking policy. During an interview with the DON on December 5, 2019, at 10:34 AM, she confirmed there was no care plan to address Resident 11's non-compliance with the facility's smoking policy. Page 1 of 3 555494 555494 12/06/2019 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 adequate supervision to address one of one sampled resident (Resident 11) repeated non-compliance with the facility's smoking policy. This failure resulted in a risk of fire and had the potential to put residents and staff at risk for harm. Findings: During a concurrent observation and interview on December 2, 2019, at 11:23 AM, with Resident 11, in Resident 11's room, she stated she smokes unsupervised and that she keeps her cigarettes and lighter in her room. Resident 11 revealed her cigarettes and lighter that were stored in the cup holder of her wheelchair in her room. During a review of Resident 11's smoking assessment dated [DATE], the smoking assessment indicated , .8 d. Resident is safe to smoke independently and 9. Facility to store lighter and cigarettes? 1. Yes (marked) During a concurrent observation and interview on December 2, 2019, at 3:47 PM, with a Licensed Vocational Nurse (LVN 1), Resident 11 observed to be in her room in possession of her cigarettes and lighter. The LVN 1 stated it is acceptable for the resident to be in possession of her lighter. During a review of the facility's policy and procedure titled, [Name of facility], Smoking Policy, signed and dated August 24, 2018 by Resident 11 indicated, 1. If a Resident is a smoker, the nurse shall insert an appropriate entry into the Resident Care Plan (RCP) outlining what steps will be implemented to ensure that Resident smoking is done safely. 2. If a Resident is deemed to be an unsafe or safe smoker, he or she shall not be permitted to retain his or her smoking materials; rather they will be maintained at the nursing desk under the supervision of the nurse. During a concurrent observation and interview on December 3, 2019, at 11:30 AM, with the Director of Nursing (DON), in Resident 11's room, she stated the smoking policy of the facility does not permit residents to keep lighters in their rooms, but residents can keep cigarettes. She observed Resident 11 in her room in possession of a lighter and stated the possession of a lighter in inconsistent with the facility's policy. During a concurrent observation and interview on December 3, 2019, at 11:45 AM, the DON presented a plastic bag containing 4 lighters and stated that the lighters were confiscated from Resident 11 and stated that the resident is non-compliant. 555494 Page 2 of 3 555494 12/06/2019 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure that an opened bag of carrots in the walk-in refrigerator was dated, labeled, and sealed. This failure had the potential to cause food-borne illnesses for 86 out of 88 residents in the facility who received food from the kitchen and were a medically vulnerable resident population. Findings: During a concurrent observation and interview on December 2, 2019 at 8:20 AM, with the Dietetic Services Supervisor (DSS), a bag of unsealed carrots was observed in the walk-in refrigerator which was not dated and not labeled. The DSS acknowledged the bag of carrots was not dated, labeled, or sealed. During a review of the facility's policy on General, Receiving of Delivery of Foods and Supplies Section 6.3 (undated), the policy indicated, Label all items with the delivery date or use-by date. During a review of another facility policy on Storing Produce Section 6.14, Number 8 (undated), the policy indicated When storing vegetables should remain crisp .they will stay fresh longer if you place them in a sealed bag or container. 555494 Page 3 of 3