Health inspection·July 10, 2024

42 CFR §483.25 (d)(2) Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident. 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. (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 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. The California Department of Public Health (CDPH) received a facility reported incident (FRI) on 5/17/2024 regarding a resident-to-resident altercation. On 5/29/2024, an unannounced visit was conducted at the facility to investigate the FRI regarding a resident-to-resident altercation, and an additional concern was identified. Three residents were observed with smoking materials (cigarette lighters and cigarette sticks) in their possession. The facility failed to: 1. Ensure Resident 1 did not have a cigarette lighter on his bedside table on 5/29/2024 at 11:24 a.m. 2. Ensure Resident 2 did not have a lighter and two (2) cigarette sticks in her (Resident 2) purse on 5/29/2024 at 2:51 p.m. 3. Ensure Resident 3 did not have a lighter and 2 cigarette sticks while in the hallway, and at the bedside table on 5/30/2024 at 9:07 a.m. 4. Implement its policy and procedure (P&P) titled, "Smoking: Nursing Manual-Nursing Administration," which indicated smoking materials such as cigarettes, and lighters should be stored in a secured area (area where access was limited to authorized persons only), and residents who smoked will be assessed for the most appropriate method to securely store smoking materials such as lighters, and cigarettes. These deficient practices had a potential for Residents 1, 2, and 3 to turn on the lighters, cause a fire which could result in serious injuries, hospitalization, and death for all 118 residents in the facility, staff and visitors. 1). Resident 1 was a 63-year-old female, admitted to the facility on 10/13/2021 with diagnoses that included cerebral infarction (stroke), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and extrapyramidal movements (involuntary, uncontrollable movements). A review of Resident 1's care plan titled, "At risk for accidental injuries due to smoking, but not limited to risk/benefit/outcome explained and understood," dated 9/21/2023, indicated the facility will provide a safe smoking environment and the resident will smoke safely while abiding by (following) the facility's policy. The care plan interventions indicated; staff will inform Resident 1 of designated smoking areas because smoking was prohibited within the facility and facility staff will perform visual monitoring on Resident 1 during scheduled smoke breaks. The care plan interventions indicated the smoking policy will be discussed with Resident 1 during resident council meetings (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care and quality of life) and as needed. A review of Resident 1's "Smoking Safety Evaluation," dated 4/11/2024, indicated supervision will be required for all residents during designated smoking times. The Smoking Safety Evaluation indicated evaluation will be utilized for resident's smoking care plan on admission and as indicated. The Smoking Safety Evaluation form did not indicate a system for safe storage of Resident 1's smoking materials. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 4/15/2024, indicated Resident 1 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required supervision or touching assistance (staff provided verbal cues and/or touching/steadying assistance as residents completed activity) for Activities of Daily Living (ADLs) such as upper and lower body dressing, personal hygiene, sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), chair/bed-to-chair transfer (ability to transfer to and from a bed to a chair (or wheelchair) and walk of 10 feet. The MDS indicated Resident 1 independently used a wheelchair for mobility (the ability to move freely). During an observation on 5/29/2024 at 11:24 a.m. in Resident 1's room, a cigarette lighter was observed on Resident 1's bedside table. During a concurrent observation and interview with the Director of Nursing (DON) on 5/29/2024 at 11:28 a.m., in Resident 1's room, a lighter was observed at Resident 1's bedside table. The DON stated residents should not have a lighter in the room or at the bedside because it was dangerous and could cause accidents to happen. 2). Resident 2 was a 69-year-old female, admitted to the facility on 7/12/2021 with diagnoses including paralytic syndrome (progressive weakness) following cerebral infarction and generalized weakness (weakness on most areas of the body). A review of Resident 2's care plan titled, "At risk for accidental injuries due to smoking," dated 9/21/2023, indicated the facility will provide Resident 2 with a safe smoking environment and the resident will smoke safely per the facility's policy. The care plan interventions indicated staff will inform Resident 2 of designated smoking areas because smoking was prohibited within the facility. The interventions indicated staff will perform visual monitoring on Resident 2 during scheduled smoke breaks. A review of Resident 2's "Smoking Safety Evaluation," dated 4/11/2024, indicated supervision will be required for all residents during designated smoking times. The Smoking Safety Evaluation indicated evaluation will be utilized for resident's smoking care plan on admission and as indicated. The Smoking Safety Evaluation form did not indicate a system for safe storage of Resident 2's smoking materials. A review of Resident 2's MDS dated 4/12/2024, indicated Resident 2 had an intact cognition. The MDS indicated Resident 2 had impairment to both sides (left and right) of the lower extremities (lower body). The MDS indicated Resident 2 was dependent with chair/bed-chair transfer. The MDS indicated Resident 2 independently used a wheelchair for mobility. During an interview on 5/29/2024 at 2:09 p.m. with the Activity Assistant the Activity Assistant stated smoking paraphernalia (materials) should be stored in the activity's office. The Activity Assistant indicated residents were not allowed to keep smoking materials with them because it was a safety hazard and residents could burn themselves. During a concurrent observation and interview on 5/29/2024 at 2:51 p.m. with the DON in Resident 2's room, Resident 2 was observed with 2 cigarette sticks and a lighter in her purse. Resident 2 stated she (Resident 2) always kept the lighter and cigarettes in her (Resident 2) room. 3). Resident 3 was a 68-year-old male, originally admitted to the facility on 7/19/2019 and readmitted on 9/8/2023 with diagnosis of unspecified (not named or stated) mood disorder (unstable mood) and schizophrenia. A review of Resident 3's care plan titled, "Resident is a smoker and agreed to abide with facility's policy for smoking, (risk/benefit/outcome explained and understood), risk for injuries to self and others," dated, 9/15/2022, indicated the resident will be free from injuries related to smoking and no injuries to others. The care plan interventions indicated the facility will monitor Resident 3 frequently during smoke durations and remind the resident of the designated smoking area. A review of Resident 3's care plan titled, "Resident is a smoker, at risk for injury to self or others, required supervision with smoking," dated 9/16/2022, indicated Resident 3 will not smoke without supervision or suffer any injury from unsafe smoking. The care plan interventions indicated Resident 3 required supervision while smoking and staff will inform Resident 3 about smoking locations, times, and safety concerns. The interventions indicated staff will allow Resident 3 to smoke only in designated areas, and monitor Resident 3 frequently during smoking breaks. A review of Resident 3's "Smoking Safety Evaluation," dated 3/19/2024, indicated supervision will be required for all residents during designated smoking times. The Smoking Safety Evaluation indicated evaluation will be utilized for resident's smoking care plan on admission and as indicated. The Smoking Safety Evaluation form did not indicate a system for safe storage of Resident 3's smoking materials. A review of Resident 3's MDS, dated, 3/21/2024, indicated Resident 3 had cognitive impairment. The MDS indicated Resident 3 had no impairment with upper and lower body and was able to walk 10 feet with supervision. The MDS indicated Resident 3 required supervision with sit to stand, and chair/bed-to-chair transfer. The MDS indicated Resident 2 independently used a wheelchair for walking. During an observation on 5/30/2024 at 9:07 a.m., Resident 3 was observed in the hallway with 2 cigarettes in one hand and a cigarette lighter on the other hand. During a concurrent observation and interview on 5/30/2024 at 10:05 a.m. with Resident 3, in Resident 3's room, a cigarette lighter and a pack of cigarettes were observed on Resident 3's bedside table. Resident 3 stated the cigarettes were provided by the facility and the cigarette lighter was kept in his (Resident 3) room. Resident 3 stated he always had the cigarette lighter in his room and was never taken away by the staff. Resident 3 stated he did not have to wait for staff to provide him a cigarette or a lighter, whenever he wanted to smoke. During a concurrent observation and interview on 5/30/2024 at 10:17 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 3's room, LVN 2 stated there was a cigarette lighter and a pack of cigarettes on Resident 3's bedside table. LVN 3 stated some of the residents bought their own packs of cigarettes. LVN 3 stated cigarette lighters should not be kept by residents because it could be a safety hazard and could result in a fire. LVN 3 stated all lighters should be kept in the Activities Department. During an interview on 5/30/2024 at 11:56 a.m. with the Activity Director (AD), the AD stated, he (the AD) assessed all residents who smoked during admission, by completing the "Smoking Safety Evaluation" form in the electronics medical record. The AD stated residents' lighters and cigarettes were stored in the activities department. The AD stated the facility did not have documentation of room checks performed by the activities department to ensure residents did not have smoking materials in their room. During an interview on 5/30/2024 at 3:55 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated residents should not have lighters or cigarettes in their room due to the risks involved. Residents could light up linens which could lead to a fire, burn themselves or other safety concerns (not specified) if residents had oxygen in the room. During an interview on 5/30/2024 at 4:33 p.m. with Registered Nurse (RN) 1, RN 1 stated residents should not keep lighters or cigarettes by themselves. RN 1 stated if a resident lit a cigarette in a room with oxygen, it could lead to injuries and burns. RN 1 stated appropriate storage of residents' smoking materials was part of the safety assessment for residents who smoked. During a concurrent interview and record review on 5/30/2024 at 4:50 p.m. with the DON, Resident 1's Smoking Safety Evaluation dated 4/11/2024 was reviewed. The DON stated appropriate assessment and storage of smoking materials were part of safety evaluation because residents who were not responsible, could light a cigarette anytime and cause burns. The DON stated the evaluation did not indicate where Resident 1's smoking materials should be stored. The DON stated residents' bedside tables were not a secure area to store smoking materials, especially a lighter, as anyone could grab the lighter and start a fire even if they were alert and oriented. The DON stated residents using oxygen were in danger if a resident lit a lighter or cigarette close to oxygen. The DON stated per the facility's smoking policy, smoking materials were to be stored in a secured area. A review of the facility's P&P titled, "Smoking: Nursing Manual - Nursing Administration" dated 2/19/2022, indicated all smoking materials should be stored in a secured area basing on the resident's smoking safety assessment to ensure safety. The P&P indicated the facility staff should determine the most appropriate method of secured storage. The facility failed to: 1. Ensure Resident 1 did not have a cigarette lighter on his bedside table on 5/29/2024 at 11:24 a.m. 2. Ensure Resident 2 did not have a lighter and 2 cigarette sticks in her purse on 5/29/2024 at 2:51 p.m. 3. Ensure Resident 3 did not have a lighter and 2 cigarette sticks while in the hallway, and at the bedside table on 5/30/2024 at 9:07 a.m. 4. Implement its P&P titled, "Smoking: Nursing Manual-Nursing Administration," which indicated smoking materials such as cigarettes, and lighters should be stored in a secured area, and residents who smoked will be assessed for the most appropriate method to securely store smoking materials such as lighters, and cigarettes. These deficient practices had a potential for Residents 1, 2, and 3 to turn the lighters on, cause a fire which could result in serious injuries, hospitalization, and death for all 118 residents in the facility, staff, and visitors. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.