Health inspection·September 6, 2024

§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. 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. (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. 22 CCR § 72637 (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff, and visitors. (b) Buildings and grounds shall be free of environmental pollutants and such nuisances as may adversely affect the health or welfare of patients to the extent that such conditions are within the reasonable control of the facility. On 7/24/2024, the California Department of Public Health (CDPH) conducted an annual recertification survey at the facility. The facility failed to: 1. Implement guidance from the “Resident Smoking Assessment Form” which indicated all residents’ smoking materials and paraphernalia (cigarettes and lighters) must be safely stored by facility staff for Residents 6, 117, 122, 141, and 157) 2. Provide supervision while smoking for Residents 141, 157, and 117 who were identified as unsafe smokers. 3. Follow its policy and procedure (P&P) titled, “Accidents and Supervision, which indicated staff will observe and identify potential hazards in the environment. 4. Follow its P&P titled “Resident Smoking,” which indicated smoking materials of residents requiring supervision while smoking would be maintained by nursing staff. These failures had the potential for Residents 6, 141, 122, 157, and 117 to use lighters, cause a fire that could affect the health, safety, and wellbeing of all 118 residents in the facility, staff and visitors and result in serious injuries, hospitalization, and death. 1. Resident 6, was a 76-year-old male, who was admitted to the facility on 12/01/2023 with diagnoses that included dementia (loss of thinking, remembering, and reasoning), schizophrenia (mental illness that affects how a person thinks and behaves), and seizures (abnormal activity in the brain). A review of Resident 6’s History and Physical (H&P), dated 3/26/2024, indicated Resident 6 had the capacity to understand and make decisions. A review of Resident 6’s Resident Smoking Assessment Form, dated 6/6/2024, indicated Resident 6 was not able to light a cigarette safely with a lighter and not able to use an ashtray safely. The Resident Smoking Assessment Form indicated Resident 6 was not able to extinguish a cigarette safely and completely. The Resident Smoking Assessment Form indicated Resident 6 was an unsafe smoker and must be supervised at all times when smoking. A review of Resident 6’s care plan titled, “Cognitive (thinking, reasoning) Loss,” dated 3/27/2024, indicated Resident 6 had periods of forgetfulness. A review of Resident 6’s care plan titled “Occupational Therapy (therapy focused on abilities for daily activities),” dated 3/27/2024, indicated Resident 6 had impaired strength to his bilateral (both sides) upper extremities. During a concurrent observation and interview on 7/24/24 at 3:00 p.m., at Resident 6’s bedside, Resident 6 was observed lifting the seat on his rollator walker (a four-wheeled walker with handlebars and a built-in seat) revealing the cigarettes and lighter in his possession. Resident 6 stated he always kept his own cigarettes and lighter. Resident 6 stated the facility staff did not inform him of the facility’s smoking policy. Resident 6 stated the staff were aware he had a lighter. 2. Resident 141, was a 54-year-old female, admitted to the facility on 7/9/2024 with diagnoses that included deformity of the fingers and hand, lack of coordination, and seizures. A review of Resident 141’s H&P, dated 7/11/2024, indicated Resident 141 had the capacity to understand and make decisions. A review of Resident 141’s Resident Smoking Assessment Form, dated 7/9/2024, indicated Resident 141 was not able to light a cigarette safely with a lighter and was not a safe smoker. The smoking assessment indicated Resident 141 was not able to use an ashtray safely or extinguish a cigarette safely and completely. The assessment indicated Resident 141 must be supervised at all times and wear a protective apron when smoking. A review of Resident 141’s care plan titled “Smoking”, dated 7/9/2024, indicated Resident 141 was an impaired smoker and needed constant supervision with protective gear. The care plan indicated the facility would provide Resident 141 with constant supervision while smoking. A review of Resident 141’s care plan titled “Occupational Therapy” dated 7/10/2024, indicated Resident 141 had impaired strength to her bilateral upper extremities. During a concurrent observation and interview on 7/24/2024 at 2:53 p.m. with Resident 141, on the smoking patio, Resident 141 was observed smoking unsupervised. Resident 141 stated staff were aware she had cigarettes and a lighter in her possession. Resident 141 stated the facility never told her about the smoking policy. Resident 141 showed the surveyor her lighter. 3. Resident 122, was a 50-year-old male, admitted to the facility on 12/3/2021 with diagnoses that included schizophrenia, heart failure (heart doesn’t work as well as it should), and kidney disease (damage to the kidney). A review of Resident 122’s H&P, dated 1/8/2024, indicated Resident 122 had the capacity to make decisions for activities of daily living. A review of Resident 122’s Resident Smoking Assessment Form, dated 5/31/2024, indicated Resident 122 was not able to light a cigarette safely with a lighter. The Resident Smoking Assessment Form indicated Resident 122 was an unsafe smoker and must be supervised at all times when smoking. A review of Resident 122’s care plan titled “Smoking”, dated 1/8/2024, indicated Resident 122 may smoke under supervision. The care plan indicated the facility would observe Resident 122 for unsafe smoking behaviors and/or practices and supervise Resident 122 based on the Smoking Assessment. The care plan indicated the facility would store smoking and incendiary-related (devices designed to cause fire) material per the facility policy. During an observation on 7/24/2024 at 4:42 p.m, in Resident 122’s room, Resident 122 was observed with three cigarettes and two lighters in his bedside drawer. During a concurrent observation and interview on 7/25/2024 at 8:52 a.m. with Licensed Vocational Nurse (LVN 4), at Resident 122’s bedside, Resident 122 was observed with one cigarette in his bedside drawer. LVN 4 stated cigarettes should not be kept in the drawer. LVN 4 stated cigarettes were stored at the receptionist’s desk and staff monitored for lighters. LVN 4 stated a resident could start a fire and everyone’s safety was in jeopardy. 4. Resident 157, was a 75-year-old male, admitted to the facility on 10/19/2023 with diagnoses that included schizophrenia, dementia, and diabetes (abnormal blood sugar). A review of Resident 157’s H&P, dated 2/5/2024, indicated Resident 157 had the capacity to understand and make decisions. A review of Resident 157’s Resident Smoking Assessment Form, dated 7/23/2024, indicated Resident 157 was not able to use an ashtray safely and was not able to extinguish a cigarette safely and completely. The assessment indicated Resident 157 was an unsafe smoker and must be supervised at all times when smoking. A review of Resident 157’s care plan titled “Smoking”, dated 2/5/2024, indicated Resident 157 may smoke under supervision. The care plan indicated the facility would observe Resident 157 for unsafe smoking behaviors and/or practices and would supervise Resident 157 per the smoking assessment. The care plan indicated the facility would store smoking and incendiary-related material per facility policy. A review of Resident 157’s care plan titled “Cognitive Loss”, dated 2/5/2024, indicated Resident 157 had periods of confusion. A review of Resident 157’s care plan titled “Occupational Therapy” dated 2/6/2024, indicated Resident 157 had impaired strength to his bilateral upper extremities. During an observation on 7/24/2024 at 2:39 p.m., Resident 157 was observed on the smoking patio handing Resident 117 a cigarette. There were no facility staff observed on the smoking patio at that time. During a concurrent observation and interview on 7/24/2024 at 2:44 p.m. with LVN 3, in the hallway outside the smoking patio, LVN 3 observed Resident 157 in the smoking patio. Resident 157 stood up from a chair and lit Resident 117’s cigarette with a lighter. LVN 3 stated Resident 157 should not have a lighter because it was a risk for fire and there was no one monitoring the resident. LVN 3 stated Resident 157 could have started a fire if there was a resident on oxygen in the patio area. 5. Resident 117, was a 66-year-old female, admitted to the facility on 7/17/2023 with diagnoses that included left hemiplegia (unable to move one side of the body), heart failure, and left above the knee amputation (removal of a body part). A review of Resident 117’s H&P, dated 9/8/2023, indicated Resident 117 had the capacity to understand and make decisions. A review of Resident 117’s Resident Smoking Assessment Form, dated 4/22/2024, indicated Resident 117 was not able to light a cigarette safely with a lighter, was not able to use an ashtray safely, and was not able to extinguish a cigarette safely and completely. The assessment indicated Resident 117 was an unsafe smoker and must be supervised at all times when smoking. A review of Resident 117’s care plan titled “Smoking”, dated 9/8/2023, indicated Resident 117 needed observation while smoking. The care plan indicated the facility would provide Resident 117 with observation while smoking. During a concurrent observation and interview on 7/24/2024 at 2:39 p.m. with Resident 117, in the smoking patio, Resident 117 was observed with cigarettes in her possession. Resident 117 stated she kept her own cigarettes. During a concurrent observation and interview on 7/24/2024 at 2:50 p.m. with Certified Nursing Assistant (CNA) 1, in the smoking patio, Resident 117 and Resident 157 was observed actively smoking on the smoking patio. CNA1 stated he had to go answer a call light and was observed leaving the smoking patio. Resident 117 and Resident 157 were observed unmonitored on the smoking patio. CNA 1 stated when he entered the patio no one was monitoring the residents smoking. CNA 1 stated the facility’s policy indicated a staff must always monitor residents while smoking. During a concurrent observation and interview on 7/24/2024 at 2:54 p.m. with Activity Assistant (AA) 1, in the smoking patio, AA 1 was observed checking Resident 157’s pockets. AA 1 observed that Resident 157 had cigarettes but did not take the cigarettes from the resident. Resident 117 was observed pulling out her lighter for the surveyor to view but AA 1 did not take Resident 117’s lighter. AA 1 stated someone must monitor the residents while they smoke to ensure no one burns their clothes. AA 1 stated if no one was monitoring the residents they may get burned. AA 1 stated a staff member should also monitor the patio. AA 1 stated some residents kept their own cigarettes and lighters in their possession. During an interview on 7/25/2024 at 9:41 a.m. with AA 1, AA 1 stated cigarettes and lighters should be kept in a locked box at the receptionist’s desk where residents did not have access. AA 1 stated some residents keep their own cigarettes and lighters in their possession. AA 1 stated Resident 141, Resident 6, and Resident 122 had smoking items in their possession and were not allowed to keep smoking paraphernalia. AA 1 stated he did not take away the items because the residents would be upset. AA 1 stated the residents needed to be monitored to avoid burns. During an interview on 7/26/2024 at 9:05 a.m. with the Director of Nursing (DON), the DON stated per the facility’s policy, residents must be supervised at all times while smoking. The DON stated residents must be supervised because there was a risk for burns or injury because some residents were forgetful. The DON stated staff must provide and light the cigarette for the residents. The DON stated residents’ personal cigarettes were kept in a locked box at the receptionist’s desk. The DON stated residents should not have cigarettes or lighters in their possession. The DON stated upon admission smokers were assessed using the Resident Smoking Assessment Form to determine if they were safe to smoke. A review of the facility’s policy and procedure (P&P) titled,” Resident Smoking”, (undated), the P&P indicated residents who smoke would be assessed using the Resident Smoking Assessment to determine whether supervision was required when smoking, or if the resident was safe to smoke at all. The P&P indicated smoking materials of residents requiring supervision with smoking would be maintained by nursing staff. A review of the facility P&P titled, “Accidents and Supervision”, (undated), indicated the resident would receive adequate supervision to prevent accidents. The P&P indicated all staff were to be involved in observing and identifying potential hazards in the environment. A review of the facility’s “Resident Smoking Assessment Form,” (undated) indicated for safety reasons, residents may not store cigarettes, lighters, or any smoking materials at the bedside, in their bedside stand, in their closets or in any drawers in their room. The Resident Smoking Assessment Form indicated for everyone’s safety, any and all smoking materials and paraphernalia must be safely stored by facility staff. The facility failed to: 1. Implement guidance from the “Resident Smoking Assessment Form” which indicated all residents’ smoking materials and paraphernalia must be safely stored by facility staff for Residents 6, 117, 122, 141, and 157. 2. Provide supervision while smoking for Residents 141, 157, and 117 who were identified as unsafe smokers. 3. Follow its P&P titled, “Accidents and Supervision, which indicated staff will observe and identify potential hazards in the environment. 4. Follow its P&P titled “Resident Smoking,” which indicated smoking materials of residents requiring supervision while smoking would be maintained by nursing staff. These failures had the potential for Residents 6, 141, 122, 157, and 117 to use lighters, cause a fire that could affect the health, safety, and wellbeing of all 118 residents in the facility, staff and visitors and result in serious injuries, hospitalization, and death. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.