Health inspection·August 14, 2024

42 CFR §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. On 6/24/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual Recertification Survey. The facility failed to ensure that Resident 139 was kept free from accident and failed to provide a safe environment free from accident hazards (elements of the resident environment that have the potential to cause injury or illness) for the residents, staff, and visitors, as indicated in the facility's policies and procedures by: 1. Failing to identify that Resident 139 had a torch lighter (a device that creates a flame that is hotter [reaching 2,500 degrees Fahrenheit {°F- a unit of measure}] and more intense than a soft flame lighter (a device that procedures a small, soft, yellow flame reaching temperatures of 1400 °F, that is not as powerful as a torch flame) in possession while admitted in the facility. 2. Failing to ensure Resident 139’s capability to smoke and safely use a lighter independently was assessed taking into account the resident's functional, cognitive (relating to the mental process involved in knowing, learning, and understanding things), and medical factors as per facility policy and procedure. 3. Failing to provide safe water temperatures of less than 121 degrees °F in Room 50 and Room 51 restroom hand sinks. 4. Failing to provide safe water temperatures of less than 121°F in Shower Room 1 and Shower Room 2. 5. Failing to ensure the circulating pump (used to circulate hot water within the pipes to allow instant access to hot water when the hot water faucet fixture [used to control the flow of water for sinks] is opened) for Water Heater 3 was in good working order. 6. Failing to ensure the cold-water shutoff valve (also called under-sink shut off valve, used to turn off the water to the sink without having the use of the main shutoff) under a resident hand sink was not partially closed for Room 51 resident restroom hand sink. As a result, Resident 139 was placed at increased risk for severe burns and life-threatening injuries from the use of a torch lighter and had the potential for residents, staff, and visitors to sustain burns, scalding (injury from hot liquid or steam), and uncomfortable water temperatures. 1. A review of Resident 139's Admission Record indicated that the facility originally admitted Resident 139 on 5/2/2024 with diagnoses that included muscle weakness, hemiplegia (paralysis [inability to move] that affects only one side of the body) and hemiparesis (the weakness or inability to move one side of the body) following cerebral infarction (also known as a stroke or cerebrovascular accident [CVA- brain tissue death caused by a lack of blood flow to the brain]) affecting the right dominant side. A review of Resident 139's History and Physical (HP) dated 5/4/2024 completed by Medical Doctor 1 (MD 1) indicated that Resident 139 had a diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), due to CVA. The HP further indicated that Resident 139 had fluctuating capacity to understand and make decisions. A review of Resident 139's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/8/2024 indicated that Resident 139 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated that Resident 139 required partial to moderate assistance (facility staff does less than half the effort) with personal hygiene, lower body dressing, putting on and taking off footwear, and oral hygiene. The MDS further indicated that Resident 139 required substantial to maximal assistance (facility staff does more than half the effort) with toileting hygiene and bathing. A review of Resident 139's Occupational Therapy (OT - a program designed to improve a resident's ability to perform daily tasks) Evaluation and Plan of Treatment dated 5/3/2024 indicated that Resident 139's right upper extremity strength was impaired. A review of Resident 139's Inventory of Personal Effects dated 5/2/2024 did not indicate that Resident 139 was in possession of a torch lighter upon admission. The form was completed and documented by Certified Nursing Assistant 2 (CNA 2) and counter signed (a signature attesting the authenticity of a document already signed by another) by Registered Nurse 2 (RN 2). During an observation on 6/24/2024 at 9:53 a.m. inside Resident 139's room, observed a torch lighter placed on top of Resident 139's nightstand. During a concurrent observation and interview on 6/26/2024 at 9:46 a.m. with Registered Nurse 1 (RN 1) and Resident 139, inside Resident 139's room, observed Resident 139 with a torch lighter. RN 1 attempted to collect Resident 139's torch lighter, but Resident 139 refused. RN 1 stated that a torch lighter should not be kept at the resident's beside because a torch lighter can burn down the facility. During an interview with the Activity Assistant (AA) on 6/26/2024 at 10:18 a.m., the AA stated that a torch lighter is very dangerous, and that Resident 139 should not have a torch lighter in his (Resident 139) possession. During an interview with the Assistant Director of Nursing (ADON) on 6/26/2024 at 10:24 a.m., the ADON stated that torch lighters are not allowed in the facility because they are a fire hazard. During an interview with Resident 139 on 6/26/2024 at 10:45 a.m., Resident 139 stated that the torch lighter has been in his (Resident 139) possession since he was admitted to the facility (5/2/2024). Resident 139 stated that the Administrator (Admin) has always been aware of Resident 139's torch lighter. During an interview with Certified Nursing Assistant 1 (CNA 1) on 6/27/2024 at 5:08 p.m., CNA 1 stated that she (CNA 1) has on multiple occasions been assigned to provide care to Resident 139. CNA 1 stated that while assigned to Resident 139, CNA 1 will occasionally take the resident to the designated smoking area. CNA 1 stated that from her (CNA 1) recollection, Resident 139 used a "regular" (referring to a soft flame lighter) lighter when smoking. CNA 1 stated that she (CNA 1) is familiar with what a torch lighter is and did not see Resident 139 use a torch lighter when smoking. CNA 1 stated that a torch lighter produces a flame at a high concentration and can burn through things such as a cigarette much quicker because the flame is stronger. CNA 1 stated that she (CNA 1) would be concerned if CNA 1 was to observe Resident 139 with a torch lighter because it is much more dangerous than a soft flame lighter. During a concurrent observation and interview with Resident 139 on 6/27/2024 at 6:24 p.m., the surveyor observed Resident 139 inside the Administrator's office. Resident 139 stated that he (Resident 139) has had the torch lighter since Resident 139's admission to the facility (on 5/2/2024). Resident 139 stated that he (Resident 139) uses a torch lighter while smoking because Resident 139's right hand is "limited" and that he (Resident 139) cannot "really use" the right hand. The surveyor observed Resident 139 slowly open and close his (Resident 139) right hand, and then slowly move his (Resident 139) right hand in small circular motions. Resident 139 stated that upon Resident 139's admission to the facility, the facility's staff did not thoroughly check and document his (Resident 139) belongings. Resident 139 stated that had the facility's staff thoroughly check Resident 139's belongings, they would have found the torch lighter in Resident 139's pocket. When asked which facility staff checked Resident 139's belongings upon the resident's admission, Resident 139 stated he (Resident 139) was unable to recall. During an interview with MD 1 on 6/27/2024 at 6:43 p.m., MD 1 stated that he (MD 1) completed Resident 139's HP dated 5/4/2024. MD 1 stated that Resident 139's HP dated 5/4/2024 that included Resident 139's diagnosis of dementia due to CVA and Resident 139's fluctuating capacity to understand and make decisions was an accurate assessment made by MD 1. MD 1 stated that MD 1 was not made aware until today (6/27/2024) that Resident 139 was in possession of a torch lighter. MD 1 stated that a torch lighter should be kept in a safe place such as a locked box. When MD 1 was asked if he (MD 1) was aware that Resident 139's torch lighter was found on top of the resident's nightstand unattended on 6/24/2024, MD 1 stated that he (MD 1) was not aware. MD 1 stated that because Resident 139's torch lighter was not in a locked box, and was left unattended on the resident's nightstand, the torch lighter increased the risk for danger for the facility. MD 1 stated Resident 139's torch lighter would especially be dangerous if a confused resident obtained the torch lighter while it was left unattended. During a concurrent interview and record review with RN 2 on 6/27/2024 at 7:39 p.m., reviewed Resident 139's Inventory of Personal Effects dated 5/2/2024. RN 2 stated that there was no torch lighter listed on the inventory of personal effects form of Resident 139. RN 2 stated that he (RN 2) admitted Resident 139 to the facility on 5/2/2024. When RN 2 was asked how the facility checks for the inventory of a resident upon admission, RN 2 stated that upon admission, a Certified Nurse Assistant (CNA) will take inventory and itemize all the belongings that is brought in by the resident. RN 2 stated that after a CNA has completed the Inventory of Personal Effects form, the assigned Registered Nurse (RN) will counter sign the form as a confirmation check that the CNA completed the form. RN 2 reviewed Resident 139's Inventory of Personal Effects dated 5/2/2024 and stated that RN 2 counter signed the form and then pointed to CNA 2's signature. RN 2 stated that it was CNA 2 who completed and documented Resident 139's Inventory of Personal Effects dated 5/2/2024. When RN 2 was asked about Resident 139's torch lighter, and if RN 2 knew the difference between a torch lighter and a soft flame lighter, RN 2 stated he (RN 2) knows the difference between a soft flame lighter and a torch lighter. RN 2 stated that the intensity of the flame is much higher in a torch lighter. RN 2 stated that the heat and flame size produced by the torch lighter would make it more likely for an injury or a burn to occur. RN 2 stated there are safety concerns as well such as if a torch lighter is left unattended and a confused resident was able to obtain the torch lighter. RN 2 stated that he (RN 2) would not leave a torch lighter with a resident even if the resident was alert and oriented (refers to a person's level of awareness of self, place, time, and situation) because it is a safety issue. During an interview on 6/27/2024 at 7:39 p.m. with the Director of Nursing (DON), the DON stated that there is no safety issues or concerns with Resident 139 possession or use of a torch lighter while admitted to the facility because Resident 139 knows how to use a torch lighter. DON stated that even though a torch lighter, which has a higher intensity and concentrated flame, and is able to burn through things faster than a soft flame lighter; a torch lighter is not any more dangerous nor does it impose any more of a safety risk than a soft flame lighter. The DON further stated that she is just now learning about what a torch lighter is. During an interview on 6/27/2024 at 7:39 p.m. with the Admin, the Admin stated that there is no increased risk for safety or injury when comparing a torch lighter to a soft flame lighter. The admin stated that even though a torch lighter has a higher intensity and more concentrated flame, and even though a torch lighter can burn through things much faster than a soft flame lighter, a torch lighter does not increase the risk of injury or safety when compared to a soft flame lighter. During an interview on 6/27/2024 at 8:28 p.m. with the Admin and DON, the Admin and DON stated that the SSA and the surveyors are to be blamed for putting the facility's residents at risk because the surveyors did not inform the Admin and the DON of Resident 139's torch lighter sooner and did not inform the Admin and DON sooner of the dangers and concerns of Resident 139's torch lighters. The Admin again stated and repeated that it was the SSA that put the safety of the residents of the facility at risk. A review of the facility's policy and procedure titled "Resident Smoking," reviewed date 12/19/2023 indicated that it is the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. 2. A review of Resident 139's Initial Smoking Safety form dated 5/7/2024 documented by the Activities Director (AD) indicated that Resident 139 can smoke independently. The form identifies Risk Factors (a characteristic, condition, or behavior that increases the likelihood of getting a disease or injury) of smoking under safety factors and concerns to assess the following: a. Burn skin, clothing, furniture or other, b. Cognitive deficit (impairment in an individual's mental processes that lead to the acquisition of information and knowledge, and drive how an individual understands and acts) c. Drops ashes on self, d. Impaired gait (pattern of walk) and balance e. Impaired vision f. Insufficient fine motor skills (the coordination of small muscles in movement with the eyes, hands, and fingers) needed to securely hold cigarette, g. Is on medication that affects alertness and function, h. Lethargic (a condition marked by drowsiness and an unusual lack of energy and mental alertness), falls asleep easily during tasks or activities, i. Total or limited Range of Motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) in arms or hands, j. Unable to extinguish (to put out) a cigarette safely, k. Unable to hold a cigarette safely, l. Unable to light a cigarette safely, m. Unable to use ashtray to extinguish a cigarette, During an interview and concurrent record review with the Activities Director on 6/27/2024 at 4:16 p.m. with the Admin, DON, and Resource Nurse Consultant (RNC) present in the room, reviewed Resident 139's HP dated 5/7/2024 and Initial Smoking Safety form dated 5/7/2024. Admin stated that he (Admin) along with his team (DON and RNC) will be joining any facility staff that will be interviewed by Surveyor 1. AD stated that she (AD) completed Resident 139's Initial Smoking Safety Form dated 5/7/2024. When asked about AD's professional background and how AD is able to assess the risk factors listed on the facility's Smoking Safety form such as a resident's cognition, the types of medications that affect the alertness and function of a resident, or the total or limited ROM in the arms or hands of a resident; AD stated that she is not a professional and that a professional such as a "nurse" is supposed to complete a follow up smoking safety assessment after the AD's initial assessment. AD stated that it is the "nurse's" responsibility to assess a resident's cognition, medications, and range of motion and ultimately determine if the resident has the capability to smoke independently. AD stated that she (AD) does not assess the resident's range of motion or a resident's medication regimen (a treatment plan that specifies the dosage, schedule, and the duration of treatment) when completing the facility's Smoking Safety form. AD stated that the facility "pressures" AD to complete the Smoking Safety form for the residents. When the AD was asked how the AD assesses the cognition of a resident when completing the Smoking Safety Form, AD stated that she (AD) asks the residents questions such as where the resident was born, the resident's occupation, the education background of the resident, and the religious preference of the resident. AD stated that based on her assessment of Resident 139 on 5/7/2024, AD determined that Resident 139 did not need supervision a