Health inspection·May 15, 2025

REGULATORY VIOLATION(S): Title 22 California Code of Regulations § 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 the admission of the patient and be completed within seven days after admission. (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 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 each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. Title 22 California Code of Regulations § 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. F689 Title 42 Code of Federal Regulations §483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 4/3/2025, the California Department of Public Health (CDPH) made an unannounced visit at the facility to conduct a complaint investigation related to a fire in a resident’s room due to a resident smoking in the room. During the survey CDPH determined that the facility failed to provide a hazard-free environment and adequate supervision (an intervention and means of mitigating the risk for accidents) and implement both its policy and procedure (PnP) on smoking safety and the plan of care for smoking safety for Residents 7, 8, 9, 10 and 11. The facility failed to: 1. Supervise, monitor, and reevaluate Resident 7 who was not compliant with the facility’s Smoking Policy. 2. Supervise and monitor Residents 8, 9, 10 and 11 for safe smoking by conducting an Interdisciplinary Team (IDT- Interdisciplinary facility staff that meet with the residents to discuss the policies in the facility and care plans to the residents and their representatives) meeting to discuss the risk and benefit of smoking safely prior to allowing the residents to keep in their possession and/or access to smoking materials. 3. Complete IDT meetings for residents that smoke in the facility before allowing unsafe behaviors (e.g., possession of lighters, unsupervised smoking) to continue. These deficient practices resulted in Resident 7 smoking in bed and setting bed linen on fire on 4/2/2025, at 12:50 AM, while three roommates were in the room. The fire department was called and after the fire, there were burn marks on a towel and bedding. In addition, these failures placed others in significant harm which could have potentially led to extensive fire in the facility, severe smoke inhalation (damaging the airways and lungs, potentially leading to difficulty breathing, lung damage, and even death due to lack of oxygen) and death to the residents, staffs, and visitors. 1. A review of Resident 7's Admission Record indicated Resident 7 was admitted on 10/19/2023, and readmitted on 12/29/2024, with diagnoses including heart failure (heart can't pump enough blood to meet the body's needs or demand) and diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). A review of Resident 7's History and Physical Examination (H&P), dated 10/26/2023, indicated Resident 7 had the mental capacity to make medical decisions. A review of Resident 7’s Care Plan for Smoking dated 10/27/2023, but revised on 3/24/2025, indicated Resident 7 may smoke with supervision. The care plan goal indicated Resident 7 may smoke in a designated area safely x (times) 90 days. The interventions included that the facility would supervise Resident 7 when smoking in accordance with assessed needs; monitor resident's compliance with smoking policy and maintain resident's smoking materials at the nurses' station. A review of Resident 7's IDT notes dated 4/10/2024, indicated an IDT meeting was held on 4/10/2024, to address resident behaviors related to nicotine (a chemical in tobacco, which is used in cigarettes, cigars, pipes tobacco, chewing tobacco, some vaping liquids) use. Resident 7 was alert and oriented, acknowledged their concerns, and signed the facility's behavior contract to smoke in the designated smoking areas outside of the facility. A review of Resident 7’s IDT notes dated 5/14/2024, indicated the IDT met with the resident and used a translator to discuss the risks of smoking in unauthorized areas. Resident 7 was encouraged to follow the scheduled smoking times, and Resident 7 agreed to smoke during the smoking times in the designated areas. A review of Resident 7's "smoking evaluation form", dated 2/12/2025, indicated Resident 7 required supervision when smoking due to poor safety judgement and had history of unsafe smoking habits. A review of Resident 7's Change in Condition (COC) Evaluation form, dated 4/02/2025, indicated Resident 7 was smoking in bed and setting fire to bed linen on 4/2/2025 at 12:50 AM. A review of Resident 7 IDT notes dated 4/2/2025, it indicated the IDT met with Resident 7, to discuss the smoking incident when the staff responded to smoke in Resident 7's room and found burn marks on a towel and bedding. There were no injuries noted. Police were notified, and a lighter was confiscated. Roommates were unharmed and had no concerns. Resident 7 was placed on 1:1 (one resident and one staff) monitoring. Resident 7 expressed a desire to smoke freely and agreed to discharge to a lower level of care. MD approved the discharge. During an interview with the Interim Director of Nursing (IDON) on 4/3/2025, at 6:51 PM, the IDON stated Resident 7 was known to be noncompliant with the smoking policy, and had a history of unsafe smoking habits, but she was not aware that Resident 7 kept cigarettes and lighter in his possession. 2. A review of Resident 8’s Admission Record indicated the facility admitted Resident 8 on 1/27/2017, and readmitted Resident 8 on 3/31/2022, with diagnoses including hypertension (high blood pressure) and heart failure. A review of Resident 8's H&P, dated 3/18/2024, indicated Resident 8 had the mental capacity to make medical decisions. A review of Resident 8's "Smoking Evaluation Form", dated 2/12/2025, indicated Resident 8 required supervision with smoking due to poor safety judgement. A review of Resident 8's Care Plan for Smoking, initiated on 2/27/2025, indicated Resident 8 may smoke with supervision. The care plan goal indicated Resident 8 will smoke in designated area safely x 90 days per smoking assessment. The interventions included that the facility would explain to Resident 8 the risk and benefit of smoking safety and will supervise the residents with smoking in accordance with assessed needs and maintain Resident 8’s smoking materials at nurses' station. During an observation in the patio area and concurrent interview on 4/4/2025, at 2:45PM, Resident 8 was observed with a cigarette and a lighter in the pocket of his wheelchair. In an interview Resident 8 stated, he has possession of his lighter and cigarettes because it is his property so he will hold on to them. 3. A review of Resident 9's Admission Record, the facility admitted Resident 9 on 11/23/2022, and readmitted on 9/22/2024, with diagnoses including hemiplegia (unable to move one side of the body) and hemiparesis (severe loss of strength to one side of the body) of the left side of the body and depression (severe sadness and hopelessness). A review of Resident 9's H&P, dated 12/25/2024, indicated Resident 9 had the mental capacity to make medical decisions. A review of Resident 9's Care Plan for Smoking, initiated on 2/27/2025, indicated Resident 9 may smoke with supervision. The care plan goal indicated Resident 9 was to smoke in a designated area safely for 90 days per smoking assessment. The interventions indicated that the facility would explain risks and benefits, supervise residents with smoking in accordance with assessed needs. During an observation on 4/3/2025, at 3:38 PM, in the smoking patio, Resident 9 was observed smoking with a staff supervising the area. Resident 9 had a lighter and stated it was her right to keep the cigarette and lighter in her possession. Then Resident 9 proceeded to place the lighter in a pouch in her wheelchair. 4. A review of Resident 10's Admission Record, the facility admitted Resident 10 on 7/14/2023, with diagnoses including hypertension and diabetes mellitus. A review of Resident 10's H&P, dated 7/18/2023, indicated Resident 10 had the mental capacity to make medical decisions. A review of Resident 10's Smoking Evaluation Form, dated 2/12/2025, indicated that Resident 10 required supervision while smoking due to poor safety judgment. A review of Resident 10's Care Plan for Smoking, initiated on 2/27/2025, indicated Resident 10 may smoke with supervision. The goal was for Resident 10 to safely smoke in designated areas for 90 days, as indicated by the smoking assessment. The interventions included educating the Resident 10 on the risks and benefits of smoking and providing supervision during smoking in accordance with the resident’s assessed needs. A review of Resident 10's clinical record indicated an IDT was not conducted to discuss with the resident about risk and benefit of smoking safely. During an observation and concurrent interview on 4/3/2025, at 2:39 PM, in Resident 10's room, Resident 10 was observed with a box of cigarettes on top of a walker that belonged to Resident 10. Resident 10 stated she holds on to cigarettes because it is her right to keep her possession but was not observed smoking in the room. 5. A review of Resident 11's Admission Record (Face Sheet), the facility admitted Resident 11 on 3/14/2025, with diagnoses including hypertension and heat failure. A review of Resident 11's History and Physical (H&P), dated 3/15/2025, indicated that Resident 11 had the mental capacity to make medical decisions. A review of Resident 11's Smoking Evaluation Form, dated 3/14/2025, indicated Resident 11 was not allowed to smoke due to not being able. During an observation of the Smoking Patio on 4/3/2025. at 12:23 PM, Resident 11 pulled a cigarette out of his hospital gown pocket and lit his own cigarette with another resident's cigarette and started smoking. During an interview with Resident 11 on 4/3/2025, at 12:45PM, Resident 11 stated he smoked a few times a day. When Resident 11 was asked where his lighter and cigarettes were kept, Resident 11 responded that he kept his cigarettes at his bedside. A review of Resident 11's Care Plans from 3/14/2025-4/3/2025, indicated no evidence that a care plan was developed for smoking and an IDT meeting was not conducted to discuss with Resident 11 about the risk and benefit of smoking safely. During an interview on 4/3/2025, at 11:45 AM, Licensed Vocational Nurse (LVN) 1 stated she was not aware that residents kept cigarettes and lighters in their possessions. LVN 1 stated the residents cannot have lighters with them due to fire and safety reasons and because there are residents on oxygen. During an interview on 4/3/2025, at 2:50 PM, Registered Nurse (RN) 1 stated residents are not allowed to have lighters with them due to safety issues, the safety of others, and the presence of oxygen in the residents' rooms. RN 1 stated once residents finished smoking, the lighters are collected by the staff supervising the smoking area. RN 1 stated some residents do keep cigarettes and lighters in their possession, but “I confiscated them because they should not keep cigarettes and lighters with them.” During an interview on 4/3/2025, at 4:45 PM, CNA 5 stated she was working the night of the fire in Resident 7’s room. CNA 5 stated “I smelled something burning and went into the room. The resident’s blanket was burning with smokes and had holes in it.” CNA 5 stated she immediately notified the Charge Nurse and removed the blanket. CNA 5 stated: “Some of the residents have lighters in their rooms. We’re not supposed to let them keep them, but sometimes they won’t give them up, and we’re told to just report it.” CNA 5 stated she was unsure of the smoking policy and said she does not recall the last time the facility provided in-service training specific to smoking safety. During a concurrent interview and record review on 4/3/2025, at 6:59PM, the IDON stated that all the residents that smoke should go through an IDT meeting to discuss residents’ rights and to determine if it's unsafe for them to retain cigarettes and lighters without supervision and a care plan should be developed about smoking safety. The IDON stated according to a record review only 3 residents out of 13 residents that smoke attended an IDT meeting to discuss safety and importance of compliance with the policy. A review of the facility's policy and procedure (P&P) titled, "SMOKING," dated 08/09/22, indicated that the Licensed Nurse would evaluate residents who express a desire to smoke upon admission, quarterly, annually, significant change of condition identification and present the evaluation to the Interdisciplinary Team (IDT). The IDT is required to develop an individualized plan for safe storage, use of smoking materials, and supervision as needed. The policy further noted that residents requiring supervision or monitoring for safety are not allowed to retain smoking materials or smoke unaccompanied and were allowed to smoke outside the facility in designated, marked smoking areas. During the survey CDPH determined that the facility failed to provide a hazard- free environment and adequate supervision and implement both its PnP on smoking safety and the plan of care for smoking safety for Residents 7, 8, 9, 10 and 11 The facility failed to: 1. Supervise and monitor and reevaluate Resident 7 who was not compliant with the facility’s Smoking Policy. 2. Supervise and monitor Residents 8, 9, 10 and 11 for safe smoking by conducting an Interdisciplinary Team meeting to discuss the risk and benefit of smoking safely prior to allowing the residents to keep in their possession and/or access to smoking materials. 3. Ensure to complete IDT for residents that smoke in the facility before allowing unsafe behaviors (e.g., possession of lighters, unsupervised smoking) to continue. These deficient practices resulted in Resident 7 smoking in bed and setting bed linen on fire on 4/2/2025, at 12:50 AM, while three roommates were in the room. The fire department was called and after the fire there were burn marks on a towel and bedding. In addition, these deficient practices placed others in significant harm which could have potentially led to extensive fire in the facility, severe smoke inhalation and death to the residents, staffs and visitors. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.