Health inspection·August 20, 2025

F689 Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 7/7/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to conduct the annual recertification survey. As a result of the investigation, the facility failed to ensure Residents 48, 50, and 64 who required supervision while smoking had an environment free of accident hazards by failing to: 1. Implement the facility’s Policy and Procedure (P&P) titled, “Smoking Policy,” which indicated “no lighting materials, tobacco products, or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility.” 2. Ensure Residents 48, 50, and 64 were not in possession of smoking materials. 3. Implement Residents 48, 50 and 64’s Care Plans (CPs) interventions to keep Resident 48, 50 and 64’s smoking materials at the Nurses’ Station and ensure for staff to observe Resident 64 while smoking in designated areas. As a result, Residents 48, 50, and 64 had the lighters and cigarettes in their possession, and had the potential for to turn on their lighters, smoke cigarettes unsupervised inside the facility, cause fire that could affect the health, safety, and wellbeing of all 135 residents, staff, and visitors in the facility. A review of Resident 48’s Admission Record (AR), indicated the facility admitted Resident 48, a 71 yrs old female on 3/12/2025 with diagnoses that included anxiety and bipolar disorder. A review of Resident 48’s Smoking Evaluation (SE) dated 6/17/2025 indicated Resident 48 was a smoker. The SE indicated Resident 48 smoked three to four times a day. The SE indicated for Resident 48’s safety, Resident 48 needed to use adaptive clothing/ device/assistance while smoking and required supervised smoking. A review of Resident 48’s untitled CP dated 6/17/2025 indicated Resident 48 had potential for injury related to smoking. The CP interventions included for facility ‘s staff to maintain smoking materials at the nurse’s station or other designated areas and to monitor to assess compliance with the facility’s smoking policy. During a concurrent observation inside Resident 48’s room and interview with Resident 48 and Certified Nurse Assistant 1 (CNA 1) on 7/7/2025 at 11:30 am, Resident 48 was lying in bed. Resident 48’s room was located next to Resident 15. Resident 15 had chronic obstructive pulmonary disease and was on continuous oxygen use at 2 liters via nasal cannula. Resident 48 stated Resident 48 had been smoking for many years. Resident 48 stated Resident 48 kept cigarettes and lighter in Resident 48’s possession. Resident 48 stated Resident 48’s family member brought cigarettes and lighter to Resident 48 during visitation. Resident 48 stated Resident 48 would smoke anytime Resident 48 wanted to smoke. CNA 1 stated CNA 1 did not know Resident 48 had cigarettes and lighter in Resident 48’s possession. During a concurrent observation at Station 1 Nurse’s Station and interview on 7/7/2025 at 11:40 am with Licensed Vocational Nurse 1 (LVN 1), a blue box was seen on the top shelf inside Station 1 Nurse’s Station. The blue box was locked with residents’ smoking materials. LVN 1 stated Resident 48 did not have cigarettes and lighter locked up inside the blue box. During an interview on 7/7/2025 at 11:57 am with the Activity Director (AD), the AD stated Resident 48 was a smoker and Resident 48 needed supervision while smoking. The AD did not know Resident 48 kept cigarettes and lighter in Resident 48’s possession. The AD stated all residents’ cigarettes and lighters should be kept and locked in a box at Station 1 Nurse’s Station for the safety of the residents and prevent potential fire hazard. During an interview on 7/7/2025 at 12:21 pm with the facility’s Director of Nursing (DON), the DON stated Resident 48 “admitted that Resident 48 currently had cigarettes and lighter in Resident 48’s possession. The DON stated the DON did not know how Resident 48 had cigarettes and lighter in Resident 48’s possession. The DON stated that all residents who smoke were not allowed to keep cigarettes and lighters inside the residents’ room because of fire risks and to ensure the safety of all 135 residents in the facility from fire. During an interview on 7/7/2025 at 12:54 pm with the facility’s Administrator (ADM), the ADM stated the ADM retrieved one functional white lighter and 1 pack of cigarettes from Resident 48. The ADM stated the ADM did not know Resident 48 had cigarettes and lighter in Resident 48’s possession and did not know how Resident 48 obtained the cigarettes and lighter. The ADM stated that none of the smokers were allowed to keep cigarettes and lighters in their possessions inside their rooms to prevent them from lighting the cigarettes up for the safety of all 135 residents in the facility.  b. A review of Resident 50’s AR indicated the facility admitted Resident 50, a 65 yrs old male on 2/9/2023 and readmitted on 5/3/2023 with diagnoses that included heart failure and a pacemaker. A review of Resident 50’s untitled CP revised 4/25/2025 indicated Resident 50 had the potential for injury related to smoking. The CP interventions included explaining the smoking policy to Resident 50, maintaining smoking materials at the nurses’ station, and monitoring Resident 50 to assess compliance with the facility’s smoking policy and individual plan. The CP goal indicated for Resident 50 to be compliant with smoking protocols, individual smoking plan, and follow the smoking policy. A review of Resident 50’s SE dated 5/15/2025 indicated for Resident 50’s safety, Resident 50 needed to use adaptive clothing/device/ assistance while smoking and required supervised smoking. During an interview on 7/7/2025 at 12:13 pm Resident 50 stated Resident 50 kept Resident 50’s cigarettes and lighter in Resident 50’s possession and smoked in the patio. Resident 50 shouted and refused to answer how long Resident 50 had cigarettes and lighter in Resident 50’s possession. During an interview on 7/7/2025 at 12:58 pm with the facility’s DON, the DON stated the DON was not aware Resident 50 had kept Resident 50’s cigarettes and lighter at Resident 50’s bedside. The DON stated Resident 50 could only smoke with supervision and no residents were allowed to keep cigarettes in their possession according to the facility’s policy on smoking. The DON stated all cigarettes and lighters needed to be kept locked at Station 1 Nurse’s Station. The DON stated residents who smoke were not allowed to keep lighters at their bedside for safety. The DON stated, due to oxygen being flammable, there was a potential risk that the whole facility could catch fire when smokers had lighters and cigarettes in their possession. During a concurrent observation in the hallway and interview on 7/7/2025 at 1:25 pm with the ADM, one box of cigarettes and one yellow lighter were in a clear bag with Resident 50’s name on the bag. The ADM stated the items were taken from Resident 50 on 7/7/2025 and the lighter in Resident 50’s possession was functioning. c. A review of Resident 64’s AR indicated the facility admitted Resident 64, a 58 yrs old male on 5/9/2022 and readmitted on 8/25/2023, with diagnoses that included anxiety disorder and palliative care. A review of Resident 64’s untitled CP revised 2/21/2025 indicated Resident 64 had the potential for injury related to smoking. The CP goal indicated for Resident 64 to be compliant with the facility’s smoking protocol and individual smoking plan. The CP intervention included maintaining Resident 64’s smoking materials at the nurse’s station or other designated area and monitoring Resident 64 to assess compliance with facility smoking policy/individual plan. The CP interventions also indicated for staff to observe Resident 64 while smoking in designated areas. A review of Resident 64’s SE dated 2/21/2025 indicated Resident 64 smoked four to five times per day. The SE indicated for Resident 64’s safety, Resident 64 needed to use adaptive clothing/devices/assistance while smoking and required supervised smoking. A review of Resident 64’s Minimum Date Set (MDS, a resident assessment tool) dated 5/21/2025 indicated Resident 64 had short term memory problem. A review of Resident 64’s Interdisciplinary Team (IDT) Brief Interview for Mental Status Assessment dated 5/21/2025 indicated Resident 64 had severely impaired cognition status. During an interview on 7/7/2025 at 12:15 pm with Resident 64, Resident 64 stated Resident 64 had a lighter and cigarettes inside Resident 64’s pocket. During an interview on 7/7/2025 at 12:16 pm with the AD, the AD stated Resident 64 should not have lighters because it would not be safe for Resident 64 to smoke inside Resident 64’s rooms due to fire hazard. The AD stated the only location for smoking would be the facility’s smoking patio.  The AD stated no residents could keep cigarettes and lighters at the bedside.  During an interview on 7/7/2025 at 1:23 pm with the ADM, the ADM stated there were 40 sticks of cigarettes and a blue lighter retrieved by the ADM from Resident 64’s pocket. The ADM stated Resident 64 could have bought the cigarettes when Resident 64 went out on pass. During an interview on 7/7/2025 at 1:29 pm with Resident 64, Resident 64 stated Resident 64 found the lighter last night (7/6/2025) inside the pocket of Resident 64’s jacket. Resident 64 stated Resident 64 bought the cigarettes when Resident 64 went outside of the facility during an out on pass. During an interview on 7/7/2025 at 2:23 pm, CNA 7 stated Resident 64 was independent and would go anytime to the smoking patio because Resident 64   had access to the pin code to the smoking patio. CNA 7 stated Resident 64 would go to the smoking patio even if it was not the scheduled smoking time because Resident 64 had access to the pin code to the smoking patio. CNA 7 stated, if Resident 64 would come and go to the smoking patio anytime, facility staff would not be able to monitor Resident 64 while smoking. During an interview on 7/7/2025 at 5:15 pm, with the facility’s DON and ADM, the DON and ADM stated Resident 64 needed to be monitored and supervised when smoking. During an interview on 7/8/2025 at 4:00 pm, with the Assistant Director of Nursing (ADON), the ADON stated only a designated person should know the access pin code to the smoking patio to ensure residents who smoke would be supervised when smoking. The ADON stated the residents who smoke should not have the access pin code to the smoking patio. A review of the facility’s P&P titled, “Smoking Policy,” revised 4/2024, the P&P indicated, “Designated smoking areas outside the building are available for this purpose based on the facility smoking schedule with assigned staff to supervise. No lighting materials (e.g. matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility. If it is determined that a resident is a safe smoker (someone who smokes in a way that reduces risk to others) all smoking materials will still be retained by nursing staff.” The facility failed to ensure Residents 48, 50, and 64 who required supervision while smoking had an environment free of accident hazards by failing to: 1. Implement the facility’s P&P titled, “Smoking Policy,” which indicated “no lighting materials, tobacco products, or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility.” 2. Ensure Residents 48, 50, and 64 were not in possession of smoking materials. 3. Implement Residents 48, 50 and 64’s CP interventions to keep Resident 48, 50 and 64’s smoking materials at the Nurses’ Station and ensure for staff to observe Resident 64 while smoking in designated areas. As a result, Residents 48, 50, and 64 had the lighters and cigarettes in their possession, and had the potential for to turn on their lighters, smoke cigarettes unsupervised inside the facility, cause fire that could affect the health, safety, and wellbeing of all 135 residents in the facility, staff, visitors. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 48, 50 and 64.