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F0689
D

Unsecured Smoking Materials and Oxygen Use Create Accident Hazard

Modesto, California Survey Completed on 04-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safety of 89 residents from accidental hazards related to unsecured smoking materials. One resident, who was receiving oxygen via nasal cannula, kept cigarettes and a lighter unsecured in her purse within her room and did not have a lock box, despite a history of noncompliance with the facility's smoking policy and a signed agreement acknowledging the need to secure such items. The resident expressed a desire to smoke at will and kept her smoking materials accessible, even while on oxygen, which was confirmed during interviews and observations with facility staff and the administrator. Additionally, another resident's room was found to have unsecured smoking paraphernalia, including loose tobacco and an unfilled cigarette wrapper, left unattended on the bed while the resident was not present. Staff interviews confirmed that these items should have been secured, typically in a locked medication cart or at the nurse's station, and that the resident did not have a lock box in the room. The facility's smoking policy required assessment and individualized interventions for safe smoking, including secure storage of smoking materials, but these procedures were not followed for the residents involved.

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