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F0656
D

Failure to Secure Smoking Materials as Directed in Care Plan

Lakeport, California Survey Completed on 06-19-2025

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 implement a comprehensive, person-centered care plan for one resident when the intervention to store cigarettes and a lighter in a lock box was not followed. During observations, it was noted that the resident's room door was open while the resident was not present, and cigarette lighters and packs of cigarettes were left unattended on the bed and nightstand. Staff interviews confirmed that cigarettes and lighters should have been secured in a lock box as per the resident's care plan to prevent unauthorized access by other residents. Record review showed that the care plan specifically required cigarettes and lighters to be stored in the resident's lock box. Both a CNA and an LVN acknowledged that the care plan was not implemented as directed, and the Director of Nursing confirmed that all staff are responsible for following care plan interventions. The facility's policy also requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident.

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