That resident was identified in inspection records only as R2.
Nursing Home News — Page 17
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Resident 35, as he is identified in the report, was admitted to the Rosemead facility sometime before February 2026.
The man in the room, identified in inspection records only as Resident 32, is in his seventies.
The dietary supervisor, interviewed at 10:05 that morning, said staff were supposed to check the red onions every day.
Federal inspectors documented the lapse during a complaint inspection on March 27, 2026.
Inspectors cited Hawthorne Healthcare & Wellness Centre, LP, on 11630 South Grevillea Avenue following a survey completed March 27, 2026.
Federal inspectors cited the facility following a complaint inspection on March 27, 2026.
They found him again two days later, on March 27, in the same condition: oxygen flowing, cigarette box in his shirt pocket, lighter inside it.
Federal inspectors watched the procedure unfold at 11:41 p.m.
Inspectors with the Centers for Medicare and Medicaid Services visited the facility at 2400 Quaker Ave on March 27, 2026.
The incident at North Pointe Care Center, a skilled nursing facility at 500 Jessie Avenue in Sacramento, took place on February 6, 2025.
A cook on the morning shift had told him they were out of breakfast meat.