Failure to Complete and Update Smoking Evaluations per Facility Policy
Summary
The deficiency involves the facility’s failure to follow its smoking policy and procedure for a resident who smoked. The resident had diagnoses including diabetes mellitus and heart failure and was documented in a recent H&P as having the capacity to understand and make decisions. An MDS assessment indicated the resident was independent in cognitive skills for daily decision making and independent in most ADLs, with supervision needed only for showering/bathing and footwear. The facility’s smoking evaluations for this resident, dated 11/13/2025 and 2/12/2026, were incomplete and did not document smoking frequency, smoking safety, whether the care plan was updated, or whether the resident received education on safe smoking practices, risks of smoking, or locations of designated smoking areas. A care plan for noncompliance with the smoking policy, dated 3/10/2026, only indicated that the intervention was to explain smoking P&P. Record review and staff interviews showed that the facility’s policy required all residents to be assessed to determine if it was safe for them to smoke, with results placed in the medical record, and that residents’ ability to smoke safely would be reassessed quarterly and whenever there was a change in cognition. The MDS nurse stated that smoking evaluations are to be completed quarterly, annually, or with a change in condition, that the form must be completely filled out to be valid, and that she had not completed the smoking evaluation for this resident. The DON confirmed that smoking evaluations are used to determine if it is safe for a resident to smoke, are to be completed quarterly and annually, and that all sections of the form must be completed or a reason documented if the resident refuses. The resident’s medical record did not contain a reassessment of smoking ability after a change of condition on 3/10/2026, and staff acknowledged that incomplete or untimely smoking evaluations could create smoking safety issues and that failure to complete the form could mean the resident was not informed of the smoking P&P.
Penalty
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The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
Unsafe Smoking Area Maintenance and Policy Enforcement: The facility failed to enforce smoking safety policies in a smoking area outside the dining room. An observation found paper trash in ashtrays and cigarette butts in a trash can with a plastic liner. The Maintenance Supervisor and Administrator both stated trash should not be in ashtrays and cigarette butts should not be placed in the trash, and the facility policy stated ashtrays are emptied only into designated receptacles.
Lack of Smoking Policy and Unsafe Resident Smoking Practices: A resident who was allowed to smoke was observed using a lighter without staff present, with her procedure mask pulled down around her chin, and using a cup on her wheelchair to extinguish cigarettes instead of facility ashtrays. Staff stated the resident sometimes kept the lighter and that the facility had no policy outlining smoking expectations for residents allowed to smoke; the DON said the resident was expected to smoke in the designated area, use facility ashtrays, and return the lighter to the charge nurse.
Smoking Area Fire Cans Contained Trash: The facility failed to enforce its smoking policy in the main designated smoking area under the car port. An observation found two red fire cans containing cigarette butts, empty cigarette paper boxes, soda cans, chip bags, and other paper and plastic trash. The Maintenance Director said he was responsible for maintaining the smoking areas and emptying the fire cans, and the DON stated staff assisting residents with smoking should ensure there was no trash in the red fire can. The facility policy stated that ashtrays were to be emptied only into designated receptacles.
A resident with continuous O2 via NC was observed on a patio while several residents were smoking nearby, including one resident standing about 2 to 3 feet from the portable O2 tank with a lit cigarette. Staff were unsure of the required separation distance, and the smoking policy prohibited O2 use in the smoking area but left the distance requirement blank.
Failure to Follow Smoking Policy for Multiple Residents: The facility did not consistently implement its smoking policy for multiple residents who smoked. A resident with COPD and nicotine dependence kept a lighter under her wheelchair cushion, another resident with serious mental health diagnoses kept cigarettes, lighters, matches, and e-vapes on her person and in her room, and a third resident with a history of TIA/CVA kept cigarettes and a lighter in her room and on her person despite a signed policy requiring secure storage. Staff interviews showed conflicting understanding of whether smoking materials could be kept by residents.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Unsafe Smoking Area Maintenance and Policy Enforcement
Penalty
Summary
The facility failed to formulate, adopt, and enforce policies regarding smoking, smoking areas, and smoking safety that also considered non-smoking residents for 1 of 2 smoking areas reviewed, the smoking area outside the dining room. During an observation on 4/27/2026 at 11:46 a.m., three ashtrays were present in that smoking area, and two of the three ashtrays contained paper trash. The trash can in the area had a plastic liner with cigarette butts inside. During interviews, the Maintenance Supervisor stated he had worked at the facility since October 2025 and said he and housekeeping staff checked the smoking areas daily for trash and made sure trash and butts were in the right spots. He said trash should be in the trash receptacles and butts should be in the ashtray and/or in the red cans, and that butts should never be placed in the trash. He also said there should not be any trash in the ashtrays and there could be a risk of fire. The Administrator stated the smoking areas were the responsibility of housekeeping and Maintenance daily, that the smoking area outside the dining room was for everyone that smoked, and that staff should empty the ashtrays into the cans after each smoke break. She said trash should not be in the ashtrays and there was a risk of potential fires. Record review of the facility's Smoking Policy-Residents dated October 2022 stated the facility shall establish and maintain safe resident smoking practices and that ashtrays are emptied only into designated receptacles.
Lack of Smoking Policy and Unsafe Resident Smoking Practices
Penalty
Summary
The facility failed to develop and implement a policy and procedure for smoking for one resident who was allowed to smoke. During an observation on 4/21/26 at 11:06 a.m. in the courtyard outside the activities room, the resident used a lighter to light a cigarette while her procedure mask was pulled down around her chin, and no facility staff were present. No ashtrays were within reach, and there was a no smoking sign on the activities room door. During another observation at 11:20 a.m. the same day, the resident extinguished her cigarette on the side of a cup hanging on her wheelchair and placed the cigarette butt in the cup, then lit another cigarette while still wearing the mask pulled down around her chin, again with no staff present. On 4/23/26 at 9:25 a.m., the resident was observed lying in bed with eyes closed and not responding when greeted. Her wheelchair had a cup attached to the side containing a cigarette case, and the case contained a lighter. During a concurrent observation and interview, a CNA stated the resident was not allowed to keep the lighter and was supposed to give it back to staff after smoking. An RN stated the resident sometimes did not return the lighter and staff had to look for it, and that the resident sometimes used the cup on the wheelchair for cigarette butts instead of the facility-provided ashtrays. The RN also stated the facility had multiple confused residents who liked to wander and were at risk of injury due to access to the lighter. The DON stated there was no policy outlining expectations for residents who were allowed to smoke, and that the resident was expected to smoke in the designated smoking area, use facility-provided ashtrays, and return the lighter to the charge nurse to be locked up until needed again.
Smoking Area Fire Cans Contained Trash
Penalty
Summary
The facility failed to ensure that its smoking policies were formulated, adopted, and enforced for the main designated smoking area under the car port. During an observation on 04/13/26 at 12:20 p.m., the two red fire cans in that smoking area were found to contain cigarette butts, empty cigarette paper boxes, empty soda cans, chip bags, and other plastic and paper trash. The Maintenance Director emptied the trash from both fire cans and stated that he was responsible for maintaining the smoking areas, including emptying the red fire cans, and that he had done so that morning. He said he would schedule rounding more frequently and stated that the red fire cans should only contain cigarette butts because other trash could be a fire hazard. During an interview on 04/13/2025 at 4:00 p.m., the DON stated that the designated smoking areas were to be maintained by the Maintenance Director, but all staff who assisted residents to smoke should be mindful of the ashtrays and fire cans and ensure there was no trash in the red fire can. She said she would see to it that staff were re-trained on the smoking policy and maintenance of the smoking areas. Record review of the facility's Smoking Policy-Resident dated 2001 stated that the facility had established and maintained safe resident smoking practices, that metal containers with self-closing cover devices were available in smoking areas, and that ashtrays were emptied only into designated receptacles.
Oxygen Used Near Smoking Residents
Penalty
Summary
The facility failed to ensure that oxygen was kept away from residents who were smoking for 1 of 1 resident observed with oxygen in use. Resident #13 had diagnoses including CVA, anemia, hypertension, and CHF, and the MDS indicated the resident did not use tobacco but did use continuous oxygen. The care plan documented continuous O2 via nasal cannula due to risk for altered oxygen levels, chest pain, and shortness of breath, and the order summary showed continuous oxygen at 1.5 to 2 liters per minute. During observation, Resident #13 was seated in a wheelchair on the patio with portable oxygen connected and running at 2 liters per minute while several residents were smoking nearby. A male resident was observed approximately 2 to 3 feet from the resident's portable oxygen tank while holding a lighted cigarette. Resident #13 stated she did not know the smokers would be coming out to smoke. Staff interviews showed that smoking residents were taken to a designated smoking patio, nonsmoking residents used the front patio, and staff did not know how far a smoking resident should be kept from someone on oxygen. The Administrator stated she preferred a resident on oxygen to be a little ways away from someone smoking, estimating probably 20 feet, while the facility's smoking policy stated oxygen use in the smoking area is prohibited and left the distance requirement blank.
Failure to Follow Smoking Policy for Multiple Residents
Penalty
Summary
The facility failed to implement its smoking policy for three residents who were identified as smokers. Resident #12 had diagnoses including type 2 diabetes mellitus, nicotine dependence, COPD, depression, anxiety, and seizures, and had a BIMS score of 15. Although a safe smoking assessment and smoking evaluation were documented, the resident stated that she kept cigarettes and an orange lighter under the cushion of her wheelchair in her room, and an observation confirmed the lighter was stored there. The resident also stated that she smoked in the designated smoking area and that the Activity Director purchased and supplied cigarettes and lighters for residents. Resident #26 was admitted with diagnoses including paraplegia, major depressive disorder, anxiety disorder, bipolar disorder, and schizoaffective disorder, and had a BIMS score of 15. The record showed a progress note identifying her as a smoker and orienting her to the smoking areas, but there was no evidence of a smoking assessment or signed smoking policy in the record at that time. During interviews and observation, Resident #26 stated that she kept cigarettes, lighters, matches, and electronic vapes on her person and in her room, and she showed six electronic vapes, a box of cigarettes, and a lighter. The interim DON observed the items and confiscated them during the interview. Resident #41 had diagnoses including a history of TIA and cerebral infarction without residual deficits, major depressive disorder, and polyneuropathy, and had a BIMS score of 15. The record included a smoking assessment and a signed smoking policy stating that smoking materials were to be stored in a secure area and not kept on the resident’s person. However, interviews and observation showed that Resident #41 kept smoking materials on her person and in her room, including two boxes of cigarettes and a lighter. Staff interviews showed conflicting understanding of the smoking policy, with some staff stating residents were not allowed to keep smoking materials in their rooms or on their persons, while others stated unsupervised smokers could keep them on their person.
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