Non-Compliance with Smoking Policy and Resident Safety
Summary
The facility failed to ensure compliance with its smoking policy, resulting in several deficiencies. One resident was observed smoking only a few feet away from the activities room door, allowing cigarette smoke to enter the facility, contrary to the policy requiring smoking to occur at least 25 feet from exits and common spaces. Additionally, a resident was found with personal tobacco in their room, indicating that smoking materials were not stored in the designated secure location as required by the facility's policy. Furthermore, the facility did not adequately assess the cognitive abilities of residents to determine their need for supervision while smoking. Two residents with low Brief Interview for Mental Status (BIMS) scores, indicating severe cognitive impairment, were listed as not needing supervision while smoking. This oversight suggests a failure to properly evaluate and document the residents' ability to safely smoke independently, as outlined in the facility's smoking policy.
Penalty
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A resident with DM, heart failure, and documented decision-making capacity was allowed to smoke without the facility completing required smoking evaluations in accordance with its P&P. Two smoking evaluation forms were left incomplete, lacking documentation of smoking frequency, smoking safety, care plan updates, and resident education on safe smoking practices, smoking risks, and designated smoking areas. Despite a care plan problem for noncompliance with the smoking policy and a noted change in condition, no reassessment of the resident’s smoking ability was found in the medical record. The MDS nurse and DON confirmed that smoking evaluations must be completed quarterly, annually, and with changes in condition, that all sections must be filled out or refusals documented, and that failure to do so could create smoking safety issues.
The facility failed to enforce its safe smoking policies, allowing multiple residents to possess cigarettes and lighters in their rooms or on their person instead of in required lockboxes, and to smoke outside designated areas. A resident with extensive medical conditions and nicotine dependence was documented smoking and drinking alcohol in her room and later found with a lighter, despite being classified as a supervised smoker who could not safely use a lighter. Other residents were observed with smoking materials at bedside while oxygen equipment was in use, with burn holes in clothing, storing cigarettes in trash or under bedding, and smoking at the facility entrance rather than in the designated smoking area. Staff acknowledged that residents sometimes obtained smoking materials from families or store trips and that room sweeps occurred, but unsecured smoking materials and noncompliance with smoking rules remained widespread.
The facility failed to implement and maintain a clear and safe smoking policy, resulting in residents using an unsafe smoking area in a parking garage that was littered with cigarette butts and had blocked or improperly placed fire safety equipment. Although the written policy prohibited on-premises smoking and required certain residents to smoke off premises under supervision, it did not define the premises, a designated smoking area, or rules for residents admitted before a specified date. The administrator and DON identified multiple resident smokers, allowed some to be grandfathered to smoke in the garage, and reported that smoking supplies were kept on the med cart and checked out by residents, but both acknowledged the policy was unclear and not followed, and that there was a breakdown in the system for managing resident smoking.
A resident with psychiatric diagnoses but intact cognition, who had been evaluated as safe to smoke independently and educated on the facility smoking policy, was observed smoking in a front patio area instead of the designated smoking area. Staff were seen entering and exiting without intervening, despite a care plan goal to prevent smoking-related accidents and observe for unsafe smoking behaviors. The DON acknowledged prior awareness that this resident did not always follow the smoking policy and confirmed that smoking was permitted only in the designated outdoor area equipped with safety devices.
The facility failed to follow its own smoking and smoke‑free policies, which require a designated smoking area with posted signage and restrict smoking to that area. Four residents who smoke were instead instructed by staff to leave facility property to smoke, with cigarettes stored on the med cart and signed out before departure. One resident was observed independently wheeling across uneven terrain in cold weather to an off‑property location to smoke without staff supervision, and other residents reported propelling themselves in wheelchairs to a public sidewalk or up a hill off the grounds to smoke, sometimes being told to remain out of sight. No designated smoking area or signage existed on or off the property, despite policy requirements and staff and administrator acknowledgment that residents were smoking outside the facility.
The facility failed to follow its smoking policy and standard care plan procedures for multiple residents who smoked. Several residents with complex medical conditions had either no identified smoking risk on their care plans or, when smoking risk was documented, lacked the required MD orders for smoking, despite having signed smoking contracts. The standard care plan and smoking policy required an MD order, supervised smoking only in designated areas at designated times, and quarterly assessment, but these elements were not consistently implemented or documented. Staff interviews showed that a CNA did not know the smoking policy or where smoking status was recorded, an LPN believed smoking orders were unnecessary despite care plan language requiring them, the admissions coordinator was often unaware of smoking status at admission and unfamiliar with the full policy, the DON knew only what was in the smoking contract and acknowledged that providers might be unaware of residents’ smoking status without orders, and the administrator described policy elements such as supervision and smoking aprons while indicating that care plan interventions were part of the policy.
Failure to Complete and Update Smoking Evaluations per Facility Policy
Penalty
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.
Failure to Enforce Safe Smoking Policies and Control Smoking Materials
Penalty
Summary
The deficiency involves the facility’s failure to implement and enforce its own safe smoking policies and procedures for residents who smoke. The facility’s smoking policy required that smoking occur only in designated areas and times, that all smoking materials (including cigarettes and lighters) be locked when not in use, and that supervised smokers not be given personal possession of smoking materials. Despite this, multiple residents were observed with cigarettes and lighters in their rooms or on their person, and smoking paraphernalia was found in inappropriate locations within the facility. The facility census included 37 smokers out of 164 residents. One resident with multiple medical diagnoses including hypertensive heart and chronic kidney disease, type 2 diabetes, end stage renal disease, atrial fibrillation, vascular dementia, post-traumatic stress disorder, anxiety, and nicotine dependence had a care plan addressing potential tobacco-related injuries and infection control issues. This resident was documented as having been found drinking vodka and smoking in her room, and later having a lighter in her room, despite being care planned as a supervised smoker who could not safely use a lighter and was to smoke only in designated areas. Other residents were observed with cigarettes and lighters not stored in lockboxes as required. One resident’s room contained a pack of cigarettes and a lighter on the bedside table while an oxygen concentrator was running, and this situation was observed on more than one occasion. Another resident was reported by CNAs to have smoked in his room while his roommate, who used oxygen, was present. Additional observations showed residents keeping cigarettes and lighters at bedside or on their person, including a resident in the hallway with cigarettes and a lighter and clothing with multiple burn holes, and another resident with cigarettes and a lighter at bedside who stated she could not access the designated outdoor smoking area due to a damaged sidewalk. Cigarettes and lighters were also found on the floor of a resident’s room across from a room where oxygen was in use, and smoked smoking paraphernalia was found placed on a vitals machine at a nursing station. Other residents were seen with cigarette packs on the floor or hidden in trash or under bedding, refusing to relinquish them, and one resident was observed smoking in front of the facility rather than in the designated smoking area. Staff interviews confirmed that residents sometimes obtained cigarettes and lighters from family or store trips and that room sweeps were done, but these measures did not prevent the widespread presence of unsecured smoking materials and smoking outside of designated areas, contrary to facility policy.
Failure to Implement and Maintain Safe Smoking Policy and Area
Penalty
Summary
The facility failed to implement and effectively maintain a smoking policy in accordance with Federal, State, and local laws and regulations, resulting in unsafe smoking practices for resident smokers, non-smokers, and staff. The written smoking policy prohibited residents from smoking cigarettes, marijuana, tobacco products, e-cigarettes, and vaping devices anywhere on the premises and required residents admitted after 04/18/2024 to smoke off premises under direct supervision of a non-staff responsible party, with all smoking supplies stored off premises. The policy stated that staff would assess smokers for smoking safety, handling of smoking materials, and use of mobility devices outside, and that residents would sign out to smoke and sign back in upon return, with a section for residents to acknowledge and comply with the policy. However, the policy did not define where the premises ended, did not identify a designated smoking area, did not define smoking safety, and did not address rules for residents admitted prior to 04/18/2024. Surveyor observation showed that the designated smoking area used by residents was in the back of the parking garage, where the ground was littered with hundreds of cigarette butts. A fire extinguisher was found lying on the ground in the gravel, and a fire blanket and a second fire extinguisher were mounted on the wall but blocked by two large trash cans, a chair, and a bed frame, making them inaccessible. A maintenance assistant confirmed that certain residents were allowed to smoke in this area, acknowledged the large number of cigarette butts, and identified the fire extinguisher on the ground as unsafe. The administrator and DON reported that 17 residents were known smokers, that residents signed a non-smoking policy on admission, and that three residents were grandfathered under a prior policy allowing them to smoke in the parking garage while other residents were required to go off property to smoke. The DON stated that active smokers were assessed as independent, with assessments and smoking-focused care plans in their records, and that smoking supplies were kept on the med cart and checked out by residents who then signed out to smoke. When asked if the policy was being followed, the administrator stated the policy was unclear and not followed by residents or staff, and the DON stated there was a breakdown in the system of residents smoking. An interim administrator later stated that the facility did not implement or maintain a smoking policy that supported resident rights and safety.
Failure to Enforce Designated Smoking Area Policy
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible by not enforcing its smoking policy for one resident. The resident had a history of bipolar disorder, depression, anxiety, schizophrenia, and post-traumatic stress disorder, but a BIMS score of 15/15 indicating no cognitive impairment. Her initial smoking evaluation documented no deficits preventing her from smoking independently and unsupervised, and staff had reviewed the smoking policy with her, with documentation that she verbalized understanding. Her care plan, revised on 6/16/25, identified her as a smoker with a goal to prevent accidents while smoking and to observe her for unsafe smoking behaviors or attempts to obtain smoking materials from outside sources. On observation, the resident was seen sitting in a wheelchair and smoking a cigarette in the front patio area, which was not the designated resident smoking area. When asked if she was allowed to smoke in the patio, she stated she was allowed to sign out and could smoke when she left the premises, and did not answer when asked again if she could smoke in the patio. Staff were observed entering and exiting the facility during this time, and none approached the resident. The DON reported awareness that the resident did not always follow the smoking policy and stated she had previously seen the resident smoking in the front patio. The DON confirmed that per policy the resident was only allowed to smoke in the designated smoking area at the back of the facility, where metal ashtrays, a fire blanket, and a fire extinguisher were located, and stated that all staff were responsible for monitoring and reporting residents who smoked outside designated areas because the resident could start a fire and other residents could get hurt.
Failure to Implement Smoking Policy and Provide Designated Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to implement and enforce its own smoking policies, which require that residents deemed safe to smoke may do so only in designated smoking areas, at designated times, and in accordance with their individualized care plans. The facility’s smoke-free policy also states that smoking, including e‑cigarettes, is prohibited in all areas except a designated smoking area, and that a designated smoking area sign will be prominently posted. Surveyors reviewed these policies and then observed that there was no designated smoking area or signage on or off facility property. The Administrator acknowledged awareness that four residents smoke outside the facility and confirmed that the facility was not following its smoke-free policy because no designated smoking area had been established. Surveyors identified four residents as smokers. A RN reported that the facility is a non‑smoking facility and that residents who smoke are instructed to leave the property to do so, with their cigarettes stored in the medication cart and signed out on a log before they leave. One resident was observed independently wheeling himself in a wheelchair across uneven terrain in cold weather to an off‑property location to smoke, without staff supervision or redirection, and this location was not identified as a designated smoking area. Another resident stated he obtains cigarettes from nursing staff and is instructed to go to the public sidewalk along the street to smoke and to remain out of sight while smoking. A third resident reported he smokes twice per day and must propel himself in his wheelchair up a hill and off facility grounds to smoke, having been informed the facility is non‑smoking and that residents must go off grounds. A smoking assessment for another resident documented that the resident smokes, does not follow the non‑smoking policy, was determined able to smoke independently, and had been educated on the facility’s smoking policies and risks, yet the facility still lacked a designated smoking area as required by its own policies.
Failure to Implement and Document Required Smoking Policy and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its smoking policy and standard care plan procedures for multiple residents who smoked. For seven residents with various medical conditions, including end stage renal disease, COPD, cardiovascular disease, diabetes, and psychiatric and neurologic diagnoses, the clinical record review showed either no initial identification of smoking risk on the care plan or, when smoking risk was identified, the required physician orders for smoking were absent. One resident’s care plan initially lacked any identified smoking risk, and another resident’s smoking activity was only documented under activities interests as a desire to be included in smoke breaks, without a corresponding smoking risk care plan. In all reviewed cases, the residents had signed smoking contracts acknowledging the facility’s smoking policy. Further review of the care plans for several residents showed a standardized problem of “risk related to smoking” with interventions that explicitly required an MD-signed order, consent signed by the responsible party, smoking only with supervision in a designated area, and quarterly smoking assessment per protocol. Despite these written interventions, the physician order sections of the records contained no smoking orders for any of the seven residents. The facility’s written policy, “Resident Smoking,” stated that smoking safety is included in the Standard Care Plan and reviewed at least quarterly, and the Standard Care Plan specified that an MD order is required, smoking is allowed only with supervision at designated times and locations, and smoking supplies are to be left with personnel. Staff interviews revealed a lack of awareness and inconsistent practices regarding identification and management of residents who smoke. A CNA reported she was unsure where in the chart a resident’s smoking status was documented and learned who smoked only when other staff informed her; she also stated she did not know the smoking policy. An LPN stated he knew which residents smoked based on familiarity and did not think residents needed a smoking order, believing that signing the contract was sufficient, even though he read aloud from a care plan that an MD order was an intervention. The admissions coordinator stated she was not often aware of smoking status at admission, sometimes documented it when known, and did not know the full policy beyond designated times and the need for accompaniment. The DON stated all residents sign the smoking contract regardless of smoking status and acknowledged not being aware of the smoking policy beyond the contract, noting that without smoking orders providers may be unaware of residents’ smoking status. The administrator stated the smoking policy includes supervision and use of smoking aprons and, after reviewing the policy, indicated that the care plan interventions were part of that policy.
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