Failure to Assess Smoking Risks Leads to Fire Incident
Summary
The facility failed to adequately assess a resident for unsupervised smoking and did not adhere to its smoking policy, which led to a fire incident. The resident in question, who had a history of paranoid schizophrenia, cognitive impairment, and other medical conditions, was allowed to smoke unsupervised. Despite having a physician's order for oxygen use, the resident was assessed as a safe smoker without considering his medical and mental health conditions. The smoking assessment form used by the facility did not require evaluation of these critical factors, leading to the resident being classified as an unsupervised smoker. On the day of the incident, the resident was observed on video surveillance entering an auditorium, where he started a fire using tissues and a lighter. The fire was quickly extinguished by staff, and the resident was found with cigarettes and a lighter in his possession. Despite the resident's cognitive impairment and history of hallucinations, the facility's smoking assessment did not account for these issues, allowing the resident to maintain smoking materials unsupervised. Interviews with staff revealed inconsistencies in the smoking assessment process and a lack of clarity in the smoking policy. The facility's policy did not provide clear guidelines on evaluating medical conditions, mental health symptoms, or cognition when determining a resident's supervision level for smoking. This oversight contributed to the incident, as the resident's cognitive and mental health status were not adequately considered in the assessment process.
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.
Smoking policies were not implemented in accordance with Federal, state, and local requirements. A canopy smoking area was set up over one of two handicapped parking spaces near the main entrance, with smoking aprons, receptacles, and a fire extinguisher present, and two residents were observed smoking there. The area was later moved to a location within 25 feet of the entrance and nearby windows that could open, and the Administrator stated there was no definitive plan for the smoking area placement.
Smoking Materials Kept in Resident’s Possession: A resident with cognitive intactness and a smoking eval allowing her to light her own cigarette was observed multiple times removing cigarettes and blue flame lighters from her purse and smoking on the designated patio. The facility’s smoking policy prohibited residents from keeping tobacco products or lighting materials on their person, and staff interviews confirmed that smoking items were supposed to be stored in lockers or secured by clinical staff.
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.
Smoking Area Placement Did Not Comply With Policy or Regulations
Penalty
Summary
The facility failed to ensure its smoking policies were implemented in accordance with applicable Federal, state, and local laws and regulations regarding smoking areas and smoking safety. The facility policy titled, "Resident Smoking Safety," updated January 2025, stated that no smoking was allowed on the facility grounds, including parking lots, except in designated areas. During an observation on 04/07/2026 at 11:00 AM, two handicapped accessible parking spaces were present in the front parking lot to the left of the main entrance, and a pop-up canopy style tent had been set up over one of those spaces. A wooden post with a fire extinguisher was placed next to the canopy, and smoking aprons and smoking receptacles were observed in the area. Two residents were observed sitting under the canopy smoking. During an interview on 04/07/2026 at 1:30 PM, Resident 83 stated they were a smoker, had been in the facility since January 2026, and had been concerned that the smoking area was in the parking lot and blocking one of the handicapped parking spaces. On 04/08/2026 at 2:00 PM, the smoking area had been relocated, but it was then observed to the right of the facility entrance within 25 feet of the entrance and nearby windows that could open. During an interview on 04/13/2026 at 2:00 PM, the Administrator stated they were aware there were issues with the location of the smoking area and that there was not a definitive plan regarding the smoking area or its placement.
Smoking Materials Kept in Resident’s Possession
Penalty
Summary
The facility failed to ensure its smoking policy was followed for one resident who had been readmitted with diagnoses including a displaced fracture of the medial condyle of the right tibia, chronic pain syndrome, schizoaffective disorder, bipolar type, and depression. The resident’s care plan identified a focus for potential injury related to smoking and included interventions for education on safe smoking practices, keeping smoking materials in designated areas, and monitoring compliance with the smoking policy. The resident’s MDS showed a BIMS score of 14, indicating cognitive intactness, and the smoking evaluation stated the resident could light her own cigarette and had received education on safe smoking practices. Despite the smoking policy stating that residents may not keep lighting materials, tobacco products, e-cigarettes, or smoking devices on their person or in their possession, observations showed the resident repeatedly removed cigarettes and a blue flame lighter from her purse. On the smoking patio, the resident took a lighter and pack of cigarettes from her purse, lit a cigarette, and returned the items to her purse. In a later observation in her room, she again removed two packs of cigarettes and two blue flame lighters from her purse. The resident stated she kept her smoking materials in her purse at all times and said there were no set smoking times and she could go out whenever she wanted. Staff interviews confirmed the facility expectation that residents are not allowed to keep smoking materials in their possession and that such items should be stored in lockers or secured by clinical staff. A housekeeping assistant filling in as a smoking attendant stated residents should not keep smoking materials on their person because it posed a safety risk. The RN and DON both stated residents are not allowed to keep lighters or cigarettes in their possession, and that if a resident were found with such items, they should be confiscated and reported immediately. The Activities Supervisor stated independent residents were required to store smoking materials in assigned lockers and were not permitted to keep them on their person, yet the resident was observed with cigarettes and lighters in her purse during the survey.
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