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
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Complete Quarterly Smoking Evaluations: The facility did not ensure that five residents with schizophrenia or paranoid schizophrenia were evaluated quarterly for smoking as required by policy. Their most recent smoking evaluations were past due, and RN and DON interviews confirmed the evaluations should have been completed every three months and reviewed by the IDT.
Smoking Policy Not Consistently Enforced: A cognitively intact resident with COPD was allowed independent leave to smoke off-property, but staff did not consistently collect his cigarettes and lighter or prevent him from keeping smoking materials on his person inside the facility. The resident reported inconsistent enforcement of leave-of-absence hours, and an observation found cigarettes and a lighter stored on his walker.
A resident with intact cognition and physical weakness was allowed to keep cigarettes on his person, but the facility had no documented safe smoking evaluation, no smoking care plan area, and no smoking assessments in the EMR. Staff also observed smoking in a no-smoking area on the back patio, where no-smoking signs, an ashtray, and a trash can were present, while the ADM stated residents were allowed to smoke unsupervised and smoking items were found in non-designated areas.
A resident was observed smoking cannabis about 10 feet from a building entrance in a non-designated area, despite the facility’s smoking policy and THC policy prohibiting cannabis use on the property. The resident was cognitively intact, had diagnoses including CKD, GERD, neuropathy, MDD, and edema, and stated he/she obtained marijuana from an outside source and would not stop using it. Staff interviews showed inconsistent understanding of smoking locations, and the resident’s care plan documented tobacco dependence and prior cannabis use on facility grounds.
A facility failed to enforce smoking safety policies in the smoking area for halls C/D when a red butt can was found holding cigarette butts plus a plastic wrapper, gloves, and a plastic wrist band. The Housekeeping Supervisor, ADON, DON, RDO, Administrator, and Maintenance Supervisor all stated that the red cans were for cigarette butts only and that trash belonged in the trash can, while the Maintenance Supervisor said staff were always putting trash in the smoking can and a sign had been posted to remind staff.
Smoking Break Schedule Not Followed: A facility failed to enforce its smoking schedule and related smoking policies for residents who smoked. Several residents were scheduled for a 10:30 A.M. supervised smoke break, but they were still inside during observation and did not go out until later. Interviews showed the SS created the schedule, but staffing changes were not communicated timely, and staff reported the smoke breaks were often late.
Failure to Complete Quarterly Smoking Evaluations
Penalty
Summary
The facility failed to ensure that five sampled residents were evaluated quarterly for smoking in accordance with its Smoking policy and procedure. Residents 5, 6, 7, 8, and 9 each had diagnoses including schizophrenia or paranoid schizophrenia, and their MDS assessments indicated intact cognition and independence with personal needs. Their most recent Smoking Evaluations were dated 11/1/2025, 9/15/2025, 1/17/2026, 1/8/2026, and 3/26/2026, respectively, showing that the evaluations were not completed on a quarterly basis. During interview, RN 1 stated smoking evaluations should be completed every three months and as needed with a change in condition. The DON stated the Smoking Evaluations for Residents 5 through 9 were past due and should have been completed quarterly per the facility’s policy. The facility’s Smoking policy, revised 08/09/2022, required the licensed nurse to evaluate residents who express a desire to smoke upon admission, quarterly, annually, with significant change of condition, as needed, and present the evaluation to the IDT for review.
Smoking Policy Not Consistently Enforced
Penalty
Summary
The facility failed to consistently implement and enforce its smoking policy for one resident who smoked. The policy stated that smoking was not allowed on the premises, that residents who were alert, oriented, and able to leave independently could smoke only off the property on an approved leave of absence, and that cigarettes, lighters, and other smoking materials were to be maintained by facility staff rather than kept by residents in their rooms or on their person. The resident involved had COPD, was cognitively intact with a BIMS score of 15, and had a physician order allowing independent leave of absence to smoke off the facility premises. The resident stated that after the physician order was issued and before he signed the leave-of-absence acknowledgment, he routinely kept cigarettes and a lighter on his person inside the facility and staff did not ask him to surrender them. He also stated he was able to leave to smoke without staff consistently enforcing the facility’s leave-of-absence hours. During observation, the resident showed a pack of cigarettes and a lighter stored beneath the seat of his walker, and stated that when he returned from a leave of absence the prior evening, no staff member was at the reception desk to receive his smoking materials, so he placed them on the desk with his name attached. The Nursing Home Administrator was unable to provide evidence that staff consistently collected smoking materials, prevented residents from retaining cigarettes or lighters inside the facility, or consistently enforced the leave-of-absence procedures.
Smoking Policy Not Followed
Penalty
Summary
The facility failed to follow its smoking policy for Resident #59 by not completing a documented safe smoking evaluation and by not having a smoking-related care plan problem area or smoking assessments in the electronic medical record. Resident #59 was admitted with hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, and lack of coordination. His MDS assessment showed a BIMS score of 15, indicating intact cognition. During observations, he stated he could go out to smoke by himself and keep his smoking supplies on him, and a pack of cigarettes was observed in his shirt pocket. He also stated he did not remember a staff member going out to smoke with him to see how he smoked. The facility also allowed smoking in non-designated areas. During observations, a resident was seen smoking on the back patio by the exit door in the no smoking area, and no smoking signs, an ashtray, and a red trash can were observed in that same area. The ADM stated the designated smoking area was outside the dining room door on the back patio to the left of the metal gate, that smoking materials should be on the left side of the gate, and that residents had been allowed to smoke unsupervised. He also stated he made daily rounds and moved smoking items found in non-designated areas to the back patio, and that there was not a 24/7 smoking tenant to monitor smoking.
Smoking Policy Not Followed for Resident Using Cannabis Near Facility Entrance
Penalty
Summary
The facility failed to implement its Resident Smoking Policy when Resident #3 was observed smoking cannabis about 10 feet from the building in a non-designated smoking area. The resident was observed outside the front lobby door smoking a small rolled cigarette, and the smell of cannabis was strongly noticeable from 50 feet away. During interview, the resident stated he/she was smoking marijuana, obtained it from an outside source, and was not going to stop using it. The resident’s face sheet showed diagnoses including neuropathy, gastric ulcer, GERD, stage 3 kidney disease, major depressive disorder, and edema, and the MDS indicated the resident was cognitively intact with no mood or behavioral concerns. Record review showed the facility’s Smoking Policy allowed smoking only in designated areas and stated that smoking of other federally illegal substances is never permitted. The THC Policy & Procedure stated cannabis smoking is not permitted at the facility. The resident’s care plan documented tobacco dependence, instruction on the smoking policy, that the resident could smoke unsupervised, and that the resident had a behavior problem using cannabis products while on facility grounds. Staff interviews reflected inconsistent understanding of where residents could smoke, with one CNA stating independent smokers usually went out in front of the building near the entrance, while the Administrator stated residents smoking outside the facility must move at least 100 feet away from the buildings and that she had prior issues with the resident regarding illegal substances. The Nurse Practitioner stated the resident had not been prescribed cannabis and that cannabis could have an adverse effect with the resident’s current medication regimen.
Smoking Area Trash Placed in Butt Can
Penalty
Summary
The facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also considered non-smoking residents for 1 of 3 smoking areas reviewed, specifically the smoking area for halls C/D. During an observation and interview on 6/23/2026 at 9:10 am, the smoking area outside halls C/D had a red smoking can containing cigarette butts along with a plastic wrapper, gloves, and a plastic wrist band. A sign above the can stated, "put cigarette butts in ashtray, do not throw on ground. Thanks Administration Staff." The Housekeeping Supervisor said she and the Maintenance Supervisor checked the cans daily and emptied them, and she acknowledged there was a risk of fires if trash was placed in the butt cans. During interviews later that day, the ADON, DON, RDO, Administrator, and Maintenance Supervisor all stated that trash should be placed in the trash can and that the red cans were for cigarette butts only. They also stated that Maintenance and Housekeeping were responsible for checking the smoking areas daily. The Maintenance Supervisor said staff were always putting trash in the smoking can and that a sign had been placed above it to remind staff. Record review of the facility's Smoking Policy-Residents, revised October 2023, stated that the facility maintains safe resident smoking practices, that metal containers with self-closing cover devices are available in smoking areas, and that ashtrays are emptied only into designated receptacles.
Smoking Break Schedule Not Followed
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 3 of 3 residents reviewed. Record review showed the residents who smoked were scheduled for supervised smoke breaks at 10:30 A.M. daily, with additional break times listed at 8:30 A.M., 1:30 P.M., 3:30 P.M., 6:30 P.M., and 8:30 P.M. A list of 15 residents who smoked was emailed by the RNC, but no printed list was provided, and a smoking policy was requested but not provided prior to exit. During observation, the residents who smoked had not gone out for the scheduled 10:30 A.M. smoke break. The smoking area was observed outside at the end of hall B, and no one was outside in the smoking area between 10:30 A.M. and 10:55 A.M. Interviews with three residents confirmed they were supposed to go out at 10:30 A.M. with CNA A, and they stated CNA A was often late taking residents on their scheduled smoking breaks. One resident who did not smoke also stated the residents who smoked were supposed to go out at 10:30 A.M. and that they often went later than scheduled several times a week. Staff interviews showed the smoking schedule was created by the SS, but the assigned staff member was changed when other staff called in, and the change was not communicated in time. The SS stated CNA B did not find out until almost 11:00 A.M. that he was supposed to supervise the 10:30 A.M. smoke break, and the schedule was not changed until around 11:00 A.M. to reflect who would supervise it. CNA B stated he was not notified of the change and had been assigned other tasks. LVN B stated the schedule was off due to staff being out and that residents were upset when they did not go on smoke breaks on time, which happened often. The VPO stated the SS was responsible for ensuring smoke breaks were taken timely and for advising staff of schedule changes.
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