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:
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 did not complete or document required smoking assessments for three residents who used tobacco, failing to follow its own policy for evaluation upon admission, readmission, and at regular intervals. Staff interviews and record reviews showed that assessments were missing or incomplete, and some staff were unaware of the policy's requirements.
A resident with a history of respiratory and psychiatric conditions, who was dependent for all ADLs but had intact cognition, was repeatedly observed smoking on facility grounds and possessing smoking materials despite the facility's non-smoking policy. Staff interventions and re-education were not effective in ensuring compliance, and the resident continued to access and use smoking materials in violation of facility rules.
Staff did not follow the facility's smoking policy, as cigarette butts were found in multiple mulch beds and a trash can with ash marks and flammable materials was observed outside the designated smoking area. The Maintenance Director confirmed these findings, and review of the policy showed smoking was only allowed in a specific patio area.
The facility did not follow its smoking policy in the designated outdoor area, as observed by an administrator. Numerous cigarette butts were found on the ground and in overfilled, combustible plastic receptacles, with additional butts mixed in piles of leaves. The facility had identified multiple residents who actively smoked, but did not provide noncombustible ashtrays as required by policy.
A resident with several medical conditions, who was supposed to be supervised while smoking, was found to have four packs of cigarettes in her room's refrigerator, contrary to the facility's smoking policy. Staff interviews revealed a lack of awareness about the resident's possession of cigarettes, which were supposed to be stored securely by staff.
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 Complete and Document Smoking Assessments per Facility Policy
Penalty
Summary
The facility failed to implement its smoking policy as required, specifically by not completing smoking assessments fully or in a timely manner for three residents who used tobacco products. According to the facility's policy, residents who smoke must be evaluated upon admission, readmission, with significant change, and at regular intervals thereafter. However, documentation and interviews revealed that these assessments were either missing or incomplete at critical times, such as after readmission or during required evaluation periods. One resident with a history of acute kidney failure was admitted and later readmitted, but did not have a smoking evaluation completed upon readmission as required by policy. Another resident with chronic diastolic heart failure was also readmitted without a subsequent smoking evaluation. A third resident with polyneuropathy had a smoking evaluation on file, but the assessment was left incomplete, with the summary section blank, failing to indicate whether the resident was a safe or unsafe smoker. Interviews with facility staff, including the MDS nurse, ADON/Infection Preventionist, DON, and Administrator, confirmed that smoking assessments were not consistently completed according to the facility's policy. Some staff were unaware of the specific requirements for reassessment, and documentation in the medical records did not reflect adherence to the policy. The facility's own smoking policy clearly outlined the need for timely and complete evaluations, but these procedures were not followed for the residents reviewed.
Failure to Enforce Non-Smoking Policy for Resident
Penalty
Summary
The facility failed to effectively implement its non-smoking policy for a resident with a history of respiratory failure, metabolic encephalopathy, delusional disorder, and visual hallucinations. The resident was assessed as having intact cognition but was dependent for all activities of daily living. Despite being informed of the facility's non-smoking policy prior to admission and during periodic assessments, the resident was observed smoking on facility grounds and in possession of smoking materials, which was against the facility's stated policy. The resident had previously demonstrated non-compliance with the smoking policy, including not smoking only in designated areas and not adhering to correct smoking times. On one occasion, the resident was observed outside the facility in a wheelchair, removing cigarettes and a lighter from her purse and lighting a cigarette. Staff were notified and intervened to educate the resident. Later, the resident was asked by an RN to remove smoking materials from her purse, but she attempted to avoid compliance by leaving the area and denying possession of the materials when approached by a social worker. The facility's policy required informing residents and responsible parties of the non-smoking policy prior to admission and posting the policy within the facility, but these measures were not effectively enforced in this case.
Failure to Enforce Smoking Safety and Policy Compliance
Penalty
Summary
The facility failed to ensure that smoking safety protocols were followed according to its own policy, which only allowed smoking in designated areas. During an observation of the facility parking lot with the Maintenance Director, cigarette butts were found disposed of in multiple mulch beds around the facility, including those near the dumpsters, the main entrance's covered porch, and the 300 Hall entrance. Additionally, a trash can under the covered porch showed ash marks from extinguished cigarettes and contained flammable materials inside. The Maintenance Director confirmed these findings during the interview. Review of the facility's smoking policy and designated smoking area information confirmed that smoking was only permitted on the 100/200 Hall dining room patio, indicating that the observed smoking activity and disposal of cigarette butts in other areas were not in compliance with facility policy.
Failure to Implement Smoking Policy and Maintain Safe Smoking Area
Penalty
Summary
The facility failed to implement its resident smoking policy in the designated outside smoking area. During an observation with the Administrator, approximately 75 to 100 cigarette butts were found scattered on the ground, with additional cigarette butts mixed in piles of leaves. Six cigarette receptacles made of combustible plastic were present, each about 75% or more full, and a seventh receptacle, a plastic bucket, was over 90% full. In total, three to four hundred cigarette butts were observed in the area, both on the ground and in receptacles. The facility had identified twenty residents who actively smoked. Review of the facility's policy indicated that ashtrays made of noncombustible material and safe design were required, but this was not followed as combustible plastic containers were used.
Failure to Safely Store Smoking Materials
Penalty
Summary
The facility failed to ensure that smoking materials were stored safely, affecting one resident. The resident, who was cognitively intact and required limited assistance with activities of daily living, had several medical diagnoses including hypokalemia, peripheral vascular disease, and depression. According to the resident's smoking assessment, she was to be supervised when smoking, and all smoking materials were to be stored by staff in a locked location. However, during an observation, it was found that the resident had four packs of cigarettes stored in her room's refrigerator, contrary to the facility's smoking policy. Interviews with various staff members revealed a lack of awareness regarding the resident's possession of cigarettes in her room. The Housekeeper Supervisor and Medical Records Coordinator both confirmed that the resident's cigarettes were supposed to be stored behind the nurse's station. The resident herself admitted to purchasing cigarettes through a staff member and storing them in her refrigerator, which she forgot about until they were discovered. The facility's smoking policy clearly stated that residents should not have smoking materials on their person during non-smoking times and that all unsmoked cigarettes should be returned to staff for secure storage.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
