Failure to Enforce Smoking Policy and Safety Measures
Summary
The facility failed to implement and enforce its smoking policy in a safe and consistent manner for all sampled residents who smoke. Observations revealed that one resident, who had no cognitive impairment but suffered from nicotine dependence, lack of coordination, and muscle weakness, was not provided with or wearing a smoking apron/blanket while smoking. The smoking blanket and fire extinguisher were kept in a locked glass case, and the resident did not know how to access them. Staff confirmed that residents were not being offered the protective blanket, despite the resident's care plan requiring its use. Another resident with moderately impaired cognition and a history of tremors and schizophrenia was observed smoking without staff supervision, contrary to the care plan that required supervision. Multiple staff interviews confirmed that residents often smoked without staff present, and there was no designated staff or department responsible for supervising residents during smoking times. Staff acknowledged that the facility's smoking policy was not being strictly enforced, and that supervision was important for resident safety. Additionally, a resident with moderately impaired cognition and COPD was found to be keeping his own cigarettes, despite his care plan and smoking assessment not permitting this. Staff and the infection preventionist confirmed that this practice was a safety risk and not in accordance with the resident's care plan. Furthermore, several residents reported and were observed smoking outside of the facility's established smoking schedule, with staff confirming that the schedule was not being enforced and residents smoked whenever they wanted. The facility's policy required the use of fire-retardant blankets, supervision, and adherence to a smoking schedule, but these measures were not operationalized as required.
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.
Cigarette butts were found in a trash can in the smoking area instead of in the designated locked red butt can. CNA K, the HSK Supervisor, and the Administrator all stated that ashtrays were supposed to be emptied into the red smoking can after each smoke break, and the facility's smoking policy required ashtrays to be emptied into a metal container with a self-closing cover device.
A resident assessed as able to smoke independently was observed smoking outside the front entrance instead of only in the designated smoking area. The resident kept cigarettes and a lighter in his room or on his person, despite signing the smoking policy and acknowledging that smoking items were not to be stored in his room. The DON confirmed the facility did not enforce its smoking policy, smoking areas, or smoking safety requirements.
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.
Cigarette Butts Placed in Trash Can in Smoking Area
Penalty
Summary
The facility failed to follow its smoking policy for 1 of 1 smoking areas when cigarette butts were found in a trash can designated for trash. During an observation and interview on 3/24/2026 at 9:01 am, the smoking area had a trash can with a plastic liner containing cigarette butts and trash, while a separate red smoking can with a lock was present and identified for cigarette butts. Five residents were outside smoking with CNA K, who stated that when residents finished smoking she would empty the ash trays into the red smoking can and that staff were supposed to empty the ash trays after each break. CNA K said cigarette butts should not be in the trash and noted there was a risk of residents going into the trash and getting them or a risk of fire. During interviews on 3/25/2026, the HSK Supervisor said Maintenance was normally responsible for emptying the ashtrays into the red smoking cans, but the Maintenance Supervisor had been terminated the prior week. She said she had started checking the red cans that week and had a key to it, and that cigarette butts should never be placed in the trash because of fire risk. The Administrator stated there was a resident who liked to empty the ashtrays into the trash and said the person supervising smokers during breaks should empty them into the red smoking can. Record review of the facility's Smoking Policy stated that ashtrays of noncombustible materials and safe design would be provided in all areas where smoking is permitted and that ashtrays would be a metal container with a self-closing cover device into which ashtrays may be emptied.
Failure to Enforce Smoking Policy and Smoking Safety
Penalty
Summary
The facility failed to enforce its established smoking policy and smoking safety requirements for one resident who was assessed as able to smoke independently. The resident had diagnoses of diabetes mellitus, hypertension, and hyperlipidemia. Facility policy stated that smoking was only permitted in the designated external courtyard area by the courtyard cafe, that smoking paraphernalia had to be kept secure by the facility, and that if staff learned a resident had smoked in an unauthorized area or possessed smoking paraphernalia, the resident would be asked to turn the items over and allow a room search. Although the resident signed an acknowledgement of the smoking policy and a smoking/tobacco/vaping safety assessment indicated he understood that smoking items were not to be stored in his room, surveyors observed him smoking outside the front entrance of the building and later again at the front entrance. During an interview and observation, the resident stated he kept his cigarettes and lighter in his room or on his person, and the cigarettes and lighter were observed in his room. He also stated he could smoke in three locations at the facility, including the front entry, the courtyard, and the back parking lot. During rounds with the DON, the resident confirmed he kept his cigarettes and lighter with him in his room and was not giving them up to anyone, and that he smoked outside the front lobby or the courtyard. The DON confirmed the facility failed to enforce its smoking policy, smoking areas, and smoking safety.
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