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F0926
D

Failure to Enforce Smoking Policy and Secure Smoking Materials

Watertown, Massachusetts Survey Completed on 05-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to implement the facility's smoking policy for one resident. The policy, as provided to surveyors, prohibits residents from keeping smoking paraphernalia in their rooms or on their person, requiring all such materials to be stored by nursing staff in a locked area. Despite this, a resident with chronic kidney disease stage 4 and chronic obstructive pulmonary disease, who was cognitively intact and a current tobacco user, was observed multiple times with cigarettes and a lighter in their room and on their person. The resident stated they were allowed to smoke independently, and staff did not intervene to store the smoking materials as required by policy. Review of the resident's care plan indicated that smoking materials should be kept by facility staff, and the resident was expected to comply with the facility smoking policy. However, the most recent smoking evaluation did not specify whether the resident could smoke independently or required supervision. Interviews with staff revealed inconsistent understanding and enforcement of the policy, with some staff believing certain residents could keep smoking materials in their rooms, while others stated that no residents were permitted to do so. The Director of Nurses confirmed that staff were expected to store all smoking materials for residents.

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