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F0689
D

Failure to Enforce Smoking Material Policies Creates Accident Hazard

Columbia, Missouri Survey Completed on 05-09-2025

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 ensure the environment was free from accident hazards by not enforcing policies regarding the retention of smoking materials among residents. The facility's admission packet and smoking policy clearly state that residents may not retain matches or lighters, and that staff are to confiscate such items if found. However, two residents were allowed to keep cigarettes and lighters in their possession, contrary to facility policy and their care plans. One resident, assessed as cognitively intact and a safe smoker, was observed lighting a cigarette in the dining room, an area where smoking is prohibited, and was found with lighters in his possession. Staff interviews revealed uncertainty about whether the resident still had access to smoking materials, and the resident himself confirmed keeping cigarettes and a lighter in his room. The care plan for this resident did not include any interventions or restrictions related to smoking, despite incidents of unsafe smoking behavior in the facility. Another resident, whose cognition was not assessed but was also documented as a safe smoker, was observed in the dining room with cigarettes and a lighter visible in a waist pouch, despite a care plan stating that these items should be kept at the nursing station and that smoking should be supervised. Staff interviews indicated a lack of clarity and consistency regarding which residents were permitted to retain smoking materials and where these items should be stored, leading to lapses in supervision and enforcement of safety protocols.

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