Unsafe Smoking Practices and Oxygen Exposure
Summary
The facility failed to implement and enforce its supervised smoking policy for multiple residents who smoked or used electronic cigarettes, including residents receiving supplemental oxygen. The policy stated that smoking was only allowed in designated areas, oxygen was not permitted, residents were to be supervised during smoking, smoking materials were to be retained by nursing staff, and no ignition devices were to be in residents’ possession. The report identified this as Immediate Jeopardy because the facility allowed ignition devices and smoking materials to be present and stored in resident rooms, including rooms where oxygen was in use. Resident #3, who had intact cognition and a functional limitation in one upper extremity, was evaluated as a safe smoker despite documentation that he did not have the fine motor skills needed to securely hold a cigarette. The clinical record did not include a care plan with individualized interventions for safe smoking, and he was not included on the facility’s smoking list. During observation, Resident #3 was seen in a shared bedroom with Resident #103, who was receiving supplemental oxygen via nasal cannula, while holding a cigarette and lighter approximately 4 feet from the oxygen source. Resident #3 later stated he had kept a lighter in his room since admission, and staff stated he had been smoking daily and that residents could keep cigarettes but not lighters in their rooms. Resident #59, who received oxygen as needed and was listed as requiring constant supervision while smoking, had a smoking evaluation that contained conflicting information and did not document evaluation of his ability to explain why oxygen must be shut off before lighting a cigarette. He was observed receiving oxygen with a lighter stored in his nightstand approximately 2 feet from the oxygen concentrator. In the shared room with Resident #74, cigarettes and a lighter were also observed on the windowsill while the oxygen concentrator was on and running. Resident #5, who received oxygen at bedtime and was not listed on the smoking list, reported that she had been vaping electronic cigarettes in her room for over a month because she could not get out of bed to go to the designated smoking area. Her care plan was inconsistent and did not include interventions to stop vaping in the room while using oxygen. Resident #95 was listed as needing apron assistance, but the smoking evaluation documented no supervision needed, and there was no new smoking evaluation after a smoking apron was added to the care plan. Resident #95 was observed smoking without the apron, and cigarettes and lighters were left unlocked and accessible in the designated smoking area when staff left the area.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Smoking Policy: Two residents who were cognitively intact were involved in smoking-related policy failures. One resident with a history including kidney transplant aftercare, muscle weakness, and HTN was observed holding a cigarette and a match in the hallway and stated she was allowed to keep them and smoke outside alone, while another resident with type 2 DM stated he smoked without supervision and shared cigarettes with another resident. The ADON stated the facility was not aware one resident was a smoker, did not have a baseline care plan on admission, and did not follow the policy prohibiting matches and sharing smoking items.
Failure to maintain resident smoking materials: A resident was observed carrying a lighter and cigarettes in his vest pocket instead of having them kept in the designated smoking box. The resident said he kept the items on his person because residents and staff took cigarettes and lighters from the box. A housekeeper reported frequent issues with items being taken from the box, and the DON stated staff were expected to follow the smoking policy and keep residents' smoking materials in the designated smoking box.
Unsecured Smoking Materials: A resident who smoked daily and was cognitively intact kept cigarettes and a lighter in an unlocked drawer and an unsecured cabinet, despite facility policy requiring smoking safety protections. The resident reported leaving the room door open at times and said a confused resident had entered the room on several occasions and rummaged through his belongings. The DON confirmed the resident was considered an independent smoker, but the smoking paraphernalia was not secured.
The facility failed to ensure its smoking policy addressed safe smoking areas for independent smokers. Two residents with COPD and other diagnoses were told they could go off property and smoke across the street outside designated smoking times, even though the written policy only allowed smoking in designated areas outside the building and did not mention LOA or off-property smoking. Surveyors observed the area across the road had no sidewalk or crosswalk and was a narrow roadway with nearby buildings and vehicles.
Failure to complete quarterly smoking evaluation for a dependent smoker. A resident with dementia was identified as needing direct supervision to smoke, but the record showed no updated smoking evaluation after the initial assessment. Staff stated smoking assessments were to be completed on admission and quarterly, and an observation found the resident smoking with difficulty holding the cigarette.
A resident with mild cognitive impairment and tobacco use had cigarette packs on his bedside table despite a care plan requiring supervised smoking, designated smoking times and areas, and storage of all smoking supplies in a locked box at the nurse’s station. The resident said he usually kept his cigarettes on the table and got them from the store when he went out. Staff, including the ADON, CNA, RN, and DON, stated that residents were not allowed to keep cigarettes or lighters in their rooms and that smoking materials were to be secured and used only during supervised smoke times.
Failure to Follow Smoking Policy
Penalty
Summary
The facility failed to follow its Smoking Policy for two residents who were identified as smokers. Resident 1’s face sheet showed admission with diagnoses including orthopedic aftercare following kidney transplant, muscle weakness, and hypertension, and the MDS indicated intact cognitive skills for daily decisions. During a concurrent observation and interview, Resident 1 was seen in the hallway in a wheelchair holding a cigarette and a match, and stated the facility allowed her to keep cigarettes and a match with her and to go outside to smoke by herself at any time. Resident 1 also stated she was not informed of the facility’s smoking policy upon admission. Resident 2’s face sheet showed admission with type 2 DM, and the MDS indicated cognition was intact and that the resident needed set-up or clean-up assistance with several ADLs. During interview, Resident 2 stated he smoked without supervision and shared cigarettes with another resident who also smoked. The ADON stated the facility failed to have a baseline care plan upon Resident 1’s admission, was not aware Resident 1 was a smoker, did not follow the policy prohibiting residents from having matches, and did not follow the policy against residents sharing smoking items with other residents. The facility’s Smoking Policy stated residents are informed of the smoking policy and designated smoking areas prior to and upon admission, smoking status is evaluated upon admission, and all forms of lighters, including matches, are prohibited.
Failure to Maintain Resident Smoking Materials
Penalty
Summary
The facility failed to implement its smoking policies and procedures to ensure residents' smoking materials were maintained by nursing staff for 1 of 3 residents reviewed for smoking safety. During observation, Resident #74 was seen carrying a lighter and cigarettes in his vest pocket and then removed the items from his pocket. In interview, the resident stated he kept the items on his person because residents and staff took cigarettes and lighters from the designated smoking box. A housekeeper stated residents were expected to place their cigarettes and lighters in the designated smoking box after smoking, but there had been frequent issues with cigarettes and lighters being taken from the box, resulting in residents keeping the items on their person. The DON stated her expectation was that staff would follow the facility's smoking policy by maintaining residents' smoking materials in the designated smoking box. The facility policy stated that all smoking and smokeless tobacco materials of residents who use them would be maintained by nursing staff.
Unsecured Smoking Materials
Penalty
Summary
The facility failed to assure that smoking paraphernalia was properly secured for one resident who smoked daily. The resident had a history of tobacco use and was assessed as cognitively intact on the quarterly MDS, with a BIMS score of 15. Facility policy stated that smoking was only allowed in designated outdoor smoking areas and that safety protections applied to smoking and non-smoking residents. The DON stated that one alert and oriented resident was considered an independent smoker and could maintain control of smoking paraphernalia if it was safely maintained and safeguarded from unsafe use. Observation and interview showed that the resident kept cigarettes in an unlocked drawer in the room with a cigarette lighter, and an unlocked cabinet contained two packs of cigarettes and a butane lighter that were unsecured. The resident stated that he did not always close his bedroom door when leaving and did not always take his cigarettes or lighter with him. He reported that a confused resident had entered his room on several occasions when the door was open and had rummaged through the room and removed food items without supervision or permission. The DON later stated the facility had re-educated the resident on safe smoking practices, and the concern was identified only after surveyor notification.
Smoking Policy Did Not Address Off-Property Smoking for Independent Smokers
Penalty
Summary
The facility failed to ensure its smoking policy included information about safe smoking areas for independent smokers. The smoking policy stated that smoking was only permitted in designated resident smoking areas outside the building, but it did not address the facility practice of allowing independent smokers to go off the property to smoke outside designated smoking times. The Administrator confirmed that residents deemed safe to smoke independently were told to smoke off the property if they wanted to smoke outside the designated times, and that this practice was not included in the written policy. Resident #8 had diagnoses including above the knee amputation of the right leg, COPD, and mantle cell lymphoma, and the admission MDS showed moderately impaired cognition and use of tobacco. Resident #53 had diagnoses including COPD, depression, and right-sided sciatica, and the quarterly MDS showed intact cognition and independence with eating. The facility identified seven residents as independent smokers, including these two residents. Surveyors observed the area across the road from the facility and noted there was no sidewalk, no crosswalk, and a narrow road with buildings and vehicles nearby. Both residents stated they had been told to go across the street to smoke outside designated smoking times, and Resident #53 stated this was not safe. The Administrator, DON, and RQAN confirmed that residents could go off property to smoke via LOA and that this practice had always been in place, but it was not written in the smoking policy.
Failure to Complete Quarterly Smoking Evaluation
Penalty
Summary
The facility failed to follow its smoking policy for Resident #40 by not ensuring a safe smoking evaluation was completed quarterly. Resident #40 was admitted with a diagnosis of dementia and was identified in the care plan as a smoker at risk for injury who required direct supervision to smoke. The care plan also directed staff to perform smoking assessments according to facility policy. A Smoking Evaluation dated 03/09/2026 identified the resident as a dependent smoker who required assistance and supervision to smoke, but the record review found no updated Smoking Evaluation after that date. During observation on 07/06/2026 at 1:45 p.m., Resident #40 was seen smoking and had difficulty holding the cigarette in his hand. In interviews, staff stated smoking assessments were to be completed on admission, with change of condition, and quarterly, and that Resident #40 should have had a safe smoking assessment at least quarterly. The smoking policy dated 7/14/2024 stated the facility must evaluate patients who smoke using the Smoking Evaluation/Smokeless Tobacco Tool upon admission, quarterly, when a non-smoking patient takes up smoking or smokeless tobacco, and if unsafe smoking practices are observed.
Smoking Materials Kept in Resident Room
Penalty
Summary
The facility failed to implement its smoking policy for one resident who was reviewed for smoking compliance. The resident had diagnoses of mild cognitive impairment and tobacco use, and his care plan required that he be supervised when he smoked, smoke only during designated times and in designated smoking areas, and keep all smoking supplies in the smoking supply box at the nurse’s station or med room. His quarterly MDS assessment documented a BIMS score of 14 and noted medically complex conditions. During an observation and interview, three cigarette packs were found on the resident’s bedside table, including two empty packs and one full pack of cigarettes. The resident stated that he usually kept his cigarettes on his table and that no one had an issue with it. He also stated that he got the cigarettes from the store when he went out of the facility. Staff interviews showed that cigarettes and lighters were not supposed to be kept in residents’ rooms and were to be stored in a locked box at the nursing station for supervised smoking times. The ADON, CNA staff, RN, and DON all stated that residents should not have cigarettes in their rooms and that staff were responsible for removing them if found. The facility’s smoking policy stated that smoking was not allowed inside the facility, smoking was only permitted in designated areas, and all smoking materials were to be stored in a secure area.
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