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F0689
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Resident Smoked in Room with Oxygen Despite Revoked Privileges

Trenton, New Jersey Survey Completed on 10-14-2025

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

A deficiency occurred when a resident, whose smoking privileges had been revoked due to repeated violations of the facility's smoking policy, was found smoking a cigarette inside another resident's room where oxygen was in use. The Nursing Supervisor observed the resident in a wheelchair, smoking in the room of two other residents, one of whom was receiving continuous oxygen therapy for chronic respiratory failure and had severely impaired cognition. Upon entering the room, the supervisor confiscated the cigarette, and a subsequent search of the resident's wheelchair revealed a pack of cigarettes and a bottle of vodka. The resident had a documented history of noncompliance with the smoking policy, including sharing cigarettes, smoking outside designated areas, and failing to leave tobacco products at the front desk, as required by facility policy. The facility's records indicated that the resident's smoking privileges had been revoked prior to this incident, and the care plan had been updated to reflect this, with interventions such as re-education on the smoking policy and the use of nicotine patches. Despite these measures, the resident continued to access and use tobacco products within the facility. Staff interviews revealed that previous incidents involving the resident's possession and use of smoking materials had been reported, but there was inconsistency in follow-up actions and documentation. Additionally, the facility's documentation did not include statements or assessments for the other residents present in the room at the time of the incident, one of whom was cognitively impaired and dependent on supplemental oxygen. The facility's smoking policy explicitly prohibited residents from keeping tobacco products or lighting materials on their person or in their rooms, especially in the presence of oxygen, due to the risk of fire or explosion. However, the resident was able to circumvent these safeguards, resulting in a situation where smoking occurred in a high-risk environment. The lack of consistent enforcement of the smoking policy and insufficient monitoring allowed the resident to possess and use prohibited items, directly leading to the identified deficiency.

Removal Plan

  • The Nursing Supervisor (NS) removed the cigarette from Resident #2.
  • Resident #2 was searched, and a pack of cigarettes and a pint of vodka was confiscated and destroyed.
  • Resident #2 was placed on 1:1 assignment until their discharge from the facility.
  • The NS educated Resident #2 and Resident #3 that smoking was prohibited in a resident room.
  • Nurse leaders began educating all residents who smoked on the facility's smoking policy and the dangers of smoking near oxygen, and their rooms and equipment were searched by the Assistant Director of Nursing (ADON) for violation of the smoking policy.
  • The nurse leaders and Consultant Registered Nurse (RN) re-educated all staff on the smoking policy and the dangers of smoking near oxygen.
See complete original report
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