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F0689
D

Failure to Supervise Residents Requiring Smoking Supervision and Control Smoking Materials

Cleveland, Ohio Survey Completed on 09-23-2025

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

The facility failed to provide appropriate supervision for residents who required monitoring while smoking and did not ensure that residents did not possess smoking items in their personal belongings. Observations revealed that three residents were smoking outside without staff supervision during designated smoking times, despite facility policy requiring direct supervision for residents with restricted smoking privileges. The Administrator confirmed that staff supervision was absent and was unsure if the residents required supervision, but acknowledged that staff should have been present if supervision was needed. Medical record reviews for two residents showed that both had been assessed as requiring supervision for safe smoking and had signed contracts indicating that they were not permitted to keep cigarettes or smoking articles in their possession. Despite these requirements, one resident was found with an empty cigarette pack and a lighter in his room, and another resident was found with a pack of cigarettes hidden in his wheelchair cushion. Both instances were confirmed by the Director of Nursing, who acknowledged that these residents were not supposed to have smoking items in their possession. The facility's policy and staff orientation materials clearly outlined the need for supervision and restrictions on possession of smoking materials for certain residents. However, the facility did not enforce these policies, as evidenced by unsupervised smoking and residents retaining smoking items. The deficiency was identified during a complaint investigation and affected multiple residents who had been assessed as requiring supervision while smoking.

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