Failure to Supervise Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and safe storage of smoking materials for three residents with cognitive impairments and other medical conditions. On the morning of 12/18/2025, three residents were observed smoking unsupervised in the designated smoking area, outside of scheduled smoking times, and without the required use of smoke aprons. Interviews with the residents confirmed that they sometimes smoke on their own before the official smoking times, and that they occasionally obtain cigarettes from other residents. Staff interviews revealed that residents are not supposed to smoke unsupervised or keep their own smoking supplies, but these practices were not consistently enforced, particularly during night shifts when no designated smoking times were scheduled. The residents involved had significant medical histories, including dementia, cognitive communication deficits, schizoaffective disorder, hemiplegia, heart disease, diabetes, and neuropathy. Their care plans and smoking assessments indicated the need for supervision while smoking, the use of smoke aprons, and secure storage of smoking materials at the nurse's station. Despite these documented interventions, the residents were able to access cigarettes and lighters and smoke without staff supervision or protective equipment. Staff interviews confirmed awareness of the risks and the facility's policy, but also acknowledged that residents sometimes circumvented these rules, and that administration was aware of previous incidents of unsupervised smoking. Facility policy required that residents only smoke in designated areas under staff or family supervision, and that all smoking materials be stored securely at the nurse's station. However, observations and interviews demonstrated that these policies were not consistently followed, particularly during overnight hours. Staff reported redirecting residents when found smoking unsupervised and notifying management, but lapses in supervision and secure storage of smoking supplies persisted, resulting in residents being able to smoke unsupervised and without appropriate safety measures.