F0656

E

Failure to Develop Individualized Smoking Safety Care Plans for Smoking Residents

Oroville, California Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement individualized, measurable care plans addressing smoking safety for four cognitively intact residents known by the facility to smoke. The facility’s own “Resident Smoking - Smoke-Free Facility” policy required that any resident deemed safe to smoke, with or without supervision, do so only in designated smoking areas in accordance with the resident’s care plan, and that all safe smoking measures be documented in the care plan and communicated to staff, visitors, and volunteers. Despite this, record reviews on 12/19/25 showed that the care plans and physician orders for Residents 1, 2, and 3 lacked documented, individualized interventions for safe smoking practices, including supervision requirements, designated smoking areas, or other smoking-related safety measures. Resident 4’s care plan addressed smoking cessation only and did not contain interventions or physician orders for safe smoking practices.

Resident 1 was admitted with COPD, tobacco use, alcohol abuse, ataxia following cerebral infarction, and psychoactive substance dependence with intoxication delirium, and had a BIMs score of 15, indicating intact cognition. An IDT progress note dated 12/17/25 documented that, despite education, this resident continued to smoke on facility grounds, had been observed smoking near hazardous areas, and was sneaking out multiple times during the day and night. The note also documented refusal of nicotine patch therapy and stated the care plan was to be updated to reflect elopement risk, substance use behaviors, and refusal of nicotine replacement therapy; however, the care plan dated 11/26/25 did not indicate elopement risk or any safe smoking plan. Resident 2, with schizoaffective disorder, muscle weakness, and frontal lobe/executive function deficit and a BIMs score of 15, also had no safe smoking plan in the care plan dated 12/12/25. In interview, this resident reported smoking cigarettes and stated he had been told he must go off the property to smoke because smoking was not allowed, and expressed feeling that staff did not care about him or what he wanted.

Resident 3, admitted with pleural effusion, malnutrition, nicotine dependence, difficulty walking, and kidney disease and a BIMs score of 14, had a care plan dated 11/19/25 that did not address safe smoking. In interview, this resident reported going outside alone to smoke 1–2 times a day, leaving oxygen in the room, and stated he had been signed off by physical therapy as safe to go outside independently, but wished he did not have to go so far to smoke. Resident 4, admitted with diabetes, COPD, muscle weakness, and difficulty walking and a BIMs score of 15, had no care plan or physician orders authorizing or directing safe cigarette smoking practices. During concurrent interview and record review, RN A confirmed the absence of such documentation, stated awareness of the non-smoking policy, and reported that she believed residents went around the corner of the building to smoke but that she had not supervised residents while smoking. Observation showed Resident 4 independently wheeling himself across uneven terrain in cold weather to an off-property area to smoke, without staff supervision or redirection, and this location was not a designated smoking area. The Administrator confirmed awareness that these four residents smoked, acknowledged there was no designated smoking area at that time, and confirmed that none of the four residents had individualized cigarette smoking safety care plans addressing supervision, location, or safety measures.