Failure to Control Smoking Materials and Prevent Oxygen-Related Fire
Summary
The deficiency involves the facility’s failure to prevent an unintentional fire and to control smoking materials for a resident who used continuous oxygen and had documented dementia with moderate cognitive impairment. The resident’s diagnoses included pulmonary fibrosis, COPD, depression, nicotine dependence, and dementia. A smoking evaluation dated 12/19/25 identified the resident as safe to smoke independently, with no cognitive loss, no visual or dexterity problems, and allowed her to store and handle her own cigarettes and lighter. This evaluation did not address whether the resident understood safety measures related to removing or positioning oxygen equipment prior to smoking. The initial smoking care plan, initiated 12/23/25, set a goal for the resident to smoke safely and independently, noted education on the dangers of oxygen and smoking, and stated she was independent with smoking per evaluation, but did not include specific interventions regarding oxygen placement or removal before or during smoking. On 12/24/25, the resident was found smoking in her room, contrary to facility expectations. The incident analysis identified that she was a new admission and independent with smoking per her admission form. She was re-educated, and the plan was to remove smoking materials and keep them at the nursing station. A smoking evaluation dated 12/24/25 again documented no cognitive loss despite the MDS showing moderate cognitive impairment and a dementia diagnosis, and it specified that the resident could light her own cigarette but could not store her own smoking materials, which were to be kept at the nursing station. However, the smoking care plan was not revised until 12/29/25 to add the intervention to store smoking materials at the nurse station. A Risk vs Benefits form dated 12/30/25 identified the concern of the resident smoking in her room while on oxygen and described the dangers of oxygen-related fires, but it did not list any benefits, was not signed by the resident or representative, and there was no documentation of monitoring or evaluation of the effectiveness of the intervention to store smoking materials at the nurse’s station. On 1/29/26 at 8:39 a.m., progress notes documented that the resident was smoking in her room and caused a fire, indicating that the 12/29/25 intervention to keep smoking materials at the nurse’s station was not followed. The resident denied smoking and refused a respiratory assessment and skin check. An incident analysis for 1/29/26 stated that staff heard the roommate yelling for help and found a fire on the resident’s oxygen tank in her room while the resident was smoking, though she denied it. The fire was extinguished, and both residents were assessed with no injuries found. A search of the room revealed a pack of cigarettes, which was taken to the nurse’s station. The smoking evaluation dated 1/29/26 again documented no cognitive loss despite the MDS and dementia diagnosis, noted that the resident smoked 5–10 times per day, could light her own cigarette, could not store her own smoking materials, and that smoking materials were supposed to be kept at the nurse’s station. It also stated that daily room checks were to be done, that the resident used oxygen, had been educated to remove and store oxygen prior to smoking, and had a wanderguard on her portable oxygen tank. Following the fire, the care plan was updated on 1/29/26 with interventions such as daily room searches with the resident’s permission, safety checks, posting signs in Spanish about no smoking and oxygen being flammable, visualizing the room every shift to remove visible smoking materials, and using a wanderguard on the portable oxygen tank. However, between 1/29/26 and 2/2/26, the record did not include a comprehensive assessment or analysis supporting that 15-minute checks were appropriate or sufficient to prevent the resident from smoking, nor did the care plan provide instructions for staff if the resident was non-compliant with surrendering smoking materials. There was no documented assessment of the resident’s task-specific decisional capacity to safely engage in smoking while using oxygen, despite her dementia, moderate cognitive impairment on the MDS, and prior non-compliance on 12/24/25 and 1/29/26. On 2/2/26, the resident told an interviewer she did not trust staff with her smoking materials and admitted refusing to give them up when asked. She produced a box of cigarettes and a lighter from her coat pocket while wearing a nasal cannula connected to oxygen at 2 LPM. A nursing assistant reported that the resident often refused to give up her smoking materials after returning from smoking outside and that staff did not always have time to check residents after smoking to ensure materials were turned in. Another nursing assistant and an RN stated the resident was non-compliant with smoking rules, hid smoking materials, and that residents sometimes shared supplies, but these refusals and hiding behaviors were not documented in the record between 12/23/25 and 2/2/26. An LPN showed that the drawer designated for smoking materials at the nurse’s station contained only office supplies and confirmed there was no log to track smoking supplies. The DON acknowledged that family brought in smoking materials without first bringing them to the nursing station and that it was difficult to take items from the resident. These observations and interviews demonstrated that the resident remained in possession of cigarettes and a lighter after the fire, that staff were aware of ongoing non-compliance and family involvement in supplying materials, and that there was no effective system or documentation to ensure smoking materials were secured as care planned, resulting in continued risk of fire.
Removal Plan
- Reviewed smoking policies with the medical director and ombudsman input.
- Developed and implemented a comprehensive system to prevent accidents, hazards, and fires related to smoking inside the facility, including a plan for residents who fail to comply with safe smoking practices.
- Reassessed R1's capacity to make safe decisions regarding smoking.
- Revised R1's care plan with individualized interventions.
- Identified residents with similar smoking risks and their level of compliance with facility smoking policy.
- Implemented individualized interventions for residents with similar smoking risks to prevent unsafe smoking.
- Re-educated residents on safe smoking policies and administered a knowledge check quiz.
- Educated all staff on smoking policies and administered a knowledge check quiz to demonstrate understanding.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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