F0657

E

Failure to Develop and Implement Comprehensive Smoking Safety Care Plans

El Paso, Texas Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans addressing smoking for multiple residents who used tobacco. The facility’s own policy required development of a comprehensive care plan within seven days of the comprehensive assessment, with ongoing review and revision based on changing needs. Record review showed that several residents had documented nicotine dependence or reported smoking, yet their care plans did not include specific smoking-related problem statements, risk assessments, or interventions such as supervision, designated smoking locations, lighter control, or fire prevention strategies. Instead, care plans focused on other medical conditions and, in some cases, only included general education about the adverse effects of tobacco without individualized smoking safety measures.

For one male resident with osteomyelitis, multiple amputations, peripheral vascular disease, CAD, DM2, impaired mobility, and chronic tobacco use, the admission MDS documented nicotine dependence and significant physical limitations, including a left below-knee amputation and toe amputations that impaired safe ambulation to and from the smoking area. His care plan addressed hypertension, diabetes, anticoagulant therapy, impaired cognition, ADL self-care deficit, and enhanced barrier precautions, and included tobacco education, but did not include smoking supervision interventions, assistance to the designated smoking area, lighter control, or individualized hazard mitigation. This resident reported that he smoked in the designated area, began smoking about a week after admission, did not know if the facility had evaluated him for smoking safety, and did not recall being educated on the facility’s smoking policies or the need to notify staff when he wished to start smoking. During observation, a CNA lit his cigarette, noted his hand tremors, and asked if he needed help, indicating concern about his ability to smoke safely.

Another male resident had extensive cardiopulmonary and psychiatric diagnoses, including CHF, CKD, pleural effusion, nicotine dependence, atherosclerotic heart disease, respiratory failure with hypoxia, pneumonia, HTN, anemia, and schizophrenia. His quarterly MDS and care plan addressed CHF, COPD, oxygen therapy, monitoring for respiratory distress, lab monitoring, fall precautions, skin integrity, antidepressant monitoring, and pain, but did not include a smoking safety assessment or smoking-related interventions. He stated he smoked in the designated area, that staff provided and lit his cigarettes, and that he did not know if he had been assessed to smoke safely. A female resident with intact cognition (BIMS 15) had her care plan updated only on the survey date to reflect that she was a smoker and required constant supervision while smoking, with interventions for designated smoking area use, removal of smoking materials from her room, and monthly safe smoking assessments. She reported that staff kept her cigarettes and lighter and were responsible for lighting her cigarettes.

A female resident with seizure disorder, DM2 with hyperglycemia, bipolar disorder, metabolic encephalopathy, anxiety, diabetic neuropathy, impaired vision, chronic pain, and other conditions had a history and physical that documented denial of tobacco use and no documentation identifying her as a smoker. Her MDS showed moderately impaired cognition (BIMS 12), supervision needs for eating, transfers, and toileting, and impaired vision requiring corrective lenses, but did not document smoking status or a smoking assessment. Her care plan addressed HTN, diabetes, diuretic therapy, impaired vision, depression, and ADL self-care deficit, and included education on adverse effects of tobacco, but lacked a specific smoking problem statement, risk assessment, or interventions for supervision or safe smoking location. She was later observed sitting in the smoking area with other residents who were smoking and stated she had started smoking about two weeks earlier, obtained cigarettes from other residents, and did not know if she had been evaluated for safe smoking or the facility’s smoking rules beyond needing to go outside.

Additional observations showed other residents possessing cigarettes and, in one case, a lighter in their rooms. One resident admitted to being a smoker, showed a pack of cigarettes in his jacket pocket, and stated he was supposed to turn them in to the facility for safekeeping, was aware of the policy that residents should not keep such items, and denied having a lighter or matches. Another resident stated he did not know he needed to inform the facility that he smoked and did not believe he had been evaluated for safe smoking; he knew he could not smoke inside and had to use the designated area. This resident had a pack of cigarettes and a lighter in his nightstand and acknowledged he knew he needed to give smoking equipment to staff, explaining that the items had been given to him by a family member the previous day. Staff interviews confirmed that cigarettes and lighters were supposed to be kept in a locked box, that staff supervised residents during smoking times, and that some staff were concerned that residents with tremors and poor hand control might not have appropriate smoking assessments. The Activities Director acknowledged the facility was not following its policies and procedures for resident safety and that residents having lighters in their rooms could result in fire hazards, while the facility’s comprehensive care planning policy required person-centered care plans addressing identified needs from the assessment, including review and revision after each MDS assessment.