F0684

E

Failure to Implement Safe Smoking Practices and Timely Fall Reporting

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, person-centered care plans, and resident choices, specifically related to smoking assessment/supervision and fall reporting. Multiple residents with documented or reported nicotine dependence or smoking behavior did not have complete or consistent smoking assessments, care plans, or supervision interventions in place as required by facility policy. For one resident with chronic tobacco use, osteomyelitis with toe amputation, peripheral vascular disease, impaired mobility, and cognitive deficits, the care plan included education on adverse effects of tobacco but did not clearly identify specific smoking supervision interventions, assistance to and from the designated smoking area, lighter control, fire prevention strategies, or individualized hazard mitigation despite his mobility and cognitive limitations. Another resident with a diagnosis of nicotine dependence, COPD, respiratory failure with hypoxia, and other serious cardiorespiratory conditions had a care plan that only encouraged refraining from smoking and did not include a specific smoking supervision plan, designated smoking area guidance, staff supervision requirements, smoking safety precautions, lighter control procedures, or fire risk mitigation interventions; there was no safe smoking assessment in the electronic record.

A third resident with a history of chronic smoking, respiratory issues, substance use disorder, and anxiety had an admission MDS that did not clearly document smoking behaviors or supervision requirements, even though a separate safe smoking assessment indicated supervision was required. Her care plan, updated later, identified her as a smoker and required that she always be supervised by a visitor or staff member, that she smoke only in the designated area, that no oxygen be present while she smoked, that no smoking materials be stored in her room, and that monthly safe smoking assessments be completed. Another resident with seizure disorder, diabetic neuropathy, impaired vision, and chronic pain denied tobacco use in the history and physical, and there was no documentation identifying her as a smoker, no smoking status on the MDS, and no smoking assessment completed. Her care plan included education on adverse effects of tobacco but did not identify her as a smoker or include interventions for supervision, safe smoking location, or monitoring for smoking-related hazards. This resident was later observed sitting in the smoking area near other residents who were smoking and reported she had started smoking about two weeks earlier using cigarettes given by other residents; she stated she did not know if she had been evaluated to safely smoke and did not know the facility’s smoking rules beyond needing to go to the designated smoking area.

Another resident with dementia, atrial fibrillation, anticoagulant therapy, and other chronic conditions had a care plan that encouraged avoidance of smoking for GERD management and stated smoking materials were kept at the nurses’ station, but it did not clearly describe supervision frequency, monitoring for burns, or risk mitigation related to his cognitive impairment and anticoagulant use. A safe smoking assessment completed by the surveyor at the time of entrance documented that he was safe to smoke unsupervised and that all smoking materials were kept at the nurses’ station, but during an interview he stated he did not know he needed to inform the facility that he smoked, did not know he had been evaluated to safely smoke, and had a pack of cigarettes and a lighter in his nightstand that had been given by a family member. Another resident admitted to being a smoker and had a pack of cigarettes in his jacket pocket, stating he had just received them from a family member and was supposed to turn them in to the facility for safekeeping; he reported he did not have a lighter and was aware of the policy that residents should not keep such items and must turn them in. Additional interviews with residents revealed that several smokers did not know whether they had been assessed for safe smoking, while staff interviews showed that CNAs supervising smoking did not know which residents had completed smoking assessments and expressed concern about residents with tremors and poor hand control smoking without clear confirmation of individualized safety evaluations.

The deficiency also includes a failure to report and respond to a resident fall according to facility policy. One resident with a nondisplaced intertrochanteric fracture of the left femur, atrial fibrillation, legal blindness, repeated falls, mild dementia, and severe cognitive impairment (BIMS score of 01) required staff assistance for bed mobility, transfers, and ambulation and had a care plan identifying him as at risk for falls, with interventions including staff assistance with transfers. A CNA reported that this resident lost balance during a transfer from wheelchair to bed and fell onto his buttocks and left side onto a floormat. The CNA acknowledged she knew she was required to report the fall immediately to the charge nurse or DON but forgot to do so and assisted the resident back to bed without notifying licensed staff at that time. Another CNA confirmed he assisted the first CNA in helping the resident after the fall and stated that the first CNA told him she would notify the charge nurse. Interviews with other CNAs, an LVN, the DON, and the Administrator confirmed that facility expectations and policies required all falls to be reported immediately to a licensed nurse for assessment, that CNAs were not permitted to independently determine a resident’s condition after a fall or reposition the resident without nursing evaluation, and that this fall was not reported as required.