F0689

K

Failure to Manage Resident Smoking and Elopement Risks Under F689

Auburn, Washington Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment free from accident hazards related to smoking and elopement, and to provide adequate supervision to prevent accidents. Surveyors found that the facility did not timely or accurately assess multiple residents’ ability to smoke safely, did not develop or implement resident-specific smoking care plans, did not secure smoking supplies, and did not maintain a safe designated smoking area. The facility’s own smoking policy prohibited smoking on the premises and required new admissions to smoke off premises under direct supervision by a non-staff responsible party, with smoking supplies stored off premises. Despite this, the designated smoking area in the parking garage was littered with hundreds of cigarette butts, had a fire extinguisher lying on the ground, and another extinguisher and a smoking blanket blocked by trash cans, a chair, and a bed frame, making safety equipment inaccessible.

One resident admitted for skilled services with impaired mobility and dependence on staff for care signed the non-smoking agreement but was later documented smoking or vaping in their room and in an indoor atrium. A smoking assessment identified this resident as wishing to smoke, having impaired short-term memory, and being unsafe to smoke independently, yet this was the only evaluation in the record. Their comprehensive care plan contained no information about smoking preferences, the failed smoking assessment, prior indoor smoking events, or interventions for smoking safety or nicotine dependence. Progress notes documented repeated indoor smoking, refusal to surrender a lighter, and use of a cigar in the room, but there was no evidence of incident logging or investigation. Observations showed this resident independently in the road outside, picking up cigarette butts, lighting them in their lap while wearing thin pants and a disposable brief, and obtaining lit cigarettes from other residents in the driveway of the parking garage. The receptionist stated the resident frequently went out to smoke, should sign out but did not, and staff were not informed that the resident was unsafe to go out or smoke independently.

Another resident with moderate cognitive impairment, dementia, traumatic brain injury, severe mental illness, and dependence on a wheelchair had no documentation of being informed of the non-smoking policy and no smoking safety assessment, despite multiple documented incidents of smoking inside the facility. Progress notes showed this resident smoked in their restroom, in a shared bathroom where smoke filled the room and disturbed a roommate, and in the atrium, and was reported by other residents to have smoked marijuana with others in the atrium. These events were not entered on the incident log, and there was no documented investigation or new interventions. A cognitively intact resident observed on camera smoking an unknown substance in the garage with another resident also had no smoking assessment or care plan, and the incident was not logged or investigated beyond a note that it would be discussed at a staff meeting. Another resident with mild cognitive impairment and a roommate on oxygen was associated with a strong smell of smoke and ash on the floor in their room, but there was no documentation of locating or removing smoking materials, implementing protective interventions, or logging and investigating the incident.

Additional residents who smoked were not properly assessed or care planned. One cognitively intact resident with wandering behaviors had an outdated and incomplete smoking assessment indicating they were not a smoker, with no subsequent assessments despite later documentation of the resident smoking outside and refusing nicotine cessation. This resident was later observed off facility property in a power wheelchair, with coats, bags, and a blanket on the chair, smoking a cigarette. Two other residents observed smoking in the driveway of the parking garage had no smoking safety assessments or care plans. Staff interviews confirmed that 17 residents were known smokers, that three were grandfathered under a prior policy allowing smoking in a designated area, and that active smokers were supposed to be assessed and have smoking-focused care plans, but the DON acknowledged that the reviewed residents lacked such assessments and that there was a breakdown in the system for managing resident smoking.

The facility also failed to reassess a resident’s ability to smoke independently after a cigarette burn and did not report or investigate the injury. A progress note documented that this resident told a shower aide they had accidentally burned their leg with a cigarette while smoking outside, but the note did not describe how the burn occurred or any new interventions to prevent future burns. The state tracking and reporting system showed the burn injury was not reported. In interviews, leadership stated that a resident burn was expected to be reported, logged, investigated, and followed by nursing assessment, provider notification, treatment orders, reassessment of independent smoking ability, and consideration of protective equipment and cessation support, none of which were documented for this resident.

The deficiency further includes failures related to elopement prevention and supervision for the cognitively impaired resident with dementia, traumatic brain injury, and severe mental illness who used a wheelchair and a Wander Guard device. This resident had an elopement care plan identifying them as a wanderer at risk for elopement, with interventions including frequent monitoring, safety interventions, and use of a Wander Guard. Progress notes documented exit-seeking behavior, agitation, and multiple episodes where the resident left the facility unassisted and went to nearby stores or was found several blocks away. Some events involved staff following and returning the resident, and one involved police notification and initiation of 1:1 supervision, but several elopements were not entered on the incident log or investigated, and there was no documentation of why the Wander Guard system did not alarm during at least one elopement. Later observation showed the resident near an elevator with a Wander Guard device on the wheelchair; the system did not alarm until the elevator button was pushed, and the resident expressed intent to go to the store, while no 1:1 staff were present despite a written 1:1 supervision guideline and staff sign-in logs indicating such supervision should have been in place.

Throughout these events, the facility did not consistently follow its own policies for smoking, incident reporting, and elopement. Smoking incidents inside the building, in resident rooms, shared bathrooms, the atrium, and the garage were not reliably reported to administration, entered on the incident log, or investigated. Elopement events for the high-risk resident were similarly omitted from the incident log and not investigated as required. Leadership interviews confirmed expectations that such incidents be reported, logged, and investigated, and acknowledged that the smoking policy was unclear and not followed by residents or staff, and that the elopement policy was not followed for the resident who repeatedly eloped.