Failure to Implement and Maintain Safe Smoking Policy and Area
Penalty
Summary
The facility failed to implement and effectively maintain a smoking policy in accordance with Federal, State, and local laws and regulations, resulting in unsafe smoking practices for resident smokers, non-smokers, and staff. The written smoking policy prohibited residents from smoking cigarettes, marijuana, tobacco products, e-cigarettes, and vaping devices anywhere on the premises and required residents admitted after 04/18/2024 to smoke off premises under direct supervision of a non-staff responsible party, with all smoking supplies stored off premises. The policy stated that staff would assess smokers for smoking safety, handling of smoking materials, and use of mobility devices outside, and that residents would sign out to smoke and sign back in upon return, with a section for residents to acknowledge and comply with the policy. However, the policy did not define where the premises ended, did not identify a designated smoking area, did not define smoking safety, and did not address rules for residents admitted prior to 04/18/2024. Surveyor observation showed that the designated smoking area used by residents was in the back of the parking garage, where the ground was littered with hundreds of cigarette butts. A fire extinguisher was found lying on the ground in the gravel, and a fire blanket and a second fire extinguisher were mounted on the wall but blocked by two large trash cans, a chair, and a bed frame, making them inaccessible. A maintenance assistant confirmed that certain residents were allowed to smoke in this area, acknowledged the large number of cigarette butts, and identified the fire extinguisher on the ground as unsafe. The administrator and DON reported that 17 residents were known smokers, that residents signed a non-smoking policy on admission, and that three residents were grandfathered under a prior policy allowing them to smoke in the parking garage while other residents were required to go off property to smoke. The DON stated that active smokers were assessed as independent, with assessments and smoking-focused care plans in their records, and that smoking supplies were kept on the med cart and checked out by residents who then signed out to smoke. When asked if the policy was being followed, the administrator stated the policy was unclear and not followed by residents or staff, and the DON stated there was a breakdown in the system of residents smoking. An interim administrator later stated that the facility did not implement or maintain a smoking policy that supported resident rights and safety.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.