F0926

D

Failure to Enforce Designated Smoking Area Policy

San Antonio, Texas Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The facility failed to ensure the resident environment remained as free of accident hazards as possible by not enforcing its smoking policy for one resident. The resident had a history of bipolar disorder, depression, anxiety, schizophrenia, and post-traumatic stress disorder, but a BIMS score of 15/15 indicating no cognitive impairment. Her initial smoking evaluation documented no deficits preventing her from smoking independently and unsupervised, and staff had reviewed the smoking policy with her, with documentation that she verbalized understanding. Her care plan, revised on 6/16/25, identified her as a smoker with a goal to prevent accidents while smoking and to observe her for unsafe smoking behaviors or attempts to obtain smoking materials from outside sources.

On observation, the resident was seen sitting in a wheelchair and smoking a cigarette in the front patio area, which was not the designated resident smoking area. When asked if she was allowed to smoke in the patio, she stated she was allowed to sign out and could smoke when she left the premises, and did not answer when asked again if she could smoke in the patio. Staff were observed entering and exiting the facility during this time, and none approached the resident. The DON reported awareness that the resident did not always follow the smoking policy and stated she had previously seen the resident smoking in the front patio. The DON confirmed that per policy the resident was only allowed to smoke in the designated smoking area at the back of the facility, where metal ashtrays, a fire blanket, and a fire extinguisher were located, and stated that all staff were responsible for monitoring and reporting residents who smoked outside designated areas because the resident could start a fire and other residents could get hurt.