F0689

E

Unsafe Smoking Environment, Inadequate Supervision, and Poor Smoking Care Planning

Santa Rosa, California Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, hazard‑free smoking environment and to provide adequate supervision and care planning for residents who smoke. Surveyors observed the designated outdoor smoking area at the back of the facility to be a 10 ft by 10 ft covered space open to the parking lot, with a table, a wooden chair, a standing cigarette butt receptacle, and a carpet mat. Numerous cigarette butts were scattered on the ground under the shade structure, and residents and staff confirmed that not everyone used the ashtray and that the area was often dirty and only occasionally swept. Approximately 10–12 ft beyond the smoking area, the maintenance/housekeeping shed and surrounding grounds contained multiple empty to full cardboard boxes, tarped boxes and furniture, wood pallets and slabs, a plastic crate with spray bottles and a plastic bottle of cleaning solution, random debris, and two overfilled garbage bins. One shed door adjacent to the smoking area was left open and unattended, allowing access to maintenance supplies, tools, chemical solutions, aerosols, documentation, broken equipment, and boxes of glass fluorescent tube lights stored in a cluttered, disorganized space. The Life Safety/Housekeeping Director acknowledged that the shed and the overflowing garbage bins were hazardous and that flammable aerosol items and boxes of ethyl alcohol‑based hand sanitizer were stored there.

The facility also failed to provide adequate supervision in the smoking area, which contributed to resident‑to‑resident abuse and unsafe smoking practices. Resident 1, with hemiplegia/hemiparesis and moderately impaired cognition (BIMS 12), was assessed as able to smoke without supervision and had signed the smoking policy and contract. Resident 2, with paranoid schizophrenia and severely impaired cognition (BIMS 5), was also assessed as independent and allowed to smoke without supervision, with his conservator signing the smoking policy and contract. Resident 3, cognitively intact (BIMS 15) with COPD, was likewise allowed to smoke unsupervised. Resident 4, with COPD, adult failure to thrive, and moderately impaired cognition (BIMS 11), was assessed as requiring supervision to smoke, and Resident 5, with a right femur fracture and history of falls and moderately impaired cognition (BIMS 11), was also assessed as requiring supervision. Resident 6, cognitively intact (BIMS 15) with a Colles fracture and repeated falls, was assessed as independent to smoke without supervision. Despite facility smoking policies and resident contracts specifying set smoking times and supervision requirements, surveyors observed residents smoking unsupervised outside of scheduled times. Resident 2 and Resident 3 were seen smoking alone, with Resident 3 positioned in the parking lot past the first row of cars. Resident 2 was observed with two small burn holes in the front of his coat, which he attributed to a burning cigarette that went out on its own while he was alone.

An incident of resident‑to‑resident abuse occurred in the smoking area when Resident 2 hit Resident 1 on the right side of the face during an altercation while both were outside smoking unsupervised. Progress notes and care plans for both residents documented the incident and indicated that staff were to continue to monitor the smoking area, but staff interviews revealed that increased supervision after the altercation lasted only briefly and that there were not enough staff to consistently supervise smoking times or prevent residents from going out to smoke independently. Resident 4, who required supervision and was non‑ambulatory, was observed smoking outside unsupervised in his wheelchair, with both legs wrapped in kerlix gauze from ankles to knees. He reported that a CNA had brought him outside and left him in the sun, and he stated he could not help himself since his legs were wrapped. He was seen extinguishing his lit cigarette with his fingers and placing the butt in his coat pocket, and he needed assistance to turn his wheelchair and open the door to re‑enter the building. Resident 1 was observed flicking his cigarette into a plastic cup holder attached to his wheelchair, which contained ash and later two cigarette butts; the Activities Director and DON acknowledged that using a plastic cup holder as an ashtray was not allowed and posed a fire hazard.

The facility also failed to adequately incorporate residents’ smoking status and supervision needs into their care plans. Resident 4’s care plan report contained no evidence of a smoking care plan, despite his documented need for supervised smoking. Resident 6’s smoking care plan was not initiated until the time of the survey, even though she had been admitted months earlier and had signed the smoking policy and contract. Facility policies required that any smoking‑related privileges, restrictions, and concerns, including the need for close monitoring, be noted on the care plan, and the DON stated that smoking status should be care planned within seven days of admission so staff would know a resident is a smoker and whether supervision is required. Staff interviews confirmed that care plans are used to guide monitoring and actions, including assessing whether residents are safe to use and keep lighters, and that without appropriate care planning, staff may not be aware of residents’ smoking needs. The DON acknowledged that residents who required supervision should not be outside unsupervised, that residents sometimes went out to smoke at any hour despite rules, that the smoking rules were not enforced, and that staff were not prepared for the interaction that occurred between Resident 1 and Resident 2 in the smoking area.

Facility policies and job descriptions emphasized maintaining a safe environment, identifying safety risks and environmental hazards, and ensuring safe smoking practices. The Safety and Supervision of Residents policy stated that the facility strives to make the environment as free from accident hazards as possible and that resident supervision is a core component of safety. The Maintenance Service policy and the Maintenance Director and Housekeeper job descriptions required maintaining buildings and grounds in good repair and free from hazards, inspecting storage and work areas, and maintaining a safe, orderly, and clean environment free of obstacles. The Smoking Policy‑Residents documents, including the version signed by residents and responsible parties, specified designated smoking times, required that smoking‑related privileges and monitoring needs be noted on care plans, and stated that residents with smoking privileges may not keep smoking articles outside of designated times and that violations could result in loss of smoking privileges or discharge. Despite these written expectations, observations, interviews, and record reviews showed that the smoking area and adjacent maintenance/housekeeping area were cluttered and hazardous, that residents smoked unsupervised and outside of designated times, that unsafe methods of extinguishing cigarettes were used, and that smoking care plans were missing or delayed for some residents, resulting in unmet care needs and inadequate care planning.