F0926

E

Failure to Enforce Safe Smoking Policies and Control Smoking Materials

Cleveland, Ohio Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and enforce its own safe smoking policies and procedures for residents who smoke. The facility’s smoking policy required that smoking occur only in designated areas and times, that all smoking materials (including cigarettes and lighters) be locked when not in use, and that supervised smokers not be given personal possession of smoking materials. Despite this, multiple residents were observed with cigarettes and lighters in their rooms or on their person, and smoking paraphernalia was found in inappropriate locations within the facility. The facility census included 37 smokers out of 164 residents.

One resident with multiple medical diagnoses including hypertensive heart and chronic kidney disease, type 2 diabetes, end stage renal disease, atrial fibrillation, vascular dementia, post-traumatic stress disorder, anxiety, and nicotine dependence had a care plan addressing potential tobacco-related injuries and infection control issues. This resident was documented as having been found drinking vodka and smoking in her room, and later having a lighter in her room, despite being care planned as a supervised smoker who could not safely use a lighter and was to smoke only in designated areas. Other residents were observed with cigarettes and lighters not stored in lockboxes as required. One resident’s room contained a pack of cigarettes and a lighter on the bedside table while an oxygen concentrator was running, and this situation was observed on more than one occasion. Another resident was reported by CNAs to have smoked in his room while his roommate, who used oxygen, was present.

Additional observations showed residents keeping cigarettes and lighters at bedside or on their person, including a resident in the hallway with cigarettes and a lighter and clothing with multiple burn holes, and another resident with cigarettes and a lighter at bedside who stated she could not access the designated outdoor smoking area due to a damaged sidewalk. Cigarettes and lighters were also found on the floor of a resident’s room across from a room where oxygen was in use, and smoked smoking paraphernalia was found placed on a vitals machine at a nursing station. Other residents were seen with cigarette packs on the floor or hidden in trash or under bedding, refusing to relinquish them, and one resident was observed smoking in front of the facility rather than in the designated smoking area. Staff interviews confirmed that residents sometimes obtained cigarettes and lighters from family or store trips and that room sweeps were done, but these measures did not prevent the widespread presence of unsecured smoking materials and smoking outside of designated areas, contrary to facility policy.