Failure to Reassess Smoking Safety After Resident-Initiated Fire
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who smoked and possessed smoking materials. The resident had multiple mental health and behavioral diagnoses, including alcohol use, generalized anxiety disorder, cocaine abuse, major depressive disorder, PTSD, and a history of restlessness, agitation, hoarding, verbal aggression, and threats toward staff. Her care plan documented that she chose to safeguard her own smoking materials in her room, was expected to adhere to the facility’s tobacco/smoking policy, and had been assessed as cognitively intact with a BIMS score of 15. The facility’s written smoking policy required that cigarettes, lighters, matches, and all tobacco products be turned in to the nurse for secure storage, prohibited smoking materials in resident rooms or on their person, and required smoking safety assessments quarterly and as needed with any change in condition or functional abilities. On the morning of 2/27/26, staff detected the smell of smoke on the resident’s hallway. An LPN reported smelling smoke while assisting another resident and directed CNAs to search rooms. CNAs discovered a wet, burned pile of ace wrap and sheet pieces on the floor of the resident’s room, several steps in front of the sink, with no active flames. The resident was not in the room at that moment but admitted to staff that she had started the fire, with one CNA reporting that the resident stated she did it on purpose and said, “We are all going to die anyways.” Staff also reported finding a knife, medications, and another item in the resident’s belongings and turning these over to the administrator. Nursing documentation noted that the resident had cut up an ace wrap and sheet and started the material on fire, that she stated she was not in her right mind and did not know why she started the fire, and that the administrator was updated. The administrator documented that staff notified him that the resident had ignited a small item in her room using a personal lighter, that he met with the resident, and that she reported burning something small near her shoe. He removed the lighter, initiated 15‑minute safety checks, and requested a review of her mental status and cognition. The resident’s care plan was updated the same day to add that she sometimes had behaviors including attempting to start a fire with her lighter, with interventions such as monitoring for danger to self or others and contacting law enforcement/administrator if the behavior recurred. However, the facility did not complete an updated Smoking and Safety Assessment immediately after the fire incident, despite the policy requirement for reassessment with changes in condition or functional abilities. Staff interviews indicated that after the incident the resident continued to have smoking materials, managed them on her own, and went in and out to smoke, while the receptionist and nursing staff reported they had not been instructed to secure her smoking materials and that she continued to safeguard them in her room lockbox. A later Smoking and Safety Assessment completed on 3/4/26, after surveyor inquiry, did not document the prior fire, did not mark burned items as a concern, and stated there were no concerns with her ability to smoke safely outside, demonstrating that the facility failed to reassess and revise her smoking safety status in response to the fire she started in her room. The surveyors determined that the facility’s failure to reassess the resident’s safety with smoking materials after she started a fire in her bedroom, and the continued care planning and allowance for her to have smoking materials on hand, constituted a failure to identify and address the risk. The facility’s own policy prohibited smoking materials in resident rooms and required secure storage and reassessment with changes in condition, yet the resident’s care plan and staff accounts showed she retained access to smoking materials and a lockbox in her room. The facility leadership stated they viewed the incident as related to mental health and not unsafe smoking, and initially did not redo the smoking assessment because they did not consider smoking itself to be the concern. These actions and inactions led to a finding of immediate jeopardy beginning on 2/27/26, later reduced to a deficiency at scope/severity level E as the facility continued to implement its action plan.
Removal Plan
- All staff re-educated on the facility's non-smoking policy prior to their next shift, including that smoking is not permitted inside the building and that smoking materials such as lighters, matches, and cigarettes must be stored at the nurse station or in an approved resident lockbox per facility policy.
- A facility wide audit was conducted to ensure residents do not possess ignition sources or weapons, and any items identified were immediately secured according to facility policy.
- All residents who smoke or possess smoking materials are being provided with a new smoking safety assessment.
- Staff were educated that any resident demonstrating unsafe behavior with smoking materials will have materials secured and will receive an immediate reassessment, with care plan interventions implemented as appropriate.
- Residents who smoke were educated regarding not using smoking materials in the facility and fire safety.
- The resident involved in the incident had smoking materials secured by staff, was reassessed for safety, and care plan interventions were updated.
- The facility generated a comprehensive list of all residents who expressed desire to smoke and completed a smoking evaluation for each identified resident along with care plan revisions.
- The facility reviewed the smoking policy and expectations regarding possession of weapons.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks on residents who smoke to ensure smoking is done safely, lighters/ignition materials are being kept appropriately or not in possession of those who are unsafe to have them, policy is followed, assessments are completed, and care plans are in place.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks of staff to ensure they know the proper procedures on what to do if a resident has a weapon.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks to ensure residents are free of weapons.
- Results of audits will be reviewed at QAPI for further recommendations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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