F0689

D

Failure to Enforce Smoking and Vaping Safety Policies for Two Residents

Oconto Falls, Wisconsin Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a resident environment as free of accident hazards as possible and to provide adequate supervision related to smoking and vaping for two cognitively intact residents. Facility policy, revised 1/2026, states that smoking is not permitted in the facility or where oxygen is in use, that residents who smoke or use e‑cigarettes must be evaluated for safe or unsafe use, and that staff are to maintain all smoking materials, including e‑cigarettes, as appropriate for the resident. The policy further requires that smoking, smokeless tobacco use, and e‑cigarette use occur only in designated locations that are environmentally separate from resident care areas, and that staff maintain smoking materials in a secure area such as the nurses’ station, distributing them only at smoking times or via a locked container for residents deemed safe.

One resident (R1), with diagnoses including quadriplegia, COPD, diabetes, anxiety, and nicotine dependence, had a BIMS score of 15/15 and was responsible for their own medical decisions. R1’s care plan documented that the resident chose to vape, was to vape only in designated areas, and was to turn in smoking materials when not smoking, with encouragement to leave all smoking items at the nurses’ station. The care plan also documented that R1 was non‑compliant with the smoking policy and had been observed vaping in the room, and that a risk versus benefits form had been completed because R1 continued to vape in the room. A Safe Smoking Evaluation dated 3/4/26 indicated R1 had been informed that all smoking materials must be secured at the nurses’ station or other designated area when not in use and that R1 must request smoking materials from staff. Despite this, the surveyor observed two vaping devices in R1’s room, including one plugged into a computer, and R1 reported vaping in the room at night and in the morning, approximately 10 to 20 times or more per hour, keeping the devices in the room and using them inside the facility.

Multiple staff confirmed awareness of R1’s in‑room vaping and the presence of vaping devices. A CNA stated staff and management were aware that R1 had and used the devices in the room. An LPN reported knowing that R1 vaped in the room and that the DON had previously been involved in a contract for R1 to store vaping materials at the nurses’ station, but that R1 had been openly vaping for a long time and had turned in only empty devices while keeping usable ones. A medication technician also knew R1 had vaping devices in the room and stated R1 turned in used, non‑working devices while keeping functional ones. When the surveyor and the medication technician checked the smoking materials lock box, there were no materials for R1, contrary to the care plan and policy requirements.

A second resident (R2), with diagnoses including acute kidney failure, diabetes, and nicotine dependence on cigarettes, also had a BIMS score of 15/15 and was responsible for their own medical decisions. R2’s care plan stated that the resident chose to smoke cigarettes, would smoke only in designated areas, and would turn smoking materials into nursing staff for safekeeping between smoking, with re‑evaluation if safety became a concern. A Safe Smoking Evaluation indicated R2 had been informed of the evaluation results. However, the surveyor observed R2 in the room holding a pack of cigarettes, then placing the cigarettes in a pocket, passing the nurses’ station with staff present, exiting the building, and lighting a cigarette. R2 initially denied keeping smoking materials in the room but then admitted doing so and stated that once cigarettes were picked up in the morning, they were kept by the resident.

Staff interviews confirmed that R2 routinely retained smoking materials instead of turning them in as required. A CNA stated R2 usually kept cigarettes and a lighter for convenience and did not return them to the nurses’ station. The LPN acknowledged knowing that R2 kept smoking materials and stated that, although materials were supposed to be stored in a lock box behind the nurses’ station, there was no follow‑up or consistency, so R2 and other residents kept their materials. The medication technician reported being aware that R2 kept cigarettes and lighters and believed R2 was not a supervised smoker and could keep these items, also noting that R2 often obtained cigarettes from other residents. When the surveyor and medication technician checked the smoking materials lock box, there were no materials for R2. The DON stated that staff and residents should follow the smoking policy and that staff were supposed to keep R1 and R2’s smoking materials, which should not be kept on their person or in their rooms, and reported not being aware that R1 kept vaping materials in the room or vaped in the room.