SPOKANE, WA — Federal health inspectors directly witnessed a medically vulnerable nursing home resident self-propelling a wheelchair with a lit cigarette toward a propane tank on an unsupervised patio at Spokane Health & Rehabilitation, triggering an immediate jeopardy citation — the most serious deficiency level in the federal nursing home oversight system. The April 2025 complaint investigation revealed a pattern of failed smoking safety protocols affecting multiple residents over a period of months.
Surveyors Witnessed Resident Smoking Near Propane Tank
On April 15, 2025, at 2:23 PM, the entire survey team observed a resident — identified in federal records as Resident 73 — moving through the facility's patio area in a wheelchair while holding a lit cigarette. The resident, who had been admitted in February 2025 with Parkinson's disease and diabetes, attempted to enter the conference room where surveyors were working before wheeling over to the barbecue area and sitting next to a propane tank.
When a surveyor entered the patio area at 2:34 PM, the space smelled of cigarette smoke. No fire blanket or ashtrays were present in the area. A white plastic table nearby displayed black streaks consistent with a cigarette being stubbed out on its surface — indicating this was not an isolated occurrence.
The resident told the surveyor they typically smoked three times per day and confirmed there was no ashtray outside. The resident also described being locked out of the facility after evening hours when the front doors were secured, stating: "I have to wait until someone sees me to let me in because the doors are locked."
This situation represents a convergence of fire hazards that could have had catastrophic consequences. Open flame near a propane tank in an enclosed patio area — particularly when handled by a resident with a neurological condition affecting motor control — creates the conditions for an explosion or rapid-spread fire in a building housing dozens of medically fragile individuals.
Months of Documented Warnings Preceded the Incident
The inspection narrative reveals the facility had been aware of the smoking issue for months before surveyors observed the dangerous situation firsthand.
Hospital transfer documents from January 2025 noted Resident 73 smoked cigarettes "on some days." A facility provider note dated February 3, 2025 — just two days after admission — documented the resident as a "current smoker some days." Yet the admission assessment completed on February 7 indicated the resident did not use tobacco, a direct contradiction of the clinical records.
Staff first observed Resident 73 smoking outside in the parking lot on February 17, 2025. A social worker spoke with the resident and reminded them of the non-smoking policy. A subsequent safety evaluation — which was not completed and signed off until 16 days later on March 5 — concluded the resident "is not a safe smoker at this time" and was unable to hold or extinguish a cigarette safely or use an ashtray properly.
The evaluation noted that the resident agreed to use nicotine patches as a cessation aid and that an order was placed. However, a review of the medication administration records for March and April 2025 showed no nicotine patches were ever prescribed or administered prior to April 15 — the day surveyors witnessed the patio incident. This represents a nearly two-month gap between the documented plan and any action.
Care Plan Gaps Left Resident Without Protection
The facility created a tobacco use care plan on March 4, 2025, but it contained significant gaps. While it instructed staff to educate the resident about smoking risks and to notify management if the resident was found smoking, it included no specific interventions to keep the resident safe from smoking-related injuries. There were no instructions regarding the level of supervision required, no documentation of where smoking supplies were stored, and no protocols that compensated for the resident's documented inability to manage smoking materials safely.
The Assistant Director of Nursing later acknowledged in an April 28 telephone conversation that the facility should have added care plan instructions specifying the level of supervision Resident 73 required during smoking after the February safety evaluation. The additional safety interventions were not implemented, the ADON explained, because "the evaluation concluded a smoking cessation program (nicotine patches) would be started" — patches that were never actually ordered.
A Pattern Across Multiple Residents
The immediate jeopardy citation affected not just one resident. Inspectors identified systemic failures in how the facility managed smoking safety across its population.
Fire Alarm Triggered by Indoor Smoking
A second resident — identified as Resident 461 — had an even more alarming history at the facility. This resident, who had been diagnosed with Chronic Obstructive Pulmonary Disease (COPD), was a daily smoker who repeatedly refused to comply with the facility's non-smoking policy.
On December 29, 2024, at 2:18 AM, the facility's fire alarm was activated. Staff detected smoke in Resident 461's bathroom. The fire department was dispatched, and the alarm monitoring company contacted facility staff. Despite this incident, the resident denied smoking indoors and refused to surrender their cigarettes or lighter.
Progress notes documented the resident's response: "I'm going to smoke no matter what."
The resident had been offered nicotine patches beginning in July 2024 but began refusing them in August and the prescription was discontinued in September. Despite multiple safety assessments identifying the resident as a tobacco user, and despite the resident openly keeping cigarettes and a lighter in their possession, the facility found no effective intervention. Records showed the resident continued to smoke on facility property throughout the fall of 2024. A discharge notice was finally issued on December 30, 2024 — the day after the fire alarm incident.
The Maintenance Director confirmed in an April 2025 interview that the fire alarm went off specifically because Resident 461 had smoked in their bathroom.
A Third Resident's Smoking History Overlooked
A third resident, Resident 86, who had severe cognitive impairment, was admitted in November 2024. Hospital records provided during the admission process clearly documented this resident smoked cigarettes daily. However, the facility's own safety assessment conducted on November 12 indicated the resident did not use tobacco products — directly contradicting the hospital records in the facility's possession.
When interviewed by surveyors in April 2025, Resident 86 confirmed they used to smoke, said staff had never spoken to them about smoking, and stated they were unaware the facility was a non-smoking building.
What Federal Standards Require
Under federal regulation 42 CFR §483.25 (F-689), nursing facilities are required to ensure that the environment is as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents. This includes identifying residents who smoke, assessing their ability to do so safely, and implementing individualized interventions.
An immediate jeopardy citation — designated as the highest severity level by the Centers for Medicare & Medicaid Services — indicates that a facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Facilities that receive this designation must demonstrate corrective action before the immediacy can be removed.
Proper smoking safety protocols in a skilled nursing setting require several key elements: an accurate assessment at admission that captures smoking history from all available records, a safety evaluation determining whether the resident can smoke independently, a care plan with specific supervision levels and safety equipment, secure storage of smoking materials when appropriate, designated smoking areas with fire safety equipment, and staff education on the facility's smoking policies.
In this case, the facility demonstrated failures at nearly every step. Admission assessments contradicted hospital records. Safety evaluations were completed weeks late. Prescribed cessation aids were never administered. Care plans lacked specific safety interventions. The patio where smoking occurred had no fire safety equipment. And during the entrance conference, the Administrator told surveyors that the facility was non-smoking and no residents smoked — despite months of documented smoking incidents in the facility's own records.
Corrective Actions Taken
Following the survey team's observations on April 15, the facility took several immediate steps. Resident 73 was placed on one-to-one surveillance, smoking materials were secured, and the resident's ability to smoke was reassessed. The facility closed access to unsupervised patio areas, added a fire blanket and outdoor ashtray to a designated smoking area, and conducted a facility-wide sweep to remove unauthorized smoking materials.
All residents in the facility received smoking safety evaluations, and care plans were developed or revised with individualized interventions and supervision levels. Staff were educated on the smoking policy and on identifying, managing, and reporting unsafe smoking behaviors. The immediacy was formally removed on April 16, 2025.
The full inspection report is available through the Centers for Medicare & Medicaid Services' Care Compare website. Families with concerns about conditions at any nursing facility can contact the Washington State Department of Social and Health Services or the federal Long-Term Care Ombudsman program.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manor Care Health Services-spo from 2025-04-24 including all violations, facility responses, and corrective action plans.
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