Federal inspectors found the lighters during three separate observations of Resident #70 on August 4, at 10:13 A.M., 12:26 P.M., and 2:50 P.M. Both lighters contained visible fluid and sat on the bedside table within the resident's reach.
The resident had been admitted to The Laurels of Walden Park in November 2024 with peripheral vascular disease and bilateral above-knee amputations. His care plan from October noted he wanted to use smoking products but was assessed as unsafe to smoke without supervision due to hand contractures and weakness.
By June 2025, his condition had deteriorated. A physician's order dated June 24 prescribed oxygen at six liters per minute every shift to maintain oxygen levels above 88 percent for shortness of breath.
The facility's own smoking assessment determined Resident #70 was "not a safe smoker" who required supervision during smoke breaks and could not safely light smoking materials. His care plan specifically stated that staff members were to maintain all smoking paraphernalia for unsafe smokers, including lighters.
Nursing Administration #130 confirmed the presence of the two lighters during the inspector's visit on August 4 at 2:53 P.M.
Activity staff explained the facility's smoking protocol during interviews on August 5 and August 11. Activity Aide #211 said even residents classified as safe smokers were prohibited from keeping lighters or other smoking materials. All smoking paraphernalia had to be locked in a smoking lock box.
Activity Aide #191 reinforced this policy, confirming that all smoking materials were secured regardless of a resident's smoking classification.
The facility's smoking policy, dated June 17, 2025, explicitly states that staff members will maintain all smoking paraphernalia for both safe and unsafe smokers, including lighters and lighter fluid.
Resident #70's medical record showed he was cognitively intact but had rejected care for one to three days during his assessment period. He required substantial to maximum assistance with personal hygiene and partial to moderate assistance with oral hygiene.
The combination of oxygen therapy and accessible lighters created a significant fire hazard. Oxygen supports combustion, making any ignition source extremely dangerous in the presence of supplemental oxygen.
The violation occurred despite multiple safeguards designed to prevent exactly this scenario. The resident had been assessed as unsafe to smoke, his care plan required staff supervision, and facility policy mandated that all smoking materials be secured.
The inspection was conducted in response to Complaint Number OH00167527, suggesting someone reported concerns about smoking safety at the facility.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the presence of lighters near a resident receiving high-flow oxygen therapy represented a serious fire safety risk that could have endangered not just the resident but others in the facility.
The resident's physical limitations from bilateral amputations and hand contractures made him particularly vulnerable. His care plan acknowledged he could not safely handle smoking materials, yet staff failed to follow their own protocols to remove the fire hazard from his immediate environment.
The violation persisted for hours, with inspectors documenting the lighters' presence during three separate observations throughout the day. This suggests the oversight was not a momentary lapse but a sustained failure to implement basic safety measures.
The facility's smoking policy had been updated just two months before the inspection, indicating recent attention to smoking safety protocols. Yet staff failed to follow these updated procedures for a resident who clearly met the criteria for enhanced supervision and material restriction.
Resident #70 remained in the facility with his complex medical needs, including ongoing oxygen therapy and mobility limitations from his amputations, while staff worked to address the safety violation that had put him and others at risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Laurels of Walden Park from 2025-08-13 including all violations, facility responses, and corrective action plans.
