Bywood East Health Care: Smoking Fire Hazard - MN
Federal inspectors found cigarette burns scattered across the floor and nightstand in the resident's room during an August complaint investigation. The maintenance director told inspectors that housekeeping discovered fresh cigarette butts and ashes in the room daily when they cleaned at 2:30 p.m.
The quality assurance nurse confirmed she could smell smoke in the room and saw cigarette butts on the nightstand and floor. She told inspectors the resident "had limited funds and had been known to pick up cigarette butts in the smoking patio area and smoke them."
Staff knew about the daily smoking but repeatedly forgot to report it. A treatment medication aide said she "forgot to inform the nurse working on the evening shift" that the resident was smoking in his room. She explained the nurse only came to the third floor for treatments and insulin, and "she often forgot to report this to the nurse."
The facility had abandoned its smoking program about a year earlier after residents became violent with staff over cigarette access. The quality assurance nurse said residents would come to the first floor every 30 minutes or hour to get cigarettes from nurses or the receptionist, but "the facility decided to stop this because the residents had several violent behaviors with the staff."
She described how "a residents attacked the receptionist" during disputes over cigarettes. The previous director of nursing and administrator ended the supervised program and "allowed the residents to have their own cigarettes and lighters for the safety of the staff and that it was too much to deal with."
The maintenance director said he had "redirected" the smoking resident out of the room often. Burns covered the floor "from what he expects are from cigarettes being put out on the floor," along with burns on the nightstand next to the second bed in the shared room.
Despite daily evidence of smoking violations, the resident's treatment record showed no incidents documented for the entire month. Inspectors reviewed records from the first through the 31st and found staff had reported zero instances of smoking in non-designated areas.
The facility's own smoking policy states that staff must immediately extinguish smoking materials when they observe residents smoking inside the building. The policy requires incidents to be "reported to Social Services, Charge Nurse/Nurse Supervisor, and/or Administrator."
The policy warns that residents who smoke irresponsibly and "put others in jeopardy because of such behavior" face consequences including "loss of smoking privileges up to discharge from the facility."
Federal inspectors issued an immediate jeopardy citation, finding the smoking violations created immediate risk to resident health and safety. The citation was removed the next day after the facility implemented emergency measures.
The facility revised its smoking policies to prohibit all indoor smoking and developed what inspectors called "an all-systems approach for enforcing the policy." This included requiring staff to immediately report any smoking concerns.
Administrators also updated all resident smoking assessments and revised care plans with new safety interventions. They educated employees on the new procedures before their next shifts.
The maintenance director told inspectors he hoped the new administrator would pay more attention to the smoking situation. He said "now that they have a new person in the administrator's office, he was hoping things would get better and more attention would be paid to the situation."
The case illustrates the dangers when nursing homes abandon safety programs due to staffing challenges. Rather than addressing the root causes of resident violence over cigarette access, the facility chose to distribute cigarettes and lighters directly to residents with cognitive impairments.
The daily cycle continued for weeks: housekeeping found evidence of room smoking every afternoon, the maintenance director redirected the resident, and staff forgot to document the violations. Meanwhile, cigarette burns accumulated on floors and furniture in a room shared by two vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bywood East Health Care from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Bywood East Health Care in MINNEAPOLIS, MN was cited for violations during a health inspection on August 27, 2025.
Federal inspectors found cigarette burns scattered across the floor and nightstand in the resident's room during an August complaint investigation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.