Federal inspectors responding to a complaint found the violations created immediate jeopardy to resident safety during their October visit.
Resident 86 had a full pack of cigarettes and a lighter sitting on top of his nightstand next to his bed when inspectors arrived at 8:17 a.m. on September 29. The resident had intact cognition according to his quarterly assessment but had no smoking contract on file.
LPN 614 confirmed the cigarettes and lighter were on the nightstand during an interview one minute later. Admission Director 69 acknowledged that all residents were supposed to have smoking contracts and locked cabinets for smoking materials, telling inspectors she was "working on obtaining them."
The violations extended beyond a single resident.
Resident 103, who was admitted for orthopedic aftercare and has moderate persistent asthma, had smoking materials spread throughout his room. Inspectors found one pack of cigars with a black lighter on top, a single cigarette sitting on a food item, and a tray table near the door containing orange and yellow lighters.
This resident had completed a smoking assessment showing he could light and dispose of cigarettes appropriately. His care plan included education about designated smoking areas and the long-term effects of nicotine use. But the materials remained unsecured.
MD 712 confirmed these findings during an interview at 1 p.m.
Resident 113 presented a different problem. The resident, who has vascular dementia and moderate cognitive impairment, kept cigarettes in the top drawer of his nightstand. When inspectors asked about the storage, the resident said the facility wanted $45 for a lost key to his cigarette lockbox.
CNA 612 confirmed the cigarettes were in the resident's drawer. This resident also lacked a smoking contract, despite a care plan intervention from 2022 requiring education about facility smoking policy and obtaining his signature.
The facility's own policy required storing smoking materials "in a secure area when not in use by the resident/patient for both independent and supervised smokers." The policy stated that smoking materials should be "returned to the facility staff upon completion of smoking."
None of the three residents followed this protocol.
Admission Director 69 repeatedly told inspectors during her interview that residents were supposed to have both smoking contracts and locked cabinets for their smoking materials. Her admission that she was working to obtain the contracts suggested the facility knew about the compliance failures.
The violations occurred despite the facility having established procedures. Resident 103's smoking assessment confirmed he understood proper cigarette disposal. Resident 113's care plan showed staff had attempted to educate him about smoking policies three years earlier.
The inspection revealed a gap between written policies and actual practice. While the facility maintained smoking assessments and care plans, residents continued storing potentially dangerous materials in easily accessible locations.
Federal inspectors classified the violations as immediate jeopardy, indicating the unsecured smoking materials posed serious risk to resident safety. The investigation stemmed from Complaint Number 2620111.
The findings highlighted how policy failures can compound safety risks. Resident 86 had intact cognition but no contract governing his smoking privileges. Resident 113 had cognitive impairment but access to cigarettes without proper oversight. Resident 103 had respiratory issues but multiple lighters and smoking materials throughout his living space.
The admission director's acknowledgment that she was "working on" obtaining required contracts suggested the violations were not isolated incidents but part of broader compliance failures affecting multiple residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenbrier Health Center from 2025-10-08 including all violations, facility responses, and corrective action plans.