The nursing supervisor immediately removed the cigarette from Resident #2 and conducted a search of their belongings. Staff found a pack of cigarettes and a pint of vodka, which were confiscated and destroyed.
The incident prompted federal regulators to cite the facility for immediate jeopardy violations, the most serious level of harm under Medicare standards. The designation means inspectors determined the facility's practices posed an immediate threat to resident health or safety that could cause serious injury, harm, impairment or death.
Resident #2 was placed under one-on-one supervision until their discharge from the facility on September 26. Another resident, identified as Resident #3, was also present during the smoking incident and received education about the facility's smoking policy alongside Resident #2.
When inspectors asked the Director of Nursing whether searches had been conducted prior to the September 16 incident, she stated "they may have but she would have to check." No documentation was provided to support any previous searches.
The facility's response to the violation faced immediate scrutiny from state regulators. On October 9, administrators submitted a removal plan to the New Jersey Department of Health at 5:09 PM, outlining steps to address the safety violations.
But when an inspector attempted to verify the plan's implementation the next morning at 11:48 AM, the Director of Nursing said the facility didn't have the required education materials in the building. She explained that a consultant Director of Nursing had the documents and was not at the facility that day.
The inspector was unable to verify the removal plan, and the Director of Nursing was informed that the immediate jeopardy designation would continue.
Two days later, on October 12 at 5:52 PM, the facility submitted an acceptable removal plan detailing the actions taken to prevent serious harm from occurring again.
The corrective measures extended beyond the initial incident response. On October 8, nurse leaders began educating all residents who smoked about the facility's smoking policy and the dangers of smoking near oxygen equipment. The Assistant Director of Nursing searched the rooms and equipment of smoking residents for violations of the smoking policy.
Two days later, on October 10, nurse leaders and a consultant registered nurse re-educated all staff members on the smoking policy and the specific dangers of smoking near oxygen.
The combination of cigarettes and oxygen creates an extreme fire hazard in nursing homes, where many residents use supplemental oxygen therapy and may have limited mobility to escape quickly in an emergency. Federal regulations strictly prohibit smoking in areas where oxygen is stored or in use.
Federal inspectors verified the implementation of the facility's removal plan during a continuation of their survey on October 14 at 2:23 PM, nearly a month after the original incident.
The immediate jeopardy citation indicates that inspectors determined the facility's failure to prevent smoking near oxygen equipment created risks that extended beyond the individual resident involved. The "many residents affected" designation suggests the safety breakdown had facility-wide implications.
Trenton Gardens Rehabilitation and Nursing Center operates at 512 Union Street in Trenton. The October 14 inspection was conducted in response to a complaint, though the specific nature of the complaint that triggered the federal investigation was not detailed in the inspection report.
The facility's struggles to provide required documentation during the inspection process highlighted systemic issues beyond the smoking incident itself. The delay in producing education materials and the reliance on off-site consultant staff raised questions about the facility's preparedness to demonstrate compliance with safety protocols.
The discovery of alcohol alongside cigarettes in Resident #2's room added another layer to the safety violations, though the inspection report did not detail how the vodka entered the facility or how long it had been in the resident's possession.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Trenton Gardens Rehabilitation and Nursing Center from 2025-10-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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