Riverstreet Manor's written smoking policy required staff to remove all smoking materials from resident rooms and store them at the front lobby desk. But when state inspectors arrived October 21 following a complaint, they discovered the facility wasn't following its own rules.
The violations affected residents with chronic obstructive pulmonary disease, emphysema, and chronic respiratory failure — conditions that require oxygen supplementation and make smoking particularly dangerous. All ten residents scored between 13 and 15 on cognitive assessments, indicating they understood the risks but were classified as independent smokers.
Resident 4, who has COPD, had a care plan directing staff to check his room for smoking materials and secure them at the reception desk. The plan specifically required staff to remove oxygen before he smoked and replace it afterward. But administrators admitted residents were keeping cigarettes and lighters in their rooms.
Multiple residents faced similar contradictions between their care plans and actual practice. Resident 5's care plan from May 2024 instructed staff to "remove oxygen to smoke, reapply when done smoking" and "check resident room for smoking materials" to secure at the lobby desk. Resident 8's plan directed staff to "remove oxygen before smoking, reapply it after" and check for smoking materials in her room.
The facility's approach to these medically fragile residents followed a pattern. Each smoking assessment identified them as independent smokers despite their respiratory conditions. Care plans consistently directed staff to educate families not to leave smoking materials in rooms and to store cigarettes, matches, and lighters at the front desk.
Resident 6, admitted with emphysema, had a care plan from September 2023 requiring staff to check her room for smoking materials and secure them at the reception desk. Her cognitive assessment showed a perfect score of 15, meaning she fully understood instructions about smoking safety.
The smoking policy itself was barely visible to residents and families. During the inspection, administrators revealed the policy was posted only outside the smoking-area exit door — not in common areas where residents and visitors would see it upon arrival.
Director of Nursing and the Nursing Home Administrator acknowledged during their October 21 interview that residents were maintaining smoking materials in their rooms. They admitted the facility's current practices for securing smoking materials and posting the policy were not consistent with the facility's written smoking policy.
Resident 9's care plan from May 2025 contained the same requirements violated throughout the facility: remove oxygen before smoking, reapply after, check room for smoking materials, and secure them at the reception desk. Her COPD diagnosis made the oxygen removal and replacement particularly critical for her safety.
The newest admission, Resident 10, arrived with chronic respiratory failure — a condition where lungs cannot adequately exchange oxygen and carbon dioxide. Her July 2025 care plan directed staff to check her room for smoking materials and educate family members not to leave smoking materials in the room.
Seven of the ten residents had COPD, a progressive disease that makes breathing increasingly difficult and requires careful oxygen management. Two others had emphysema and chronic respiratory failure. Only one resident had a different primary diagnosis — hypertension — but still required the same smoking safety protocols.
The facility's failure to implement its own smoking policy affected residents across different admission dates, from September 2023 through 2025. Care plans consistently identified the same safety requirements that staff weren't following: secure smoking materials at the front desk, educate families about policies, and manage oxygen removal during smoking.
State inspectors found the violations represented a systematic breakdown in safety protocols rather than isolated incidents. The facility had developed appropriate care plans recognizing the fire risks of combining oxygen therapy with smoking materials, but failed to ensure staff carried out these safety measures.
Each resident's cognitive assessment confirmed they could understand and follow smoking safety instructions. Their Brief Interview for Mental Status scores of 13 to 15 indicated intact cognition, meaning they were capable of cooperating with safety protocols if staff had implemented them consistently.
The inspection revealed a gap between the facility's written commitments to resident safety and daily operations, leaving vulnerable residents with serious respiratory conditions exposed to preventable fire hazards in their own rooms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverstreet Manor from 2025-10-21 including all violations, facility responses, and corrective action plans.