Medical assistant MA A discovered the smoking supplies but failed to confiscate them or report the violation to supervisors. The facility's policy explicitly prohibits residents from keeping "any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision."
MA A told inspectors on November 15 that she "did not normally supervise residents while smoking but the other staff were busy with resident care." She acknowledged receiving training on the smoking policy and knowing that residents weren't allowed to keep smoking supplies in their rooms or on their person.
Despite this knowledge, she left the cigarettes with the resident.
"She stated she had not reported the incident to the ADM or the charge nurse because she had just come in from supervising the residents," the inspection report noted.
The administrator wasn't aware that Resident #1 had smoking supplies in his room when inspectors interviewed him. He described the challenges of enforcing the policy at the facility, which sits next to a convenience store.
"I cannot search their room and keep them from going to the store next door," he told inspectors. "The convenience store was so close that the residents signed themselves out and got what they wanted. I cannot police all that."
Resident #1 had previously purchased 14 cartons of cigarettes during what staff called a "spend down" of his financial account. The social worker kept those cigarettes locked in her office and would provide individual packs as requested, marking the resident's name on top before placing them in a blue smoking box that moved between nursing stations.
But the social worker also wasn't aware the resident had additional smoking supplies in his room.
"She stated if they saw smoking supplies in a resident room the smoking supplies need to be removed," inspectors noted of their interview with the social worker.
The facility's smoking policy, dated October 2022, establishes "safe resident smoking practices" and requires direct supervision when residents have access to smoking materials. Staff described using a blue tackle box to transport approved smoking supplies between stations based on designated smoking times.
All current smoking residents had completed smoking assessments and were deemed "safe to smoke alone," but facility policy still required supervision during smoking activities, according to the social worker.
The administrator acknowledged the serious risks posed by unsupervised smoking supplies in resident rooms. "The potential negative outcomes could be smoking in room, starting fires and if there was oxygen in the room the residents could blow themselves up," he told inspectors.
Staff consistently identified fire hazards as their primary concern. MA A said "the potential negative outcome could be a resident starting a fire." The social worker warned that residents might light cigarettes in their rooms or cause fires.
The facility was transitioning smoking policies from a previous management company to new ownership during the inspection. The administrator confirmed that the policy shown by the director of nursing represented the current version.
Resident #1 was described as someone who didn't personally visit the convenience store but would arrange for other residents to purchase items for him. This workaround allowed him to obtain smoking supplies without staff knowledge, despite the facility's awareness of the nearby store's accessibility.
The social worker noted that smoking had become "an issue at the facility because residents went to the store next door and purchased smoking supplies without the facility knowing." She explained that staff weren't allowed to search residents' belongings, creating enforcement challenges.
The administrator said residents received information about prohibited items during admission, including the ban on keeping smoking supplies in their rooms. He indicated that most staff had received training on the smoking policy.
The violation occurred despite multiple layers of oversight designed to prevent exactly this scenario. The facility maintained a centralized system for managing approved smoking supplies, conducted safety assessments for smoking residents, and provided policy training to staff.
Yet when MA A encountered a clear violation of the smoking policy, she took no corrective action and made no reports to supervisors. The cigarettes remained in Resident #1's possession, creating the fire hazard the policy was designed to prevent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Oaks Nursing and Rehabilitation Center from 2025-11-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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