Federal inspectors discovered the violations at The Merriman during a November complaint investigation. Resident 13, who has been at the facility since March 2023, had a doctor's order requiring supervised smoking with a protective apron due to his inability to safely light or extinguish cigarettes and his tendency to drop ashes on himself.
The resident scored six on a cognitive assessment, indicating severe mental impairment. His care plan specifically noted he was at increased risk for injury while smoking and required supervision at all times.
On November 17 at 1:42 p.m., inspectors observed three residents in the designated smoking area with no staff present. Resident 13 was smoking a cigar without wearing the required protective apron.
The next morning brought a more alarming scene. At 8:33 a.m., inspectors again found Resident 13 in the courtyard without supervision. Another resident, identified as Resident 16, entered the area, lit a cigarette, then dropped it on the ground without extinguishing it.
Resident 13 picked up the still-burning cigarette from the ground and began smoking it. He was not wearing his protective apron. No staff members were present.
When confronted about the violations, facility administrators offered conflicting explanations. The Director of Nursing told inspectors she had educated Resident 13 the previous day about designated supervised smoking times. She claimed that if he was smoking, "someone else must have provided him with cigarettes without their knowledge."
The Administrator acknowledged the smoking apron had proven ineffective because Resident 13 continued dropping ashes on areas of his body not covered by the apron. She said the facility had switched to a smoking jacket instead, which was stored in the Director of Nursing's office.
But facility records told a different story. The smoking safety assessment for Resident 13 documented his inability to safely handle tobacco, yet failed to mark either a smoking apron or jacket as an intervention or clinical suggestion. His care plan from July specifically required supervision at all times while smoking and mandated use of a smoking apron.
The facility's own smoking policy, dated April 28, required supervised smokers to have staff or volunteer supervision during designated smoking times. All smoking materials were supposed to be kept at the nurse's station or in a designated area for supervised smokers.
Regional Nurse 566 confirmed Resident 13 had physician's orders for supervised smoking with a protective apron. The Administrator and Assistant Director of Nursing verified he was one of only two supervised smokers in the facility of 45 residents.
The violations occurred despite multiple layers of required protection. Resident 13's medical record showed diagnoses of schizophrenia, muscle weakness, and hypertension. His physician had ordered supervised smoking with an apron beginning January 23. His July care plan identified him as high-risk for smoking-related injuries.
Yet on two consecutive days, inspectors found him alone in the courtyard with burning tobacco. The second incident, where he retrieved and smoked another resident's discarded cigarette from the ground, highlighted the dangers of leaving cognitively impaired residents unsupervised around fire.
The facility census of 45 residents included only two who required smoking supervision. Despite this small number, staff failed to provide the mandated oversight for a resident whose assessment clearly documented his inability to safely manage cigarettes or other tobacco products.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. But for Resident 13, a man with severe cognitive impairment who cannot safely light or extinguish cigarettes, the absence of required supervision created risks that his care plan was specifically designed to prevent.
The smoking jacket the Administrator mentioned remained stored in an office while Resident 13 continued accessing the courtyard alone, handling lit tobacco without the protective equipment his doctor had ordered and his condition required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Merriman from 2025-11-26 including all violations, facility responses, and corrective action plans.