Bywood East Health Care: Fire Risk Immediate Jeopardy - MN
The facility received an immediate jeopardy citation on August 27, 2025, the most serious level of federal nursing home violation, after inspectors confirmed that a resident had been smoking inside the facility on a regular basis, in a room he did not live in, with lighters and cigarettes he had been taking from the outdoor smoking patio.
The maintenance director told inspectors he had redirected the resident, identified in the report as R5, out of the room often. He said he expected the floor burns came from cigarettes being stubbed out directly on the floor. He said he was hoping the facility's new administrator would pay more attention to the situation.
The room was not R5's own room.
When a quality assurance nurse walked into the room during the inspection, she could smell smoke immediately. Cigarette butts were on the nightstand and on the floor.
What made the situation possible, inspectors found, was a management decision made before the current administrator arrived. The previous director of nursing and the previous administrator had shut down the facility's formal smoking program entirely. According to the QA nurse, residents with behavioral issues had been demanding cigarettes and one had attacked a receptionist. The prior leadership's response was to let residents keep their own cigarettes and lighters. The reason given, as the QA nurse described it to inspectors, was that enforcing the smoking policy was too much to deal with and allowing personal cigarettes was safer for staff.
The facility's own written smoking policy said something different. It stated that smoking inside the facility would result in immediate extinguishment of materials and notification to the charge nurse, social services, and the administrator. It stated that residents who put others in jeopardy through irresponsible smoking behavior could lose smoking privileges or be discharged.
None of that happened with R5. His treatment record for the relevant month showed no documented incidents of indoor smoking at all, despite the daily ash and burns that housekeeping workers were cleaning around every afternoon.
The gap between the record and reality came down, in part, to a medication aide who saw the problem and said nothing. TMA-A told inspectors she had observed R5 in the room and smelled smoke but forgot to tell the evening nurse. She said the nurse only came to the third floor to complete treatments and insulin administration, and she often forgot to report things to her. She also said she did not have access to document anything on the treatment sheets herself.
The immediate jeopardy was lifted the same day it was issued, at 4:25 p.m., after the facility demonstrated it had revised its smoking policies, updated care plans, and educated all staff on the new procedures before the next shift began.
But the maintenance director's words stayed in the record. He had watched this happen repeatedly, redirecting R5 out of the room again and again, watching housekeeping find the same ash and butts every afternoon, seeing the burns accumulate on the floor and the furniture. He told inspectors he was hoping that now, with someone new in the administrator's office, more attention would be paid to the situation.
He had been hoping that for a while.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bywood East Health Care from 2025-08-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
BYWOOD EAST HEALTH CARE in MINNEAPOLIS, MN was cited for immediate jeopardy violations during a health inspection on August 27, 2025.
The maintenance director told inspectors he had redirected the resident, identified in the report as R5, out of the room often.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.