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F0689
D

Failure to Complete Smoking Assessment and Care Plan for Resident

Amesbury, Massachusetts Survey Completed on 05-29-2025

Penalty

Fine: $117,450
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement safe smoking practices for one resident who smoked cigarettes. Specifically, the facility did not complete a smoking assessment or develop a care plan for the resident prior to allowing them to smoke on the premises. Although the resident had signed the facility's smoking policy and participated in smoking groups and cessation counseling, there was no documentation of a formal assessment of the resident's cognitive and physical abilities to smoke safely, as required by facility policy. The policy mandates that such assessments be conducted upon admission, with changes in status, and at least quarterly, with the interdisciplinary team reviewing the results to determine a safe smoking plan. The resident in question was admitted with a history of opioid abuse, psychoactive substance abuse, post-traumatic stress disorder, and major depressive disorder, but was assessed as having intact cognition. Despite this, the lack of a documented smoking assessment and care plan meant that the facility did not ensure adequate supervision or safety measures were in place before the resident engaged in smoking. The deficiency was confirmed through record review, observation of the resident smoking outside with staff present, and interview with the DON, who acknowledged the expectation for a smoking assessment and care plan to be completed upon admission for residents who smoke.

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