Facility Assessment Lacked Documentation of Nicotine Dependence and Substance Use Disorders
Penalty
Summary
The facility failed to ensure that its Facility Assessment (FA) accurately reflected the needs of its resident population, specifically by omitting nicotine dependence and addiction from the list of common diagnoses and conditions. During the survey, it was found that five residents were current cigarette smokers, and the designated smoking area was located off the outside patio accessed through the dining room. The FA, last reviewed in March 2025, did not include nicotine abuse or addiction, nor did it document the number of residents with active or current substance use disorders. This omission was confirmed by the Interim DON, who acknowledged that nicotine addiction was not identified as a diagnosis in the FA and that the number of residents with substance use disorders was not documented. The facility's policy required the FA to include the care required by the resident population, considering the types of diseases and other pertinent facts present within the population. However, the FA did not meet this requirement, as it lacked documentation of residents with nicotine dependence or other substance use disorders. The surveyors referenced CDC guidance that classifies tobacco (nicotine) use as a substance use disorder, further highlighting the deficiency in the facility's assessment process.