Facility Assessment Lacked Evaluation of Residents with Tobacco, Drug, or Alcohol Use
Penalty
No penalty information released
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 ensure that its facility-wide assessment (FA) adequately evaluated the resident population and identified the necessary resources to provide care and services for residents with a history or current use of tobacco, drugs, or alcohol. The FA, completed on 05/03/2025 and provided by the DON, did not include documentation addressing residents admitted with these specific needs. During an interview, the DON confirmed that the FA did not identify smokers as a category of the population served, despite the facility currently having 41 smokers. The deficiency was identified through interviews and review of facility documentation, and the DON acknowledged the omission after reviewing the FA in the presence of the surveyor.