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F0689
D

Failure to Complete Accurate and Timely Smoking Assessments

Oxford, North Carolina Survey Completed on 11-21-2025

Penalty

No penalty information released
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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 ensure that smoking assessments were accurate and completed quarterly for a resident with a history of Parkinson's disease and chronic obstructive pulmonary disease. Upon admission, the resident was not using tobacco and was assessed as severely cognitively impaired. However, subsequent assessments and interviews revealed inconsistencies in the documentation and completion of smoking assessments. The resident began smoking after admission, and the assessments regarding his need for supervision while smoking were not consistently or accurately completed as required by facility policy. Nurse staff responsible for conducting smoking assessments admitted to missing some assessments and acknowledged confusion regarding the assessment process and documentation. The resident's smoking status and need for supervision were inconsistently recorded, with one assessment indicating a need for supervision, which was later struck through and replaced with an assessment stating the resident could smoke independently. The Director of Nursing confirmed that a quarterly assessment was missed and that the process for notifying nurses of due assessments was in place, but not followed in this instance. Observations showed the resident smoking independently in the designated area without staff supervision, and interviews with staff and the resident confirmed that he sometimes kept his own smoking materials, while at other times, they were stored by nursing staff. The facility's list of smokers did not consistently include the resident, and there was a lack of clarity and accuracy in the documentation and oversight of the resident's smoking status and supervision needs.

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