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F0656
D

Failure to Implement and Document Smoking Risk Care Plan

South Holland, Illinois Survey Completed on 09-12-2025

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 follow its smoking at risk program policy and did not develop an appropriate care plan for a resident identified as an at-risk smoker. During a survey, the resident was observed in possession of a cigarette lighter, which is against facility policy. Interviews with staff, including the DON and LPN, revealed inconsistencies in identifying and monitoring residents who smoke, as well as a lack of awareness regarding which residents are considered at-risk smokers. The list of at-risk smokers was not available on the unit, and staff could not confirm who should be monitored for smoking risks. Record review showed that the resident's smoking risk assessment was outdated and inaccurately indicated that the resident did not smoke, despite evidence to the contrary. The care plan did not reflect the resident's status as an at-risk smoker, and the required interventions, such as individualized care planning and proper documentation, were not implemented. The facility's policy requires that at-risk smokers be identified, listed, and monitored, with care plans developed accordingly, but these steps were not followed for the resident in question.

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