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F0689
D

Failure to Assess and Supervise Smoking Resident per Policy

Lexington, North Carolina Survey Completed on 12-31-2025

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 complete a smoking assessment upon admission for a resident who was identified as a smoker and did not provide supervision or retain smoking materials in accordance with its smoking policy. The resident's care plan, initiated at admission, indicated a preference for smoking and required supervision, but there was no evidence of a completed smoking assessment until several months later. Staff interviews revealed confusion and lack of awareness regarding the resident's smoking status and supervision needs, with some staff believing the resident was independent and others unaware of the care plan requirements. The resident reported smoking independently since admission and keeping smoking materials in his possession, contrary to the facility's policy for supervised smokers. Observations confirmed that the resident was never supervised while smoking and had unrestricted access to cigarettes and a lighter. Staff members, including nurse aides and nurses, stated they were not informed or educated about the resident's need for supervision and did not recall the resident being listed as a supervised smoker. Unit management and the administrator were also unaware of the lack of an initial smoking assessment and the discrepancy between the care plan and actual practice. Communication breakdowns were evident, as staff relied on posted lists and verbal updates, which did not accurately reflect the resident's assessed needs. The facility's failure to assess, supervise, and control access to smoking materials for a resident requiring supervision constituted a deficiency in accident prevention and adherence to policy.

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