Resident #50 smoked independently in the facility's outdoor smoking area while staff failed to complete mandatory quarterly evaluations designed to determine if smokers need supervision or safety equipment. The most recent assessment should have been conducted in September 2025, according to the Director of Nursing.
The Administrator told inspectors on November 19 that she could view the entire smoking area from her office window and had observed Resident #50 smoking many times. She believed he was a safe smoker but acknowledged that no formal smoking assessment had been completed for him.
"She had viewed Resident #50 smoking from her office and believed the smoking assessment was not completed accurately," inspectors wrote.
Nurse #4 had informed the Administrator that she was confused by the wording of the smoking assessment, leading to an inaccurate evaluation for Resident #50. The Administrator confirmed that residents assessed as safe independent smokers were allowed to keep their own smoking materials, while those requiring supervision had their cigarettes stored with nurses.
During interviews, Resident #50 told inspectors he never smoked in his room and kept his smoking materials secure because he feared they would go missing. Nurse #1 revealed she stored the resident's smoking supplies in her medication cart with his name labeled on them. She said family members also brought him smoking materials that he sometimes kept in his possession.
The facility's smoking policy requires assessments upon admission, quarterly, and whenever a resident's condition changes. Nurses receive electronic alerts when evaluations are due, according to both the Administrator and Director of Nursing.
Nurse #1 stated that Resident #50 did not need supervision when smoking. However, the Director of Nursing could not explain why his assessment was inaccurate or why the quarterly evaluation had not been completed.
The Director of Nursing explained that interventions for smokers depend on assessment results. Residents might need smoking aprons, staff supervision, or other safety measures based on their evaluation. The facility maintains staff specifically to assist supervised smokers and ensure safety protocols are followed.
Independent residents who pass their smoking assessments may use the smoking area at their leisure, the Director of Nursing confirmed. She said nurses are responsible for conducting the assessments and that the facility has adequate staffing to implement necessary interventions.
The inspection revealed a gap between the Administrator's informal observations and the facility's formal safety protocols. While she had watched Resident #50 smoke multiple times and considered him safe, the required documentation and assessment process had not been completed.
Federal regulations require nursing homes to assess residents' smoking abilities to prevent fires and ensure safety. The assessments help determine whether residents can smoke independently or need staff assistance and supervision.
The Administrator acknowledged that smoking assessments serve as formal safety evaluations, distinct from casual observations. She confirmed that the electronic medical record system alerts nurses when assessments are due for residents.
Inspectors found that despite the facility's established protocols and electronic reminders, Resident #50's quarterly smoking assessment had been missed. The Director of Nursing stated that nurses were notified through the electronic medical record when smoking assessments were due but could not account for why the September evaluation was not completed.
The violation represents a breakdown in the facility's safety monitoring system. While Resident #50 appeared to smoke safely based on staff observations, the formal assessment process designed to document and verify that safety had not been followed.
The facility's smoking area remains visible from the Administrator's office window, where she continues to observe residents who smoke. However, the gap between observation and documentation highlighted by inspectors suggests that informal monitoring cannot replace required formal assessments.
Resident #50 continues to smoke independently while the facility addresses the assessment deficiency identified during the federal inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oxford Health and Rehabilitation Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Oxford Health and Rehabilitation Center
- Browse all NC nursing home inspections