Lexington Health Care Center: Smoking Safety Failure - NC
The lapse surfaced during a complaint inspection completed December 30, 2025. Inspectors found that Resident #1 had never received a smoking safety assessment at admission, a step the facility's own administrator said he expected to happen for every resident who smoked. Without that assessment on record, staff treated the man as an independent, unsupervised smoker from the moment he arrived, even though his care plan told a different story.
A nurse identified in the report as Nurse #2 told inspectors that Resident #1 went in and out during her overnight shift to smoke by himself and kept his own cigarettes and lighter on him. She described the facility's system plainly: supervised smokers had their materials secured at the nurses' desk; unsupervised smokers kept everything themselves. Resident #1 had always had his own.
The unit manager, identified as UM #1, said she was unaware that Resident #1 had been care-planned as a supervised smoker at admission. She told inspectors that smokers were discussed at staff meetings and that a list existed separating supervised from unsupervised residents. She remembered that Resident #1 always had his own smoking materials. She could not explain why no smoking assessment had been completed when he was admitted. She said it should have been done by the nurse assigned to him on that day.
A smoking assessment was eventually completed on August 11, 2025. That assessment found he needed supervision. The gap between his admission and that date, during which he smoked independently with no documented evaluation of whether that was safe, was not addressed in the report.
The administrator told inspectors he had not known about the missing admission assessment until that conversation. He said he expected assessments to be done at admission and then quarterly for smoking residents. Then he offered a different account of the timeline: nursing staff had told him, he said, that Resident #1 hadn't started smoking until August 11, 2025, the same date as the belated assessment. He could not say which staff member told him that, or when. He did not explain how a resident who supposedly hadn't smoked before August could have had a smoking care plan initiated on the day he was admitted.
That contradiction sat unresolved at the end of the interview. The care plan existed. The assessment did not, not until months later. The administrator's explanation required both things to be true at once.
He told inspectors that staff should have known each resident's smoking status through nursing handoffs, staff meetings, care plan reviews, and chart notes. Those systems, he said, were all in place. Resident #1 had been smoking on his own the whole time.
CMS cited the deficiency at a level of minimal harm or potential for actual harm, affecting a small number of residents. The citation does not describe any injury to Resident #1. What it describes is a man assessed as someone who needed to be watched when he smoked, left alone with his cigarettes every time he wanted one, while the people responsible for his care believed, or said they believed, that no assessment had ever found otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lexington Health Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Lexington Health Care Center in Lexington, NC was cited for violations during a health inspection on December 31, 2025.
The lapse surfaced during a complaint inspection completed December 30, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.