Lexington Health Care Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, and resident and staff interviews, the facility failed to report reasonable suspicion of a crime to law enforcement when Resident #1 was identified with an odor of marijuana after he returned inside the facility from the smoking area. A subsequent drug screen was completed and the resident tested positive for Tetrahydrocannabinol (THC [the main psychoactive ingredient in marijuana] ). This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1). The findings included:Review of the facility policy and procedure titled Substance Use with a date of 01/29/24, states to protect the health and safety of resident, the center prohibits unprescribed use of drugs and alcohol. The policy indicated if items were found that posed a health and safety risk they were to be confiscated if in plain sight and law enforcement was to be contacted. Resident #1 was admitted to the facility on [DATE REDACTED].Resident #1's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed the resident was cognitively intact.A phone interview with Nurse Aide (NA) #1 on 12/31/25 at 12:25 PM revealed on 11/13/25 around 11:00 PM when Resident #1 came back inside the facility from the smoking area the resident smelled of marijuana. NA #1 further revealed he immediately reported the odor of marijuana to Nurse #2 who was assigned to the resident. A phone

interview with Nurse #2 on 12/31/25 at 3:20 PM revealed on 11/13/25 during the second shift (7:00 PM to 7:00 AM) NA #1 reported an odor of marijuana coming from Resident #1. Nurse #2 stated Resident #1 agreed to drug screen but denied smoking marijuana/THC.A 10-panel urine drug screen (tests for 10 common drug classes) was completed for Resident #1 on 11/14/25. Results of the screen (dated 11/15/25) indicated Resident #1 tested positive for cannabinoids (marijuana/THC). An interview with Resident #1 on 12/30/25 at 11:50 AM revealed in November 2025 he had smoked a THC vape that he obtained from another resident.During an interview with the Director of Nursing (DON) on 12/30/25 at 12:45 PM she confirmed that staff identified that Resident #1 had an odor of marijuana, a drug screen was completed, and Resident #1 tested positive for cannabinoids. The DON revealed Resident #1 allowed the facility to search his room and nothing was found. The DON stated that she felt law enforcement did not need to be contacted because no hard evidence was found during the room search. An interview with the Administrator on 12/30/25 at 1:00 PM revealed an investigation was completed after he was notified in November 2025 that staff suspected Resident #1 utilized marijuana. The Administrator indicated Resident #1 allowed the facility to drug screen him and search his room. The facility was unable to find any signs of illegal substances when they searched Resident #1's room and he (the Administrator) was unable to determine where the THC had come from. The Administrator revealed that even though the facility did an investigation and the resident tested positive for an illegal substance, he did not feel that he needed to report the incident to law enforcement because he did not think they would have been able to do anything more than the facility had done.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lexington Health Care Center

17 Cornelia Drive Lexington, NC 27292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

smoker list. He indicated he had not seen a smoking list recently. She explained that Unit Manager (UM) #1 also sometimes communicated to her (Nurse #2) when she came on shift if a resident's smoking status changed. She further explained that UM #1 did not communicate any information about Resident #1's smoking status. Nurse #2 indicated Resident #1 went in and out throughout the night (the shift Nurse #2 worked) to smoke independently and kept his smoking materials on him. Nurse #2 revealed supervised smokers had smoking materials secured and unsupervised smokers were able to keep their smoking materials in their possession. An interview with UM #1 on 12/30/25 at 12:20 PM revealed Resident #1 had been an independent (unsupervised) smoker since admission. It was further revealed she was not aware that Resident #1 had been care planned at admission for being a supervised smoker and had been assessed to be a supervised smoker on 08/11/25. UM #1 revealed smokers were discussed in staff meetings and there was a list with supervised and unsupervised smokers. UM #1 revealed independent smokers were able to have their smoking materials in their possession and supervised smokers had their smoking materials stored at the nurse's desk. UM #1 recalled that Resident #1 always had his own smoking materials. UM #1 did not recall why a smoking assessment was not completed at admission for Resident #1. UM #1 stated a smoking assessment should have been completed at admission on Resident #1 by the assigned nurse.An interview with the Administrator on 12/30/25 at 1:00 PM revealed he was not aware Resident #1 had no smoking assessment completed prior to 08/11/25. The Administrator further revealed

he expected smoking assessments to be conducted on admission and quarterly for residents who smoked.

The Administrator indicated that per nursing staff he understood that Resident #1 had not started smoking until 08/11/25. The Administrator did not indicate which nursing staff informed him of this information or when he was informed. He did not explain why Resident #1 had a care plan for smoking that was initiated

on admission [DATE REDACTED]). The Administrator stated unsupervised smokers kept their own smoking materials and supervised smokers had their smoking materials secured by nursing staff. The Administrator revealed staff should have been aware of smokers' assessed status through communication between nursing staff, discussions from staff meetings, reviewing the care plans, and reviewing the residents' charts for orders and progress notes.

Event ID:

Facility ID:

If continuation sheet