Failure to Investigate and Address Smoking Hazards
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for two residents, as evidenced by multiple documented incidents involving the presence and use of potentially hazardous and illegal smoking materials. For one resident, nursing documentation twice noted a strong smell of marijuana in the resident's room, with the resident admitting to using marijuana for pain relief. Despite these observations and notifications to supervisory staff, there was no evidence in the clinical record that the facility administration investigated these incidents or took further action to address the presence of illegal substances. Additionally, another resident was found with a vape device and was later caught smoking a cigarette in her room, with a lighter also present. Social services documentation confirmed the resident admitted to receiving a cigarette from another resident. Despite staff awareness and documentation of these events, there was no evidence that the facility conducted an investigation, obtained staff witness statements, or implemented interventions such as room searches to remove hazardous smoking materials. Interviews with facility leadership confirmed their awareness of these incidents and the lack of follow-up investigation or remedial action.