complaint·December 1, 2021

Administrator indicated that R1 recently moved into the facility on 11/01/21 and it has been brought up to his attention that R1 will smoke in his room. Administrator has spoken to resident about not smoking in his room. There are no oxygen tanks in R1's room. LPA reviewed Facility House Rules which states "no smoking is allowed in apartments" and "smoking is permitted in the designated area only". Administrator indicated he is trying to work with R1 as he is a new resident, however he has told the resident that smoking in the room will not be allowed. 8 out 9 residents interviewed indicated that they do not smoke in their rooms and they have not observed any other residents smoking in their rooms. All residents interviewed indicated that they are aware of the smoking area located in the front of the facility. 5 out of 5 staff members interviewed indicated that residents are not allowed to smoke in their rooms however some residents do. Staff members interviewed indicated that they will tell residents not to smoke in their rooms and will notify management when they observe it. Staff members interviewed indicated will assist residents to the smoking area if needed. LPA toured and observed the designated smoking area. LPA toured a random sample of resident rooms and did not observe any residents smoking in their rooms or smell any smoke in the hallways of the facility during the tour. Although it was verified that R1 has smoked in his room, facility is actively taking appropriate steps to address the situation with the resident. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.