Staff at Aviata at Seminole detected the marijuana odor on Resident #4 multiple times over an unspecified period, according to a federal inspection completed October 7. The facility's medical director said he should have been informed immediately. He wasn't.
Staff D, a nurse, told inspectors she had reported her concerns about the resident smoking marijuana to a supervisor before. But she said she doesn't notify the resident's provider because "once she reports the concern to a supervisor, it is up to them to handle the situation."
The supervisor never made that call.
Staff E, a registered nurse, confirmed he had questioned Resident #4 about the marijuana smell. The resident denied smoking it. Staff E said he "thought Staff D had spoken to Resident #4's provider about the concern," but acknowledged he himself had never reached out to the provider.
Nobody had.
Staff F, the facility's nurse practitioner who oversees all residents, said she was never made aware of any current residents using illicit drugs. The medical director said the same thing. Both said they should have been notified immediately.
"If any resident's room smelled like marijuana or staff sees signs of residents smoking marijuana, then they needed to notify the residents' provider so immediate action can be taken," the medical director told inspectors.
The facility's own policy, revised in December 2020, requires staff to "promptly notify" the attending physician when there is a change in the resident's status or condition.
Staff described Resident #4 as "very strong-willed" and someone who "sometimes gets aggressive with staff." Staff D explained that once he signs out on leave of absence, "he is responsible for himself" and "we cannot control what he does once he signs out, even if he comes back to the facility smelling like marijuana."
But the medical director had different expectations. He said if he had been informed about drug use, "he would make sure the residents know it was against the facility and federal policy."
Staff F, the nurse practitioner, said her standard response would be to have staff report drug use concerns to psychiatry "because she would not want any interactions with the resident's medications."
The breakdown in communication left multiple staff members thinking someone else had handled the situation. Staff E said he couldn't search the resident and could only ask about drug use. When the resident denied it, Staff E said "there was nothing he could do if the resident tells him something different."
The Director of Nurses told inspectors that if a resident smelled like marijuana but didn't look impaired, "there was nothing they could do about it." The Nursing Home Administrator disagreed, saying nurses should contact the resident's provider if the resident was impaired or smelled like marijuana.
Even the facility's leadership couldn't agree on the proper response.
The inspection found the facility failed to follow its own notification policy. While staff detected signs of potential drug use multiple times, the information never reached the resident's medical provider who could have addressed potential medication interactions or other health risks.
Federal inspectors classified the violation as causing minimal harm with few residents affected. But the case illustrates how communication failures can leave vulnerable residents without proper medical oversight, even when staff recognize concerning behaviors.
The resident continued returning from leave with the marijuana odor, and his medical team remained unaware of the potential drug use that could affect his treatment and medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Seminole from 2025-10-07 including all violations, facility responses, and corrective action plans.