Smoking Area Safety Deficiency
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations during a Life Safety Survey. The survey, conducted with the Maintenance Director, revealed deficiencies in the designated smoking area. Specifically, the area lacked ashtrays made of noncombustible material and safe design, as well as metal containers with self-closing cover devices for emptying ashtrays. These observations were made at 2:10 pm on April 1, 2025. During the staff interview conducted at the same time, the Maintenance Director acknowledged the absence of the required safety equipment in the smoking area. This acknowledgment indicates that the facility was aware of the deficiency at the time of the survey. The findings were also discussed and acknowledged by the Administrator during the exit conference, further confirming the facility's awareness of the issue. The report does not mention any specific patients involved or affected by this deficiency. The focus is solely on the facility's failure to maintain the smoking area in accordance with the NFPA 101 standards, which are designed to ensure safety in areas where smoking is permitted. The lack of proper equipment in the smoking area represents a failure to adhere to established safety protocols.
Plan Of Correction
Smoking Regulations Identify patients that were at risk and what did: When the surveyor identified the issue, we researched and purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you identify other patients that are at risk? No other patients are a risk as the Ashtrays have been replaced with self-closing metal lids and added the RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. Measure put in place: Purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you monitor? The Director of Plant Operations and Housekeeping will be responsible for ensuring that the ash trays are emptied on a regular basis. This is part of our daily service. Any Variances will be brought to the QAPL Committee. 5/1/25 K741 Smoking Regulations Identify patients that were at risk and what did: When the surveyor identified the issue, we researched and purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you identify other patients that are at risk? No other patients are a risk as the Ashtrays have been replaced with self-closing metal lids and added the RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. Measure put in place: Purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you monitor? The Director of Plant Operations and Housekeeping will be responsible for ensuring that the ash trays are emptied on a regular basis. This is part of our daily service. 5/1/25