Non-Compliance with Smoking Regulations
Penalty
Summary
The facility failed to maintain smoking regulations as required by NFPA 101, affecting one of three floors. During an observation on April 8, 2025, at 11:50 am, surveyors found discarded cigarette butts within the exterior mulch bed outside the main entrance of the facility. This observation indicates non-compliance with the smoking regulations that mandate proper disposal of smoking materials in designated areas. An exit interview with the Facility Administrator and Facilities Manager on the same day confirmed the deficiency in adhering to the smoking regulations.
Plan Of Correction
1. Cigarette butts have been removed from the exterior mulch bed, outside the main entrance. 2. Cigarette butts have been removed from all exterior mulch beds. 3. Maintenance/Designee will provide education to all staff on the facility non-smoking policy. 4. Maintenance will complete audits x4 weeks and then monthly x3. Audits will be reviewed at QAPI.