Non-compliance with NFPA 101 Smoking Regulations
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations during a fire safety tour. Specifically, the smoking area near Room 349 lacked a metal container with a self-closing lid for ashtrays to be emptied into, and there was no ashtray of a safe, noncombustible design available. These deficiencies were observed on April 30, 2025, at 4:43 PM, during an inspection conducted with the Director of Plant Operations. The Director of Plant Operations acknowledged the findings during an interview conducted concurrently with the observations. The deficiencies were further explained to both the Administrator and the Director of Plant Operations during the exit conference held on the same day at 6:30 PM. The report highlights the facility's failure to maintain the smoking area in accordance with the specified safety standards, which is a requirement under NFPA 101 (2021 Edition) 19.7.4 (5-6).
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K741. The smoking equipment was removed on 05/16/2025 by the maintenance director/designee as the center is a smoke free facility with no residents who smoke living in it. The center will maintain the smoke free policy. Any changes in this policy would be brought to the QAPI committee for review.