Non-Compliance with Smoking Policy
Penalty
Summary
The facility failed to maintain its smoking policy in accordance with NFPA 101 regulations. On April 7, 2025, at approximately 3:30 PM, two residents were observed smoking just outside the main entrance of the facility. This observation was made despite the facility being designated as a non-smoking campus and lacking a designated smoking area. The residents were found to have personal possession of cigarettes and lighters and were smoking without any supervision from the facility staff. An interview with the Administrator confirmed these findings. The absence of a smoking policy and the lack of supervision for residents who were smoking indicate a failure to comply with the NFPA 101 standards, which require specific provisions for smoking regulations, including the prohibition of smoking in certain areas and the provision of noncombustible ashtrays and metal containers for ash disposal in permitted smoking areas.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The 2 residents observed smoking just outside the main entrance were educated on safe smoking practices, removed from front patio and smoking materials were secured by staff. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Facility audit completed of current residents who smoke to ensure assessments completed and smoking contracts signed acknowledging facility policies and safe smoking practices. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 the facility implemented a smoking policy and a designated smoking area adopting smoking regulations as outlined in K741, for current residents identified as smoking residents; required. Newly admitted residents shall be informed that they will be admitted under the non-smoking campus policy and regulations. On 4.22.25 Administrator completed education with current staff on safe smoking practices, storage of smoking materials and designated smoking area. Newly Hired staff will be educated on safe smoking practices, storage of smoking materials and designated smoking area during new hire orientation by the Assistant Director of Nursing as part of the systematic changes. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/designee will conduct random audits of the smoking area as well as all areas of the facility premises to ensure compliance with the smoking policy 2 times a week for 4 weeks, every week for a month and then monthly. Findings will be shared with the Quality Assurance and Improvement Committee until committee determines substantial compliance has been met.