Non-Compliance with Smoking Policy Evidenced by Cigarette Butt Litter
Penalty
Summary
The facility failed to adhere to its smoking policy, as evidenced by multiple observations of extinguished cigarette butts littered on the grounds in several exterior areas, including the south egress entrance, the area by the kitchen egress and inspector test valve, and the generator area. During a tour and interviews with Maintenance Staff, it was confirmed that the facility operates as a non-smoking environment, with signs displayed throughout the premises to remind staff and residents of the policy. The facility's smoking policy, which was undated, explicitly prohibits the use of cigarettes, cigars, pipes, or other tobacco smoking products. Despite the stated non-smoking policy and posted signage, surveyors observed approximately three dozen cigarette butts at the south egress entrance, twelve by the kitchen egress, and eight by the generator area. These findings were confirmed by Maintenance Staff, who reiterated the facility's non-smoking status. The deficiency affected all 59 residents and both smoke compartments of the facility, as the presence of cigarette butts indicated non-compliance with the established smoking regulations.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. No residents were found to be affected at this time. Upon identification of this alleged deficient practice, the facility Maintenance Director and Housekeeping personnel immediately removed the extinguished cigarette buds found on the south egress entrance, the kitchen egress, and the area surrounding the generator. A sweep of the exterior of the entire facility was completed by the Maintenance Director and no other smoking products were found. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. No other residents were found to be affected at this time. All residents are potentially to be affected by this alleged deficient practice as failure to comply with NFPA 101 and smoking policies could affect patient care and has the potential to cause harm to facility residents, staff, and visitors. The Maintenance Director did a sweep of the facility exterior and found no smoking products. An all-staff inservice was conducted on 03/27/2025 regarding the facility smoking policies and procedures. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. It is the policy of the facility to ensure that emergency procedures, including smoking policies, are followed according to Life Safety Codes. The Director of Staff Development conducted an inservice on 03/27/2025 to all staff regarding the facility smoking policies and procedures. The Maintenance Director will conduct daily rounds of the exterior of the facility x 4 weeks, and weekly thereafter to ensure no smoking products are found on facility grounds. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. No other residents were found to be affected at this time. All residents are potentially to be affected by this alleged deficient practice as failure to comply with NFPA 101 and smoking policies could affect patient care and has the potential to cause harm to facility residents, staff, and visitors. The Maintenance Director did a sweep of the facility exterior and found no smoking products. An all-staff inservice was conducted on 03/27/2025 regarding the facility smoking policies and procedures. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. It is the policy of the facility to ensure that emergency procedures, including smoking policies, are followed according to Life Safety Codes. The Director of Staff Development conducted an inservice on 03/27/2025 to all staff regarding the facility smoking policies and procedures. The Maintenance Director will conduct daily rounds of the exterior of the facility x 4 weeks, and weekly thereafter to ensure no smoking products are found on facility grounds. How the facility plans to monitor its performance to make sure that solutions are sustained. Maintenance Director/Designee will present any findings from facility safety rounds during our Daily Clinical meetings. Interventions to be reviewed in the facility monthly QAPI meeting x 3 months. Administrator will bring 2567 and POC to the meeting to discuss and ensure understanding. Date of compliance: 03/27/2025