Failure to Maintain Smoking Areas per NFPA 101
Penalty
Summary
Surveyors observed that the facility failed to maintain its designated smoking areas in accordance with NFPA 101 regulations. During a fire safety tour, it was found that the Courtyard, which is used as a smoking area during rain, had more than eighty cigarette butts scattered throughout, and the screened-in porch area contained nine additional cigarette butts. There were no ashtrays, metal cans with self-closing lids, or fire extinguishers present in these areas, as required by the standard. The Administrator confirmed that the Courtyard serves as a smoking area when it rains. Additionally, the designated smoking area near Rehabilitation was found to have more than one hundred cigarette butts littered throughout the area. Both the Administrator and the Maintenance Director acknowledged these findings during the survey. The lack of proper disposal containers and the accumulation of cigarette butts in both smoking areas were documented, and photographic evidence was obtained by the surveyors.
Plan Of Correction
Rehabilitation was cleaned of cigarette butts on the ground on 5/28/2025. Method to Assess Others The Maintenance Director, or designee, performed documented inspections of the facility's other smoking areas to ensure there were no cigarette butts on the ground. Systematic Process The Maintenance Director, or designee, will perform weekly inspections X 8 weeks of all smokers areas of the facility to ensure there are no cigarette butts on the ground. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Documentation of the smokers areas inspections will be brought to the monthly QAPI meeting for review X 2 months. If substantial compliance is not met after 2 months, weekly inspections will continue and be brought to the monthly QAPI meeting until substantial compliance is met. K 741 Immediate Corrective Action 1. The Courtyard was cleaned of cigarette butts on the ground on 5/28/2025. 2. The designated smoking area near rehabilitation was cleaned of cigarette butts on the ground on 5/28/2025. Method to Assess Others The Maintenance Director, or designee, performed documented inspections of the facility's other smoking areas to ensure there were no cigarette butts on the ground. Systematic Process The Maintenance Director, or designee, will perform weekly inspections X 8 weeks of all smokers areas of the facility to ensure there are no cigarette butts on the ground. Quality Assurance Reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director at the exit conference on 05/27/2025 at 5:30 PM. NFPA 101 (2012 Edition) 19.7.4 (5-6) Photographic Evidence Obtained.