Failure to Maintain Smoking Areas and Receptacles per NFPA 101
Penalty
Summary
The facility failed to maintain smoking areas in accordance with NFPA 101-2012, Section 19.7.4, as observed during a facility tour. Numerous cigarette butts, exceeding 50, were found scattered in the back of the facility along the emergency lane parking area and the yellow line on the sidewalk. Additionally, the employee smoking area, located in front of a storage area containing combustible materials such as chairs and shelving, had innumerable cigarette butts on the floor. The storage area did not contain metal containers with self-closing cover devices for emptying ashtrays, despite ashtrays being provided. Staff interviews confirmed awareness of the issue, with one staff member stating that action would only be taken if the issue was formally documented. The deficiency had the potential to affect 22 of 46 residents in the facility. The observations indicated that the facility did not comply with required smoking regulations, including the provision of appropriate receptacles and the maintenance of designated smoking areas free from fire hazards.
Plan Of Correction
K741 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to ensure safe smoking as evidenced by cigarette butts on the ground around staff smoking area, lining the emergency lane parking, yellow line on sidewalk, floor of employee smoking area, in front of storage area that stored combustible materials. Additionally, there were no self-closing metal containers into which ashtrays could be emptied. Step 1: Director of Maintenance cleaned the staff smoking area on 6-6-25. A 16 qt. covered, self-closing, metal receptacle was obtained for placement of cigarette butts and placed in the smoking area on 6/15/25. Step 2: Audit was completed by DON/ADON on designated smoking areas on 6-6-25 for compliance issues, with no negative findings. Step 3: All staff were educated on NFPA 101 Smoking Regulations: safe smoking practices and the importance of proper disposal of used smoking materials in appropriate receptacles on 6-24-25. New hires are educated upon orientation. Step 4: To monitor and maintain ongoing compliance, the LNHA/designee will audit the staff smoking area weekly x4 then monthly x2. The results of the audits will be submitted to the QAPI committee for further review and recommendations.