Failure to Maintain Smoking Area Cleanliness
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed approximately five cigarette butts on the ground near the designated smoking area. The Maintenance Director stated that he was unaware of the cigarette butts being present and did not know how long they had been there. This observation indicated that the facility failed to properly maintain the smoking area as required by regulations, specifically regarding the disposal of cigarette butts. The deficiency affected all 192 residents across six smoke compartments. No information was provided regarding the medical history or condition of any specific residents at the time of the deficiency.
Plan Of Correction
K741 NFPA 101 Smoking Regulations How corrective action will be accomplished for those residents found to have been affected by the identified practice: All cigarette butts were immediately picked up from the smoking area ground. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to have been affected by the practice. Housekeeping staff will ensure that all smoking areas are cleaned daily, ash trays are emptied out, and any cigarette butts are picked up daily. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Housekeeping staff were in serviced on 5/27/25 by the Administrator regarding keeping smoking areas free of smoking debris on the floor. Housekeeping supervisor or designee will check smoking areas to ensure compliance weekly for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The Administrator or Designee will do rounds weekly and for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: Імие 9, 2025.