Missing Self-Closing Metal Containers in Smoking Area
Penalty
Summary
During a facility tour, surveyors observed that the designated smoking area in the courtyard gazebo did not have metal containers with self-closing cover devices available for emptying ashtrays. This observation was confirmed in interviews with the Regional Maintenance Director and the Maintenance Director at the time of the survey. The absence of these containers is a violation of NFPA 101-2012 Edition, Section 19.7.4, which requires that such containers be readily available in all areas where smoking is permitted. The deficiency was identified as having the potential to affect an undetermined number of staff and 39 residents in the event of an emergency. The report does not mention any specific incidents involving residents or staff at the time of the observation, nor does it provide details about the medical history or condition of any individuals involved. The finding is based solely on the lack of required fire safety equipment in the designated smoking area.
Plan Of Correction
Tag: K 0741 On or before 6/20/25, the designated smoking areas were equipped with self-closing cover metal devices. There are no other smoking areas on the property. The administrator provided the maintenance director with education regarding NFPA 101 smoking regulations. The maintenance director or designee will audit smoking areas for appropriate self-closing devices 3 times a week for 4 weeks. Results of the audit will be submitted to the QAPI committee for review and recommendations.