Noncompliance with Smoking Area Fire Safety Requirements
Penalty
Summary
During a fire life safety survey, it was observed that the facility failed to comply with National Fire Protection Association (NFPA) 101 smoking regulations. Specifically, the established smoking area in the courtyard, which was the only designated area for residents to smoke, did not have a self-closing metal butt can as required by the standard. This deficiency was identified during a facility tour conducted between 1:00 p.m. and 5:00 p.m. with the Maintenance Director present. The surveyor noted that the absence of a self-closing metal container for cigarette disposal in the smoking area was a direct violation of NFPA 101 (2012 and 2021 Editions) section 19.7.4(6). The regulation mandates that metal containers with self-closing cover devices, into which ashtrays can be emptied, must be readily available in all areas where smoking is permitted. The report also clarified that smoking tower disposal receptacles do not meet the requirement for ashtrays or self-closing metal containers. The Maintenance Director acknowledged the findings during the interview that was conducted concurrently with the observations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report. The deficiency was based solely on the lack of required fire safety equipment in the designated smoking area.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , an order was placed for two new red cigarette butt cans by the Director of Maintenance. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , the Maintenance Director, and Administrator will conduct an audit on facility's red cigarette butt cans to identify potential issues with the cans and to ensure they are opening and closing fully. Any issues identified were corrected. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. The cans and to ensure they are opening and closing fully. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met.