Noncompliance with Smoking Policy by Facility Staff
Summary
Facility staff failed to adhere to established smoking regulations as required by 19.7.4. During an observation, two employees were seen smoking outside on the campus grounds at a picnic table near the building, which was not in accordance with the facility's smoking policy that only permits smoking inside personal vehicles. This noncompliance was confirmed through a review of the facility's smoking policy and an interview with the Maintenance Director at the time of the observation. The deficiency was identified as potentially affecting 26 occupants in the event of a fire, as the required smoking regulations were not fully implemented or enforced.
Plan Of Correction
Element #1 The facility smoking policy was reviewed and acknowledges the facility will not provide a designated outdoor smoking area on facility property. Staff are permitted to smoke in their vehicle. Element #2 All staff will be re-educated on the smoke free facility policy and procedures by 5/26/25 or prior to their next day worked in the case of the leave of absence or vacationing employee. Element #3 The EVS manager and/or designee will audit four to six times weekly to validate staff adherence to the smoke free facility policy and smoking only off premises or in their personal vehicles. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee Monthly times one, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Penalty
Surveyors found that the facility's designated resident smoking area in the courtyard lacked a required self-closing metal butt can for cigarette disposal, as mandated by NFPA 101. The Maintenance Director confirmed the absence of this fire safety equipment during the inspection.
An employee was observed smoking outside of a designated area on facility property where required noncombustible ashtrays and self-closing metal disposal containers were not provided, despite the facility's no-smoking policy. The deficiency was confirmed by the Facility Manager during the survey.
Surveyors found that the facility lacked an updated smoking policy for staff, failed to provide noncombustible ashtrays and self-closing metal containers in the designated smoking area, and had discarded cigarette butts on the ground in multiple locations, as confirmed by the DON and Director of Maintenance.
Surveyors observed numerous cigarette butts scattered in both the back of the facility and the employee smoking area, which was located near combustible materials. The required metal containers with self-closing covers for ash disposal were not present in the employee area, despite ashtrays being provided. Staff confirmed awareness of the issue, but no corrective action was taken prior to the survey.
Surveyors found that the designated smoking area in the courtyard gazebo lacked metal containers with self-closing covers for emptying ashtrays, as required by NFPA 101. This deficiency was confirmed by maintenance staff and had the potential to affect staff and 39 residents.
Surveyors found that two smoking areas were not maintained according to NFPA 101 requirements, with large numbers of cigarette butts littered in both the Courtyard and the area near Rehabilitation. No ashtrays or metal cans with self-closing lids were present, and the deficiency was acknowledged by facility leadership.
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.
Failure to Provide Required Smoking Safety Equipment
Penalty
Summary
During a facility tour, an employee was observed smoking on the property outside of a designated smoking area. The area where the employee was smoking did not have ashtrays made of noncombustible material and safe design, nor were there metal containers with self-closing cover devices available for ashtray disposal, as required by NFPA 101 and NFPA 1 standards. These observations were confirmed in real time with the Facility Manager. At the exit conference, the administrator stated that the facility has a smoking regulations policy that prohibits smoking anywhere on the property at any time. Despite this policy, the observed smoking incident occurred, and the required smoking safety equipment was not present in the area where the violation took place. No information about residents or their medical conditions was included in the report.
Plan Of Correction
The Staff member was identified and was immediately educated on the facility's non-smoking policy. The nursing home administrator conducted walking rounds of the outdoor areas surrounding the facility as it relates to any concerns with facility adherence to non-smoking policy. No concerns were identified. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator/Designee re-educated facility staff on the non-smoking policy. The Nursing Home Administrator/Designee will conduct a random audit weekly 3 times a week on the facility staff's adherence to the facility's non-smoking policy by visual inspection. These audits will be conducted weekly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The Staff member was identified and was immediately educated on the facility's non-smoking policy. The nursing home administrator conducted walking rounds of the outdoor areas surrounding the facility as it relates to any concerns with facility adherence to non-smoking policy. No concerns were identified. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator/Designee re-educated facility staff on the non-smoking policy. The Nursing Home Administrator/Designee will conduct a random audit weekly 3 times a week on the facility staff's adherence to the facility's non-smoking policy by visual inspection. These audits will be conducted weekly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station was called for servicing and repairs. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Failure to Maintain Smoking Safety Standards and Updated Policy
Penalty
Summary
The facility failed to comply with NFPA 101 smoking regulations as evidenced by several deficiencies identified during document review, observation, and interviews. The facility did not have an updated smoking policy available for staff, as confirmed by both the Director of Nursing and the Director of Maintenance. Additionally, observations revealed discarded cigarette butts on the ground in multiple locations, including the back area by the dumpster and the rear parking area designated as a smoking area. Further inspection of the designated smoking area showed the absence of required safety equipment, specifically a noncombustible ashtray and a self-closing metal container for ash disposal. These deficiencies were confirmed by facility leadership during the exit conference. No information was provided regarding specific patients or their medical conditions in relation to these deficiencies.
Plan Of Correction
1. The facility has a Smoking Policy that is available for review. Kadima at Lititz is a no smoking campus. All ashtrays have been removed from around the facility. 2. The Smoking Policy will be placed in the Safety and Disaster Policy & Procedure Manual. 3. All staff will be educated on the smoking policy. 4. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.
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.
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.
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.
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