Non-compliance with NFPA 101: Missing Handrail Markings
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101 Life Safety Code during a life safety survey conducted on January 6, 2025. The surveyors observed that the handrails in both the East and West stairwells lacked the required contrasting colored marking stripe along the entire length of the stairwells. This deficiency was noted during the survey conducted between 9:00 am and 12:00 pm. The Director of Environmental Services acknowledged the absence of the required markings on the handrails and stated that the rails would be painted immediately. The lack of these markings is a violation of the NFPA 101 standards, which require that all handrails and handrail extensions in egress stairs be marked with a solid and continuous marking stripe to ensure safety and compliance.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The maintenance staff has permanently marked the handrails with the required contrasting yellow colored marking stripe for the length of the handrails in the East and West stairwells. II. Identification of Other Residents The facility acknowledges that the residents have the potential to be affected by this practice. The facility respectfully states that once the handrails on both the East and West stairwells from the first (1st) to the fourth (4th) floors were permanently marked with contrasting yellow marks, no other residents were affected by this practice. III. Systemic Changes The Director of Environmental Services will in-service the maintenance staff related to this requirement; lesson plan and attendance shall be filed for validation. The Director of Environmental Service/designee will inspect the stairs monthly for proper markings. The Director of Environmental Service will develop an audit tool to track compliance. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that the exit stair landings are marked with a solid continuous marking stripe. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible party: Director of Environmental Service