Failure to Maintain Clear Exit Discharges
Penalty
Summary
The facility failed to maintain means of egress free of obstructions as required by NFPA 101 Life Safety Code (2012 Edition), Section 7.1. Observations made on January 7, 2025, revealed ice and snow buildup on the pathways from the building to the public way at multiple designated exit discharges, including those located by the employee entrance and 200 Hall, the Kitchen, and Room 105. During interviews conducted at the time of the observations, the staff confirmed the findings and acknowledged awareness that the snow and ice on the sidewalks needed to be removed. This deficiency had the potential to affect all 131 residents of the facility.
Plan Of Correction
Element 1 This deficiency was corrected by shoveling the snow and salting all exit discharge pathways from the building to the public way. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Snow/Ice audit is being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K271. This audit will be completed by making rounds around the facility. Element 4 The Snow/Ice audit is being monitored by the Administrator or designee weekly for four weeks, then every other week for four weeks, and then monthly for one month. If the facility experiences any snow or icy conditions, the audit will be performed on that day, as well as the following day to ensure safe conditions. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for three months to the Quality Assurance Performance Improvement team for review and action as necessary.