Stair Tower Enclosure Deficiency
Penalty
Summary
The facility failed to maintain the stair tower enclosures in accordance with NFPA 101 standards. During an observation on December 30, 2024, at 11:36 am, a plastic storage tote was found stored under the stairs at the 1st floor, North Exit. This issue affected two of two floors in the facility. The presence of the storage tote was confirmed during an exit interview with the Facility Administrator, Facility Assistant Administrator, and a Facility Representative on the same day at 12:30 pm.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The plastic storage tote, located under the stairs in the of the first-floor north exit, was removed and the work was documented in work order #20321918. The Facilities Manager or his designee will maintain compliance through monthly safety rounding to identify and correct issues related to stairways and exits. 2. This corrective action was completed on the day of the survey. The Facilities Manager is responsible to ensure that corrections are completed and documented in the maintenance work order program.