Egress Discharge Deficiencies
Penalty
Summary
The facility failed to maintain the egress discharges at two of six exit discharges, as observed and confirmed during a survey. At 8:49 a.m., the exit discharge door near the time clock room was found with an exterior egress path that was not maintained and was snow-covered. Additionally, at 8:56 a.m., the exit discharge door near the employee lounge was found lacking panic or fire exit hardware. These deficiencies were confirmed through an interview with the maintenance supervisor.
Plan Of Correction
A. Discharge door not maintained: Maintenance immediately removed snow from the sidewalk from the exit discharge door near the time clock area. Maintenance completed an audit of all exit discharge doors to ensure clear egress. NHA/designee educated maintenance staff by 21MAR2025 on snow removal policy. Maintenance will complete snow removal of discharge exit doors as per policy whenever weather occurs. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Discharge door failed to be equipped with panic or fire exit hardware: Maintenance replaced panic bar hardware on the exit door near the employee lounge. Maintenance completed an audit of all exit doors to ensure proper function. NHA/designee educated maintenance staff by 21MAR2025 on proper exit door function and maintenance. To prevent this from recurring, maintenance will perform weekly audits on exit door hardware/function and document. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.