Obstructed Means of Egress on First Floor
Penalty
Summary
The facility failed to maintain the means of egress free of obstructions, affecting one of two levels. On December 23, 2024, at 10:45 a.m., an observation revealed that the emergency exit door in the music room on the first floor was inoperable due to a screw inserted into its panic bar. Even after the screw was removed, the door still failed to open. Additionally, at 10:55 a.m., it was observed that the emergency exit door in stair tower D on the first floor required excessive force to open. These findings were confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. On 12/23/2024 the Maintenance immediately removed the screw from the panic bar on the emergency exit door in the music room. The door was tested and opened without restriction. 2. On 12/26/2024 the maintenance team adjusted the stair tower D emergency exit door. The door opens without the use of excessive force. 3. On 12/26/2024 the maintenance team inspected all emergency exit doors to verify that there were no obstructions to egress. 4. On 12/30/2024 the NHA educated the maintenance team on maintaining that the means of egress are free of obstructions. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify the proper functionality of all emergency exit doors in accordance with NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.