Failure to Maintain Means of Egress
Penalty
Summary
The facility failed to maintain the means of egress on one of its five floors, as observed during a survey. Specifically, on December 12, 2024, at 11:22 a.m., it was noted that the right side exit door from the ground floor dining room was secured with a padlock on the corridor side. This door is designated as an exit and is marked with an illuminated exit sign within the dining room. During an interview at the exit conference on the same day, the administrator, maintenance representative, and regional facility representative confirmed that the exit was locked, preventing egress.
Plan Of Correction
Padlocks removed to ensure means of egress. NHA will educate the Maintenance Director on maintaining means of egress. An initial audit was completed to ensure means of egress throughout the facility. NHA/designee will audit weekly x 4, then monthly x 3. Findings will be reviewed in the monthly QAPI.