Stairway Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain stairways in compliance with NFPA 101 standards, as evidenced by two specific deficiencies observed during a survey. Firstly, on the 3rd floor, the South stairtower door was found to not latch properly in its frame when tested. This issue was confirmed during an interview with the administrator, maintenance representative, and regional facility representative. Secondly, environmental services supplies, including wet floor signs and various other items, were improperly stored in the East stairtower on the ground floor. This storage issue was also confirmed during the exit conference interview with the same facility representatives.
Plan Of Correction
Stair tower door fixed to ensure positive latch. Environmental supplies removed from stair tower. NHA educated the Maintenance Director on maintaining stair towers. An initial audit was completed to ensure maintenance of the stair towers. NHA/designee will audit weekly x 4, then monthly x 3. Findings will be reviewed in the monthly QAPI.