Failure to Maintain Minimum Headroom Clearance in Exit Corridor
Summary
The facility failed to maintain the minimum headroom clearance in the exit access corridor, which affected one out of five smoke compartments. During an observation and document review conducted on December 17, 2024, at 8:15 a.m., it was found that the headroom clearance within the corridors of the basement level, near the maintenance office and similar staff areas, measured at six feet at the ramp leading to the laundry. This measurement was less than the minimum height requirement of six feet-eight inches. An exit interview with the Administrator and Maintenance Director confirmed that the ceiling height was below the required minimum.
Penalty
A two-step lock, including a dead bolt, was observed on the environmental services office door next to the salon, potentially impeding emergency egress. This was confirmed by the administrator and maintenance director.
A door leading to an enclosed courtyard in the Ivy Wing South Living Room was observed without a 'Not an Exit' sign, making it possible to mistake the door for an exit. This lack of signage was confirmed by facility leadership and resulted in noncompliance with NFPA 101 requirements for maintaining clear means of egress.
Surveyors observed that the headroom in a basement corridor was approximately 6 feet 2 inches, which is below the required 6 feet 8 inches for means of egress. This was confirmed by the Administrator and affected one of two smoke compartments.
A gate leading from the patio area was found chained shut, blocking a designated emergency exit. This obstruction was observed and confirmed by the Maintenance Director, preventing proper egress in case of emergency.
Surveyors found that multiple emergency exits were inaccessible or obstructed, including a sealed exterior door, a corridor blocked by dialysis transport chairs, and a stuck exit door from the main dining room. These issues were confirmed by the maintenance director during the inspection.
Isolation carts without wheels were found stored in corridors outside several resident rooms, obstructing the means of egress and violating Life Safety Code requirements. Maintenance staff confirmed the presence of these obstructions during the survey.
Means of Egress Obstructed by Two-Step Lock on Office Door
Penalty
Summary
During an observation on December 19, 2025, it was found that the first floor environmental services office, located next to the salon, had a two-step lock on its door. This included a dead bolt, which could potentially slow down egress in the event of an emergency. The presence of this locking mechanism was confirmed in an interview with the administrator and maintenance director at the time of the observation. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The systematic change was removing the deadbolt lock after the surveyor left the building. The Director of Maintenance will audit all office doors to assure there isn't a two-step locking mechanism in place. The Director of Maintenance will audit office doors for a two-step lock and report findings to the Monthly Quality Assurance meeting.
Missing 'Not an Exit' Signage on Courtyard Door
Penalty
Summary
Surveyors observed that a door leading to an enclosed courtyard in the Ivy Wing South Living Room could be mistaken for an exit, as it lacked signage indicating 'Not an Exit.' This observation was made during a facility inspection and was confirmed in an interview with the Administrator and Maintenance Director. The absence of appropriate signage resulted in the means of egress not being continuously maintained free of all obstructions to full use in case of emergency, as required by NFPA 101 standards. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law. A temporary sign was put on the door and a permanent sign ordered and installed. An inspection of doors exiting the egress path was done and no others entering an enclosed area was without appropriate signage. Weekly random inspections of doors will be conducted by the Maintenance Director/designee for the next 6 weeks. Results of the inspections will be reported to the Quality Assurance Performance Improvement (QAPI) Steering Committee in January for further recommendation.
Insufficient Headroom in Basement Corridor
Penalty
Summary
The facility failed to maintain the required headroom clearance in a basement corridor, as observed during a survey. On July 29, 2025, it was noted that the headroom in the basement corridor measured approximately 6 feet 2 inches, which is less than the required 6 feet 8 inches above the finished floor. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the headroom did not meet the standard specified by NFPA 101 for means of egress. The deficiency affected one of two smoke compartments within the component.
Obstructed Emergency Exit Due to Chained Patio Gate
Penalty
Summary
A deficiency was identified when, during an observation, a gate providing exit from the patio area was found to have a chain wrapped around it and the adjoining fence, which prevented the gate from being used as an emergency exit. This obstruction to the means of egress was discovered at approximately 11:37 AM and was confirmed by the Maintenance Director at the time of the observation. The report does not mention any specific residents or staff being directly affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Obstructed and Inaccessible Emergency Exits Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain clear and accessible means of egress as required by code. Specifically, the Human Resources office exterior door was found sealed shut and could not be opened, preventing its use in emergencies. Additionally, an excessive number of dialysis infusion transport chairs were stored in the emergency egress corridor outside the dialysis treatment room for several hours, with no dedicated space available to relocate them during an evacuation. Furthermore, the west emergency exit door from the main dining room was stuck closed and required excessive force to open, impeding emergency evacuation from that area. These deficiencies were confirmed through interviews with the maintenance director at the time of observation.
Obstructed Means of Egress Due to Improperly Stored Isolation Carts
Penalty
Summary
Surveyors observed that aisles, passageways, and corridors were not maintained free of obstructions as required by Chapter 7 of the Life Safety Code. Specifically, isolation carts without wheels attached were found stored in the corridor outside residents' rooms 121 and 122 in the 100 hall, and outside room 213 in the 200 hall. These findings were confirmed during interviews with maintenance staff present at the time of observation. The deficiency was identified during a walkthrough on June 10, 2025, and could potentially affect 18 occupants within the smoke compartment in the event of an emergency evacuation. No information regarding the medical history or condition of the residents in the affected areas was provided in the report.
Plan Of Correction
Element 1 - Environmental service staff removed all isolation carts without wheels stored in the corridor outside resident rooms 121 and 122 located at 100 hall and isolation carts without wheels stored in the corridor outside resident room 213 located at 200 hall with isolation carts with wheels to meet Means of Egress compliance. Element 2 - The Environmental Services Director or designee inspected all remaining isolation carts to ensure compliance with Means of Egress. Element 3 - Environmental Services Director or designee will complete monthly inspections on aisles, passageways, corridors, and exit locations for isolation carts being stored without wheels for 3 months to ensure compliance with NFPA 101 Chapter 7. Element 4 - The Environmental Services Director or designee will report audit findings to the Quality Assurance / Performance Improvement (QAPI) Committee quarterly x 3 with further monitoring per QAPI recommendations. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.
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