Exiting Deficiency Through Intervening Dining Room
Summary
The facility failed to ensure compliance with the NFPA 101 Life Safety Code regarding the number of exits in corridors. Specifically, the deficiency was identified in the north exit from the second floor, which requires passage through an intervening dining room, contrary to the requirement that corridors provide access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies. This issue was observed and documented during a survey on March 17, 2025, at 11:30 a.m. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director later that day.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Penalty
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