Egress Stairs Handrail Marking Deficiency
Penalty
Summary
The facility failed to maintain egress stairs in accordance with the 2012 NFPA 101 standards. During a life safety survey conducted on March 13, 2025, it was observed that the handrails in both the East and West stairwells lacked the required contrasting colored marking stripe along the entire length of the stairwells. This deficiency was noted between 9:00 am and 12:00 pm. The absence of the marking stripe was confirmed through observation and staff interviews, where the Director of Environmental Services and Director of Maintenance acknowledged the issue and stated that the rails would be painted.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 Immediate Corrective Action All handrails and handrail extensions were marked with a solid and continuous marking in egress stairs in both of the facility's stairwells (3/17/25). Identification of others All residents have the potential to be affected by this deficient practice. An audit of all egress staircases was audited to ensure that it was maintained in accordance with 2012 NFPA 101 and that the handrails are painted with the required contrasting colored marking with a 1-inch width horizontal stripe for the length of the stairwell (3/17/25). All stairwell handrails have been painted with a 1-inch horizontal stripe to meet NFPA 101 egress requirements (3/17/25). All Maintenance staff will be in serviced on the importance of ensuring that all handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the NFPA requirements. Systematic Changes The Maintenance Director and Administrator reviewed the 2012 NFPA 101 manual and created a policy on Means of Egress Requirements. All Maintenance staff will be in serviced on the Means of Egress Requirements policy of Exit Stair Handrails (3/31/25). All handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the following requirements: (1) The marking stripe shall be applied to the upper surface of the handrail or be a material integral with the upper surface of the handrail for the entire length of the handrail, including extensions. (2) Where handrails or handrail extensions bend or turn corners, the marking stripe shall be permitted to have a gap of not more than 4 in. (100 mm). (3) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm), which shall not apply to outlining stripes listed in accordance with UL 1994, Standard for Luminous Egress Path Marking Systems. (4) The dimensions and placement of the marking stripe shall be uniform and consistent on each handrail throughout the exit enclosure. QA The Maintenance Director and Administrator developed an audit tool to ensure that all exit stair handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the NFPA requirements. There will be a visual check of all exit stairwell handrails weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person: Maintenance Director is responsible. 4/25/25 - date of correction.