Exit Obstructions in Multiple Buildings
Summary
During a recertification survey, it was observed that the exits in Building #4, Building #12, Building #16, and Building #24 were not maintained in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. Specifically, the exit doors were not kept free of obstructions or impediments for full instant use. This was evidenced by the presence of stop signs placed on the smoke barrier doors, which could potentially hinder the immediate use of these exits in an emergency situation. The observations were made on March 27, 2025, at 12:51 PM, when surveyors noted the placement of stop signs on the smoke barrier doors across multiple buildings. This placement of signs is a direct violation of the NFPA 101 Life Safety Code, which mandates that exits must be maintained free of any obstructions to ensure they are readily accessible in case of an emergency. During an interview conducted on the same day at 1:33 PM, the Facilities Manager acknowledged the presence of the stop signs and indicated that they would be removed. However, the report does not provide any further details on corrective actions or the timeline for the removal of these signs. The deficiency highlights a lapse in maintaining the safety standards required for emergency preparedness in the facility.
Plan Of Correction
Plan of Correction: Approved May 3, 2025 Element 1: The STOP sign has been removed from all smoke barrier doors. Element 2: All residents can be impacted by this practice. All exit doors were checked to ensure they were free of obstructions. No issues identified. Element 3: The facility manager or designee will provide education to the facility management staff regarding the requirement for exit doors to be free of obstructions or impediments per National Fire Protection Association (NFPA). Environmental rounds will be made daily by nursing supervisor or designee to ensure exit doors remain accessible and unencumbered. Any issues identified will be corrected immediately and education provided. Element 4: Facilities staff will complete weekly audits of all exit doors to ensure they meet the National Fire Protection Association (NFPA) requirements. Results of the audits will be presented to the Facility Quality Assurance Committee at monthly meetings. The committee will make recommendations for ongoing frequency and any need for change in plan, education, or policy based on results of review. Audits will continue until facility achieves 100 percent compliance. Facility Manager responsible for ongoing compliance.
Penalty
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