Non-compliance with NFPA 101: Uneven Emergency Exit Pathway
Penalty
Summary
The facility failed to maintain the means of egress in accordance with NFPA 101 standards, specifically regarding the walking surfaces in the means of egress. During a Life Safety recertification survey, it was observed that the pathway from the emergency exits of the Weinberg Pavilion and the Nursing Home to a public way was not level, as required by the code. The pathway consisted of a grassy surface, which did not meet the standard for a nominally level walking surface. This deficiency affected 50 percent of the emergency exit discharge from two out of three resident buildings. The Director of Plant Operations acknowledged the finding and indicated that the Administrator would be informed.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The Facility engaged a contractor to install a level walking surface from the identified courtyard emergency exit to a public way meeting the provisions of 7.1.7 with respect to changes in elevation shall be a hard packed all-weather travel surface. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout for same deficiencies. No other deficiencies were found. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The Maintenance staff will continuously maintain the pathway from an enclosed courtyard to the public way, free of all obstructions or impediments to full instant use in the case of fire or other emergency. The Director of Maintenance or designee will utilize an audit tool monthly to verify the exterior egress pathways are of a hard packed all weather travel surface and are maintained. The audit tool will document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI Committee on a monthly basis for 6 months, as well as correction plan if warranted.