Obstructed Emergency Egress Due to Construction
Penalty
Summary
The facility failed to maintain a clear and unobstructed means of egress as required by regulation. On May 6, 2025, at approximately 11:00 AM, observation revealed that the emergency egress path outside the staff entrance doors was under construction due to underground pipe replacement. The ground in this area was broken, filled with gravel, and barricaded to prevent foot traffic, which could delay or prohibit evacuation through these doors during an emergency. These findings were confirmed through an interview with the maintenance director at the time of observation.
Plan Of Correction
Element 1 On April 11, 2025, maintenance staff immediately cleared items and made a pathway for all cited exit areas, including the northwest exit and exit near Room 411. Signs were temporarily posted indicating caution until the area was verified safe and useable again. Element 2 All residents in units adjacent to and reliant upon the affected exits (northwest hallway and near Room 411) were assessed for potential risk. No residents experienced adverse effects as a result of the obstruction. Element 3 All maintenance and housekeeping staff were in-serviced on May 6, 2025, regarding the revised policy and procedures. Element 4 The Director of Maintenance or designee will audit all exits daily during week x5 days a week for a month, then once weekly for 2 months. Findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee monthly for review and further recommendations. The administrator is responsible for the sustained compliance.