Obstructed Means of Egress Due to Improperly Stored Isolation Carts
Penalty
Summary
Surveyors observed that aisles, passageways, and corridors were not maintained free of obstructions as required by Chapter 7 of the Life Safety Code. Specifically, isolation carts without wheels attached were found stored in the corridor outside residents' rooms 121 and 122 in the 100 hall, and outside room 213 in the 200 hall. These findings were confirmed during interviews with maintenance staff present at the time of observation. The deficiency was identified during a walkthrough on June 10, 2025, and could potentially affect 18 occupants within the smoke compartment in the event of an emergency evacuation. No information regarding the medical history or condition of the residents in the affected areas was provided in the report.
Plan Of Correction
Element 1 - Environmental service staff removed all isolation carts without wheels stored in the corridor outside resident rooms 121 and 122 located at 100 hall and isolation carts without wheels stored in the corridor outside resident room 213 located at 200 hall with isolation carts with wheels to meet Means of Egress compliance. Element 2 - The Environmental Services Director or designee inspected all remaining isolation carts to ensure compliance with Means of Egress. Element 3 - Environmental Services Director or designee will complete monthly inspections on aisles, passageways, corridors, and exit locations for isolation carts being stored without wheels for 3 months to ensure compliance with NFPA 101 Chapter 7. Element 4 - The Environmental Services Director or designee will report audit findings to the Quality Assurance / Performance Improvement (QAPI) Committee quarterly x 3 with further monitoring per QAPI recommendations. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.