Missing 'Not an Exit' Signage on Courtyard Door
Penalty
Summary
Surveyors observed that a door leading to an enclosed courtyard in the Ivy Wing South Living Room could be mistaken for an exit, as it lacked signage indicating 'Not an Exit.' This observation was made during a facility inspection and was confirmed in an interview with the Administrator and Maintenance Director. The absence of appropriate signage resulted in the means of egress not being continuously maintained free of all obstructions to full use in case of emergency, as required by NFPA 101 standards. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law. A temporary sign was put on the door and a permanent sign ordered and installed. An inspection of doors exiting the egress path was done and no others entering an enclosed area was without appropriate signage. Weekly random inspections of doors will be conducted by the Maintenance Director/designee for the next 6 weeks. Results of the inspections will be reported to the Quality Assurance Performance Improvement (QAPI) Steering Committee in January for further recommendation.