Deficiencies in Egress Stairs and Fire Door Labeling
Summary
The facility was found to have deficiencies in maintaining egress stairs in accordance with the 2012 NFPA 101 standards. During a life safety survey, it was observed that all four of the facility's stairwells, labeled as A, B, C, and D, were lacking the required contrasting colored marking stripes on the handrails and landings. This deficiency indicates a failure to comply with the specific requirements for exit stair treads, landings, and handrails as outlined in the NFPA 101, which mandates that these components must have consistent and uniform marking stripes to ensure safe egress. Additionally, the survey noted that the door at the first-floor landing was missing the required fire rating label, which is a violation of the NFPA 80 standards for fire doors and other opening protectives. This oversight suggests a lapse in the facility's adherence to fire safety protocols, as fire-rated door assemblies are crucial for preventing the spread of fire and smoke. The Director of Maintenance acknowledged these deficiencies during the survey, indicating awareness of the issues at hand.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1: Immediate Corrective Action: A full inspection of all stairways used as a means of egress was audited to identify areas lacking compliant marking stripes and was conducted by the maintenance director. The maintenance staff immediately began marking the handrails and landings in all areas noted for compliance. The facility engaged a licensed Fire Door vendor to inspect and affix a fire rating tag on the identified fire door on the 1st floor landing. Element 2: All residents have the potential to be affected by this practice. No residents were harmed due to this practice. Element 3: The policy and procedure for Egress and marking stripes were reviewed, and revisions have been made on means of egress and marking of handrails and landings. The maintenance director was educated on the means of egress requirements, explicitly marking the handrails and landings in all stairwells. Education and training will be given to all staff on the markings of handrails and landings. Element 4: Monitoring of Corrective Action: The maintenance director or designee will audit all stairwells and fire doors weekly to ensure that all handrails and landings are appropriately marked in accordance with 2021 NFPA 101. The results of this audit will be reported to the administrator monthly. The maintenance director will report the findings of this audit for one quarter to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5: Persons responsible: Maintenance director
Penalty
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