Facility Lacks Carbon Monoxide Detector and Exceeds Door Force Requirement
Summary
The facility was found to be non-compliant with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act due to the absence of an installed carbon monoxide detector in the Boiler/Generator Room. This deficiency was confirmed during an observation and interview conducted on March 13, 2025, at 12:12 PM, and further verified during the exit conference with the Administrator and Maintenance Director at 1:45 PM the same day. Additionally, the facility failed to maintain the required maximum force to operate exit discharge doors, as observed on March 13, 2025, at 11:35 AM. The 1st floor exit door in the Common Area required more than 30 pounds of force to set in motion, which is not in compliance with NFPA 101 Means of Egress standards. This issue was also confirmed during the exit conference with the Administrator and Maintenance Director.
Plan Of Correction
The 1st floor exit door, at the Common Area, will be repaired or adjusted so that the door opens with a force of less than 30 pounds. A Time Limited Waiver is being requested for this citation due to the construction of the metal framed glass door and metal threshold may require extensive work to make the repair or possibly a new door.
Penalty
Surveyors found that staff assigned to the designated smoking patio did not have the necessary knowledge to operate the electronic magnetic locked exit gate leading to the public way. During a fire safety tour, a CNA serving as the Smoking Area Attendant repeatedly entered the correct access code but could not open the gate because she pulled instead of pushed, demonstrating that staff were not fully able to utilize this means of egress as required by NFPA 101. The Administrator and Maintenance Director confirmed these observations, and the deficiency was noted as affecting residents who smoke.
A two-step lock, including a dead bolt, was observed on the environmental services office door next to the salon, potentially impeding emergency egress. This was confirmed by the administrator and maintenance director.
A door leading to an enclosed courtyard in the Ivy Wing South Living Room was observed without a 'Not an Exit' sign, making it possible to mistake the door for an exit. This lack of signage was confirmed by facility leadership and resulted in noncompliance with NFPA 101 requirements for maintaining clear means of egress.
Surveyors observed that the headroom in a basement corridor was approximately 6 feet 2 inches, which is below the required 6 feet 8 inches for means of egress. This was confirmed by the Administrator and affected one of two smoke compartments.
A gate leading from the patio area was found chained shut, blocking a designated emergency exit. This obstruction was observed and confirmed by the Maintenance Director, preventing proper egress in case of emergency.
Surveyors found that multiple emergency exits were inaccessible or obstructed, including a sealed exterior door, a corridor blocked by dialysis transport chairs, and a stuck exit door from the main dining room. These issues were confirmed by the maintenance director during the inspection.
Staff Inability to Operate Locked Smoking Patio Exit Gate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff assigned to the designated smoking patio had the necessary knowledge and ability to operate the electronic magnetic locked gate used as a means of egress. During a fire safety tour with the Administrator and Maintenance Director at the smoking patio, the Smoking Area Attendant, a CNA, was asked to unlock the exit gate that leads to the public way. She entered the access code several times but was unable to open the gate. The Maintenance Director confirmed that she was using the correct code. It was further observed that the Smoking Area Attendant was pulling on the gate instead of pushing it, which prevented the gate from opening despite the correct code being entered. This demonstrated that not all staff knew how to evacuate through the electronically locked gate or had the key or knowledge necessary to utilize this means of egress in accordance with NFPA 101 requirements. The Administrator and Maintenance Director acknowledged these findings during the tour and at the exit conference. This deficiency affects residents who use the designated smoking area.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K211 Means of Egress - General: It is the practice of this facility to ensure that all staff have the key, access code or knowledge, necessary to utilize the means of egress. Immediate Corrective Action: The Smoking Patio C.N.A. was educated that after entering the code or using the key at the gate, the door needs to be pushed to open. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the CNAs assigned to the smoking patio regarding the code and/or key to the egress gate. Maintenance Director and/or designee will in-service the nurses, that in the event of emergency, the key to the Smoking Patio Gate is on each nurses station key ring. A key to the Smoking Patio egress gate will be added to the all nursing station key ring and the Smoking Patio key ring. Monitoring: Maintenance and/or designee will complete random audits weekly for four weeks of the Smoking Patio to validate that the CNAs have the code and/or key to the Smoking Patio egress gate, and then monthly for 3 months. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance. The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K211 Means of Egress - General: It is the practice of this facility to ensure that all staff have the key, access code or knowledge, necessary to utilize the means of egress. Immediate Corrective Action: The Smoking Patio C.N.A. was educated that after entering the code or using the key at the gate, the door needs to be pushed to open. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the CNAs assigned to the smoking patio regarding the code and/or key to the egress gate. Maintenance Director and/or designee will in-service the nurses, that in the event of emergency, the key to the Smoking Patio Gate is on each nurses station key ring. A key to the Smoking Patio egress gate will be added to the all nursing station key ring and the Smoking Patio key ring. Monitoring: Maintenance and/or designee will complete random audits weekly for four weeks of the Smoking Patio to validate that the CNAs have the code and/or key to the Smoking Patio egress gate, and then monthly for 3 months. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance.
Means of Egress Obstructed by Two-Step Lock on Office Door
Penalty
Summary
During an observation on December 19, 2025, it was found that the first floor environmental services office, located next to the salon, had a two-step lock on its door. This included a dead bolt, which could potentially slow down egress in the event of an emergency. The presence of this locking mechanism was confirmed in an interview with the administrator and maintenance director at the time of the observation. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The systematic change was removing the deadbolt lock after the surveyor left the building. The Director of Maintenance will audit all office doors to assure there isn't a two-step locking mechanism in place. The Director of Maintenance will audit office doors for a two-step lock and report findings to the Monthly Quality Assurance meeting.
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.
Insufficient Headroom in Basement Corridor
Penalty
Summary
The facility failed to maintain the required headroom clearance in a basement corridor, as observed during a survey. On July 29, 2025, it was noted that the headroom in the basement corridor measured approximately 6 feet 2 inches, which is less than the required 6 feet 8 inches above the finished floor. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the headroom did not meet the standard specified by NFPA 101 for means of egress. The deficiency affected one of two smoke compartments within the component.
Obstructed Emergency Exit Due to Chained Patio Gate
Penalty
Summary
A deficiency was identified when, during an observation, a gate providing exit from the patio area was found to have a chain wrapped around it and the adjoining fence, which prevented the gate from being used as an emergency exit. This obstruction to the means of egress was discovered at approximately 11:37 AM and was confirmed by the Maintenance Director at the time of the observation. The report does not mention any specific residents or staff being directly affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Obstructed and Inaccessible Emergency Exits Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain clear and accessible means of egress as required by code. Specifically, the Human Resources office exterior door was found sealed shut and could not be opened, preventing its use in emergencies. Additionally, an excessive number of dialysis infusion transport chairs were stored in the emergency egress corridor outside the dialysis treatment room for several hours, with no dedicated space available to relocate them during an evacuation. Furthermore, the west emergency exit door from the main dining room was stuck closed and required excessive force to open, impeding emergency evacuation from that area. These deficiencies were confirmed through interviews with the maintenance director at the time of observation.
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