Deficiencies in Egress Door Accessibility and Signage
Penalty
Summary
The facility was found to have deficiencies related to egress doors, which are critical for safe evacuation during emergencies. Observations revealed that the main entrance's outer set of sliding doors had a lockset with a hook-type deadbolt that could restrict emergency use of the exit. Although signs indicated that the doors could be pushed open in an emergency, the engaged thumb-latch locks would prevent this action, contradicting the evacuation plan that designated these doors as an exit/egress route. Interviews confirmed that the lockset could impede exit from the egress side during an emergency. Additionally, the facility failed to label three out of six egress doors equipped with a delayed 15-second egress feature with the required signage. These doors, located on the second floor near various offices and resident rooms, lacked signs indicating "Push Until Alarm Sounds, Door Can Be Opened in 15-Seconds," as required by NFPA 101 standards. This oversight was confirmed during a building tour, and the absence of proper signage could potentially affect all residents in the event of an emergency.
Plan Of Correction
1. The lock on the front door was removed on December 24, 2024. Signs were installed on all doors with a 15 second delayed egress stating "Push until alarm sounds. Door can be opened in 15 seconds." 2. All residents in the Facility are at risk from Egress doors not meeting the requirements of the National Fire Protection Association. 3. The ability for the front door to open when pushed in case of emergency will be confirmed on the weekly checklist. The presence of signage stating to push until alarm sounds will be confirmed on weekly door checks. The Maintenance Director or designee will be responsible for completing and signing off on weekly rounds. The checklist will be audited monthly by the Administrator for 3 months. 4. The Director of Maintenance or designee will report on the status of daily door rounds to the Administrator at Quarterly QA meeting x 3.