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K0222
F

Non-Functioning Delayed Egress Locking Systems

Edison, New Jersey Survey Completed on 12-20-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the egress doors equipped with delayed egress locking arrangements were functioning properly, as required by NFPA 101:2012 Edition. During observations conducted on December 19, 2024, it was found that the 15-second delayed egress locking arrangements on the stairway enclosures near room 312 on the third floor, room 212 on the second floor, and the mauve wing did not function when tested. These deficiencies were confirmed through interviews with the U.S. FOIA present during the survey. The malfunctioning of the delayed egress locking arrangements had the potential to affect all residents within the facility. The observations were made by the USSROAD, US FOTIAD, and US FOJA, who confirmed the non-functionality of the locking systems. The facility's representative was informed of these deficient practices during the Life Safety Code exit conference held on December 20, 2024.

Plan Of Correction

1/7/25 1. All residents have the potential to be affected by this deficient Life Safety Code. NJ Ex Order 26.4(b) (1) repaired the delayed egress locks in the following locations on 1/6/25: floor 3 near room 312, floor 2 near room 212, and the stairway enclosure on the mauve wing. The Maintenance Department conducted an audit of all facility delayed egress locks to confirm function on 1/6/25. 2. The Maintenance Director will modify the scheduled maintenance calendar to include monthly delayed egress checks to confirm function. 3. The Maintenance Director will review the monthly delayed egress lock testing documentation to ensure compliance. The details of this testing will be submitted to the administrator and to the QAPI committee monthly for 6 months.

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