Failure to Maintain Emergency Exit Doors
Penalty
Summary
The facility failed to maintain emergency exit doors as required by NFPA 101 standards, affecting multiple emergency exit doors. During observations on December 3, 2024, it was noted that the C wing hallway emergency exit door next to the boiler room and the B wing hallway emergency exit next to the storage room did not release after 15 seconds as indicated on the posted signs. This failure was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, another deficiency was observed on the same day at the therapy front entrance emergency exit door next to the clinical reimbursement office, which also failed to release after 15 seconds as indicated on the sign. This issue was similarly confirmed during the exit interview with the facility's administration and maintenance personnel. These deficiencies indicate a failure to comply with the required egress door standards, potentially impacting the safety and rapid evacuation of occupants in an emergency.
Plan Of Correction
C and B wing hallway doors adjusted to release after 15 seconds. Maintenance Staff educated that emergency exit doors must release after 15 seconds. Maintenance staff will test 3 emergency exit doors weekly to assure they release after 15 seconds x 90 days. Any doors that do not release will be adjusted/repaired.