Deficiency in Delayed Egress Door Signage
Penalty
Summary
The facility failed to maintain compliance with the requirements for delayed egress doors, as observed on January 22, 2025. Specifically, the delayed egress door on the ground floor leading to the loading dock was missing the required signage. The signage should have stated: 'PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.' This deficiency was identified during an observation conducted at 10:29 a.m. The lack of proper signage was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:30 a.m. on the same day. This oversight affects one of the four levels in the facility, indicating a failure to adhere to the National Fire Protection Association (NFPA) 101 Life Safety Code requirements for egress doors, which are critical for ensuring safe and efficient evacuation in case of an emergency.
Plan Of Correction
Maintenance Director was in serviced on proper signage for egress doors. Area identified has been resolved by the maintenance director by posting signage stating "PUSH UNTIL ALARM SOUNDS DOOR WILL OPEN IN 15 SECONDS." All egress doors will be reviewed by the maintenance director to assure that all egress doors have proper signage. Maintenance Director/Designee will monitor egress doors 3 times per week for 4 weeks and 1 time a month for 2 months. Results will be brought to QAPI and variances will be addressed.