Failure to Maintain Operable Egress Doors
Penalty
Summary
The facility failed to maintain doors with Special Locking Arrangements (SLA's) in operable condition, specifically affecting one of the three levels. During an observation on January 22, 2025, at 1:40 p.m., it was noted that the East Annex double doors near the reception desk on the first floor had a malfunction. One leaf of the door failed to close when tested, despite being equipped with a magnetic locking feature. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m. The failure of the door to close properly indicates a lapse in maintaining the required egress door standards as outlined by NFPA 101, which mandates that doors in a required means of egress must be operable and not require a tool or key from the egress side unless specific conditions are met.
Plan Of Correction
East doors near reception desk are now functioning appropriately (SLA part replaced). All other egress doors in the facility were inspected and are functioning as designed. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0222: EGRESS. Maintenance Director or Designee will conduct weekly inspections on all egress doors weekly x 3 weeks to ensure all are working as designed. Results will be reported in monthly QAPI.