Delayed Egress Door Failure
Penalty
Summary
The facility failed to maintain a delayed egress door on the first floor near the main employee lounge. During an observation on December 9, 2024, at 11:45 a.m., it was noted that the exit door did not open as expected when tested. The door was supposed to open within 15 seconds, as indicated by the signage, but it failed to do so. This deficiency was confirmed during an exit interview with the Facility Administrator, Director of Plant Operations, and Facilities Manager on the same day at 1:30 p.m. The failure of the door to open as required affects one of the three floors within the facility, indicating a lapse in maintaining the egress system as per the NFPA 101 standards.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. 1. The Maintenance Director corrected the 1st floor exit door, near main employee lounge, to ensure delayed egress operates correctly. 2. The Maintenance Director/Designee will conduct an initial audit to verify doors with delayed egress operate correctly. 3. Nursing Home Administrator or Designee will re-educate the Maintenance Director on proper functions of delayed egress doors. 4. The Maintenance Director/Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that doors with delayed egress operate correctly. This plan of correction will be reviewed at the monthly Quality Assurance Performance Improvement meeting and changes will be made as needed.