Delayed Egress Door Malfunction
Penalty
Summary
The facility failed to maintain the functionality of delayed egress doors, which is a requirement for ensuring safe evacuation in case of emergencies. During an observation on January 21, 2025, it was noted that the delayed egress door located on the first floor, across from resident room 231, did not alarm or open as it should have. This deficiency was identified during a survey, indicating a lapse in the facility's adherence to the National Fire Protection Association (NFPA) 101 standards for egress doors. The issue was confirmed during an exit interview with the Administrator and the Maintenance Director, who acknowledged that the door failed to perform its intended function. This deficiency affects one of the two floors in the facility, potentially compromising the safety of residents and staff in the event of an emergency. The report does not provide details on any specific residents affected or any immediate consequences resulting from this deficiency.
Plan Of Correction
The delay egress door across from room 231 was fixed and is now functioning. The facility has determined that all egress doors have the potential to be affected. The Maintenance Director was in-serviced on ensuring that the egress doors alarm and open. The Maintenance Director will monitor the functioning of the egress doors weekly. The Maintenance Director will review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.