Failure to Maintain Egress Door Functionality
Penalty
Summary
The facility failed to maintain proper functioning of exit egress doors on one of its three levels, specifically at the AO Courtyard. During an observation conducted on January 30, 2025, at 10:10 a.m., it was noted that the egress exterior gate lock was not equipped with a delayed egress special locking arrangement (SLA) and failed to open as required. This deficiency was identified through direct observation and was confirmed during an exit interview with the Administrator and Maintenance Director later that day. The deficiency indicates a failure to comply with the National Fire Protection Association (NFPA) 101 Life Safety Code requirements for egress doors, which mandate that doors in a required means of egress should not be equipped with a latch or lock that requires a tool or key from the egress side unless specific conditions are met. The lack of a delayed egress SLA on the exterior gate lock compromised the safety and security protocols intended to ensure rapid evacuation in case of an emergency.
Plan Of Correction
A delayed egress was installed in the exterior gate lock of the A0 Courtyard to ensure the gate will open after 15 seconds. The Maintenance Director or designee will conduct quarterly inspections on the exterior gates to ensure they will open after 15 seconds. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.