Failure to Maintain Delayed Egress Doors
Penalty
Summary
The facility failed to maintain the delayed egress doors on one of its three levels, specifically on the first floor. During an observation on January 23, 2025, at 10:52 a.m., it was noted that the delayed egress door by the Laundry did not alarm and open as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director later that morning. Additionally, another observation on the same day at 11:29 a.m. revealed that the delayed egress door near resident room 701 lacked the necessary signage. The sign should have instructed individuals to 'PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.' This absence of signage was also confirmed during the exit interview with the facility's administration and maintenance staff.
Plan Of Correction
1. The delayed egress door by laundry has been repaired to alarm and properly function. The proper signage was placed on the delayed egress door next to resident room 701. 2. NHA/Designee will educate the Maintenance Director on the requirements for maintaining delayed egress doors and ensuring they have the proper signage that reads "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." 3. NHA/ Designee will audit the delayed egress doors in the facility to ensure proper function and signage. 4. NHA/Designee will conduct a random audit of delayed egress doors to ensure they are properly functioning and have the proper signage posted, weekly x4 monthly x3. 5. Results of the audit to be reported to monthly QA.