Failure to Maintain Emergency Exit Doors
Penalty
Summary
The facility failed to maintain emergency exit doors in accordance with NFPA 101 standards. During a facility tour conducted on March 6, 2025, between 11:30 a.m. and 2:00 p.m., it was observed that the exit door by Room 114 did not latch when in the closed position. This observation was made in the presence of the maintenance director, who confirmed the findings during an interview conducted concurrently with the observations. The deficiency highlights a failure in the facility's maintenance, inspection, and testing of doors, as required by NFPA 101 and NFPA 80 standards. The report indicates that fire door assemblies are to be inspected and tested annually, and non-rated doors should be routinely inspected as part of the facility's maintenance program. However, the failure of the exit door to latch properly suggests a lapse in these maintenance protocols, as the individuals responsible for door inspections and testing are expected to possess the necessary knowledge, training, or experience to ensure compliance.
Plan Of Correction
4/5/25 On March 6, 2025, a security and fire protection company repaired the latch on the exit door by room 114. A facility-wide audit on exit doors was performed by a security and fire protection company on March 6, 2025, with no variances noted. Education was provided to the Maintenance Staff by the Executive Director on March 27, 2025, about NFPA 101 Inspection & Testing Doors per (2012 and 2021 Editions). Monthly audits will be completed by the Maintenance Director or Designee to ensure the exit doors are maintained. These audits will be reviewed in the Quality Assurance Performance Improvement meeting for three months until substantial compliance is met.