Delayed Egress Door Malfunction
Penalty
Summary
The facility failed to maintain proper functioning of exit egress doors equipped with delayed egress locking arrangements. During an observation on March 12, 2025, it was noted that two exit doors did not release after 15 seconds of applying pressure against the crash bar, as required. These doors were located on the first floor, specifically door # EM-1 next to the basement stairwell and door # E4 in the dining room. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged that the doors did not release as expected. This issue affected two of the four smoke compartments in the facility, indicating a failure to comply with the necessary safety standards for egress doors.
Plan Of Correction
1. Door # EM1 repaired and released on egress and requesting a TLW for EM4 as a door repair may be necessary to be made by an outside vendor. 2. 4/28/25 3. Doors will be checked on a monthly basis. 4. Director of maintenance or designee will conduct monthly audits to ensure doors are released after 15 seconds of applying pressure.