Non-compliance with NFPA 101 Egress Door Standards
Penalty
Summary
The facility failed to maintain egress doors equipped with special locking arrangements in accordance with NFPA 101 standards. During a fire safety tour, it was observed that the Main Entrance double exit doors, which were equipped with a delayed egress special locking arrangement, were missing the required signage from both leaves. This lack of signage is a violation of the safety standards as it is essential for ensuring that individuals can identify and understand the function of the delayed egress system in an emergency. Additionally, the Dining Room Patio exit screen door was found to be locked at the latch and with a slide lock located 48 inches above the finished floor. This door had multiple locks engaged, and there was no documentation provided to indicate that the local authority had approved a clinical needs or security special locking arrangement for this setup. The presence of multiple locks without proper authorization or documentation is a breach of the regulations, which typically allow only one locking device unless specific conditions are met. Furthermore, the Rehabilitation double emergency exit doors, also equipped with a delayed egress special locking arrangement, were found to be locked with a hook deadbolt lock. This additional locking mechanism is not compliant with the standards for delayed egress systems, which are designed to allow for safe and timely evacuation. The Maintenance Director acknowledged these findings during the observations, and the issues were reviewed with both the Administrator and the Maintenance Director at the exit conference.
Plan Of Correction
K K222 NFPA 101 EGRESS DOORS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Main Entrance double doors equipped with delayed egress special locking arrangements, not having the required signage on both doors. Maintenance has installed new signage on both of the front doors. 2) In the allegation of the Dining Room patio exit screen door having multiple locks on it. Maintenance has removed the extra lock and there is currently only one. 3) In the allegation of the Rehabilitation double emergency exit doors equipped with delayed egress special locking arrangements being locked with a hook deadbolt lock. Maintenance has disengaged the hook deadbolt lock. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that proper signage on the Main Entrance double doors is on those doors. - Maintenance Director or designee will ensure that there is only one lock on the Dining Room Patio exit door. - Maintenance Director or designee will ensure that hook deadbolt lock on the Rehabilitation double emergency exit doors is disengaged. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. K222 EGRESS DOORS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Main Entrance double doors equipped with delayed egress special locking arrangements, not having the required signage on both doors. Maintenance has installed new signage on both of the front doors. 2) In the allegation of the Dining Room patio exit screen door having multiple locks on it. Maintenance has removed the extra lock and there is currently only one. 3) In the allegation of the Rehabilitation double emergency exit doors equipped with delayed egress special locking arrangements being locked with a hook deadbolt lock. Maintenance has disengaged the hook deadbolt lock. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that proper signage on the Main Entrance double doors is on those doors. - Maintenance Director or designee will ensure that there is only one lock on the Dining Room Patio exit door. - Maintenance Director or designee will ensure that hook deadbolt lock on the Rehabilitation double emergency exit doors is disengaged. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.