Delayed Egress Door Malfunction
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of delayed egress exit doors, as observed during a survey conducted on February 11, 2025. During a tour of the facility with the maintenance director, it was noted that the delayed egress exit door from the main dining room failed to close and latch properly when tested. This issue was identified as a failure to comply with the requirements set forth in NFPA 101, which governs the safety and functionality of egress doors in healthcare facilities. The maintenance director, who was present during the observation, acknowledged that the door should have closed and latched automatically but required assistance to do so. This indicates a lapse in the facility's adherence to safety protocols, as the door's inability to function correctly could impede safe egress in an emergency situation. The deficiency was documented based on both observation and interview, highlighting the importance of maintaining functional egress systems to ensure the safety of residents and staff. The findings were discussed with both the maintenance director and the facility administrator during the exit conference on the same day. The report does not mention any specific residents being directly affected by this deficiency, nor does it provide details on any immediate consequences resulting from the door's malfunction. However, the failure to maintain the door in accordance with NFPA 101 standards represents a significant oversight in the facility's safety measures.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483.1. 1. Identified doors repaired, currently closing/latching as intended. 2. Maintenance Director/Designee completed observation of other facility exit doors to verify delayed egress maintained. 3. Administrator provided education for current facility Maintenance Department regarding egress doors. 4. Maintenance Director/Designee to complete monthly preventative maintenance testing of exit doors to verify delayed egress maintained. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings. Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483.1. 1. Identified doors repaired, currently closing/latching as intended. 2. Maintenance Director/Designee completed observation of other facility exit doors to verify delayed egress maintained. 3. Administrator provided education for current facility Maintenance Department regarding egress doors. 4. Maintenance Director/Designee to complete monthly preventative maintenance testing of exit doors to verify delayed egress maintained. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.