Non-compliance with Egress Door Standards
Penalty
Summary
The facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 standards. During a fire safety tour, it was observed that several egress doors were not compliant. Specifically, the 500 Hallway Lobby double exit doors and the Main Lobby double interior egress doors were missing the required signage on both leaves. Additionally, the Main Lobby double-interior-egress doors were missing signage from the left leaf. Furthermore, the Therapy Lobby double exit doors, which were equipped with 30-second delayed egress locks, failed to open when tested. These observations were made in the presence of the Maintenance Director, who acknowledged the findings. The issues were subsequently reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during an exit conference.
Plan Of Correction
Corrective Actions 1. The following egress doors had signage added to indicate the presence of a 30 second delayed egress locking arrangement on 2/5/2025. A. 500 Hallway Lobby double exit doors. (30 second Delay Signage) B. Main Lobby double interior egress doors. (15 second Delay Signage) C. Main Lobby double interior egress doors, left leaf. (15 second Delay Signage) 2. The Therapy Lobby double exit doors were evaluated and made to function properly when the delayed egress locking arrangement was initiated on 2/5/2025. Identification of Others Potentially Affected The Maintenance Director, or designee, performed a facility-wide assessment of the other egress doors to ensure the following: 1. Doors with a delayed egress locking arrangement had the correct signage. 2. Doors with a delayed egress locking arrangement functioned properly. Systemic Changes The Maintenance Director, or designee, will continue to perform documented monthly inspections of all egress doors with a delayed egress locking arrangement to ensure the correct signage is in place, and to ensure the doors properly function, on an ongoing basis as part of the facility's life safety program. Quality Assurance Results of the monthly egress door inspections will be presented at the monthly QA meetings for 3 months. If substantial compliance is not met after 3 months, results of the ongoing monthly inspections will be brought to QA meetings until substantial compliance is met.