Egress Door Latching Deficiency
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of egress doors, as observed during a survey conducted on April 8th. During the facility tour, it was noted that one of the nine egress doors, specifically near resident room 118 on the 100 Hall, failed to positively latch. This issue was identified after testing the door three times, each time resulting in the latching mechanism not engaging properly. The Director of Maintenance was present during the inspection and acknowledged the deficiency. The failure of the door to latch properly is a violation of the National Fire Protection Association (NFPA) 101 standards, which require that doors in a required means of egress must not be equipped with a latch or lock that requires a tool or key from the egress side unless specific conditions are met. The deficiency was documented with photographic evidence. The report does not mention any specific residents affected by this deficiency or any immediate consequences resulting from the door's failure to latch. However, the presence of the Director of Maintenance during the survey and his concurrence with the findings indicate an awareness of the issue at the facility level.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. The one egress door near resident room 118 on the 100 hall, noted to not positively latch when tested will be repaired to proper function. 2. Additional egress doors will be reviewed for positive latching. 3. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Egress Doors specific to maintaining egress doors to positively latch, and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.