Deficient Egress Door Accessibility
Penalty
Summary
The facility failed to ensure that two of its fifteen exit doors in the means of egress were readily accessible and free of obstructions or impediments to full instant use in case of fire or other emergencies. During an observation at approximately 8:54 AM, it was noted that the Kitchen designated exit door to the exit discharge was equipped with a sliding bolt lock on the egress side, which was engaged and could restrict emergency use of the door. This deficiency was observed in the presence of a surveyor. Additionally, at 11:35 AM, another observation revealed that the exit door located in the facility's Main dining room to the Courtyard had a keyed lockset on the egress side. The surveyor tested the door by locking and attempting to open it, but was unable to do so, confirming that the device could restrict emergency use of the exit. These deficiencies were confirmed during an interview with the surveyor at the time of the observations. The facility's representative was notified of these issues at the Life Safety Code survey exit conference.
Plan Of Correction
The lock from the dining room door to the courtyard was immediately removed and a passage way door lock was installed. The sliding bolt lock on the kitchen exit door was immediately removed. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on ensuring designated exit / Egress doors are readily accessible and free of all obstructions or impediments. Element Four: The Maintenance Director / designee will audit the courtyard and kitchen exit doors to ensure the exit access remains readily accessible and free of all obstructions or impediments monthly x3. Results to be reported to the QAPI team for review.