Egress Door Deficiencies in Facility
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, several deficiencies were observed. At the main entrance, the electronic access-controlled double horizontal sliding exit doors' right leaf did not break away when tested, indicating a malfunction in the emergency egress system. Additionally, the reception interior-egress door and smoke doors near Room 106, both equipped with delayed egress locking arrangements, were missing the required signage, which is essential for proper identification and operation during emergencies. Further observations revealed that the corridor doors leading to the laundry area, also equipped with delayed egress locking arrangements, were missing the necessary signage and automatically reset when tested, which could hinder emergency evacuation. The Physical Therapy exit door required more than fifteen pounds of force to open due to the threshold rubbing on the bottom of the door, which is a violation of the force requirements for egress doors. These issues were acknowledged by the Plant Operations Technician during the survey. The findings were communicated to the Administrator and the Director of Plant Operations during the exit conference. The report highlights the facility's failure to comply with NFPA 101 standards for egress doors, which are critical for ensuring safe and efficient evacuation during emergencies. Photographic evidence was obtained to support these findings.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated on K222 on 05/16/2025 by the Executive Director. The maintenance director/designee completed the following corrections to the delayed egress doors: 1. The Main Entrance electronic access-controlled double horizontal sliding exit doors was inspected on 05/16/25 and the center obtained a quote to repair the lock on the door. The lock will be repaired by 05/24/2025. There is an existing fire exit on the left side of the door as of 05/16/2025. 2. The Reception interior-egress door has signage added to include the egress time on 05/22/2025. 3. The smoke doors equipped with a delayed egress locking arrangement, near Room 106 had the signage added to the doors on 05/22/2025. The maglock was inspected on 05/16/2025 by a vendor to re-engage the maglock and the egress door will be able to show functionality by 05/24/2025. 4. The corridor doors leading to laundry equipped with a delayed egress locking arrangement had the correct signage installed on 05/22/2025 and the reset was inspected by a vendor on 05/16/2025 for proper functionality. 5. The Physical Therapy exit door, equipped with a delayed egress locking arrangement was corrected to open with less than 15 pounds of pressure on 05/15/2025. Delayed egress doors will be audited for proper functioning related to signage, breakaway, pressure and resetting weekly x4 weeks and monthly x6 months. The repair reports and audits will be brought to QAPI on 05/21/2025 for review.