Exit Door Deficiency in 100-Wing Corridor
Penalty
Summary
The facility failed to maintain one of two exits in the corridor of the 100-wing, as observed during a tour conducted by the Maintenance Director and the Regional Maintenance Consultant. The exit door located by resident room 102 had a sign posted on it stating "*DO NOT EXIT" "ALARM WILL SOUND!" Additionally, the exit door did not close and latch properly when tested, which is a violation of the NFPA 101 Life Safety Code requirements. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during an interview conducted concurrently with the record review. The deficiency was further discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. Photographic evidence was obtained to document the deficiency, which is cited under NFPA 101 (2012 and 2021 Editions) sections 19.2.1, 19.2.2.2, 7.1.10.1, 7.1.10.2.1, and 7.2.1.4.5.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The sign was removed from the exit door on 3/31/2025 located by resident room 102 by maintenance staff. The door that failed to latch was repaired by Regional Maintenance Consultant on 3/31/2025 and the door now closes and latches appropriately. 2. Exit doors in facility were audited for removal of any do not exit signs and to ensure doors close and latch by Maintenance Director on 04/01/2025. 3. Education was provided to the Maintenance Director on Means of Egress Requirements. The Maintenance Director or designee will conduct quality assurance checks weekly for 12 weeks ensuring no exit signs on exit doors and doors closing and latching appropriately. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured. Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The sign was removed from the exit door on 3/31/2025 located by resident room 102 by maintenance staff. The door that failed to latch was repaired by Regional Maintenance Consultant on 3/31/2025 and the door now closes and latches appropriately. 2. Exit doors in facility were audited for removal of any do not exit signs and to ensure doors close and latch by Maintenance Director on 04/01/2025. 3. Education was provided to the Maintenance Director on Means of Egress Requirements. The Maintenance Director or designee will conduct quality assurance checks weekly for 12 weeks ensuring no exit signs on exit doors and doors closing and latching appropriately. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.