Missing Signage on Delayed Egress Door
Penalty
Summary
The facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 standards. During a facility tour conducted on April 8, 2025, between 1:30 PM and 2:45 PM, it was observed that the main lobby door, which was equipped with a 15-second delayed egress lock, was missing the required signage. This observation was made in the presence of the Maintenance Director, who acknowledged the findings. The deficiency was further discussed with the Maintenance Director during an exit conference held on the same day at 3:00 PM. The lack of required signage on the egress door represents a failure to comply with the NFPA 101 (2021 Edition) 7.2.1.6.1.1(4)(a) standards, which mandate specific requirements for delayed egress locking systems to ensure safety and compliance.
Plan Of Correction
ACTIONS TAKEN TO CORRECT THE DEFICIENCY: All doors will be monitored on a monthly basis to ensure all 15 second signs are posted on the main entry exit egress exit door. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE WILL BE IDENTIFIED: A Full audit will be completed for all for all residents to ensure that all residents are provided a safe environment. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: Audits will be completed on a monthly basis to ensure the same deficient practice does not re occur. HOW THE CORRECTIVE ACTION WILL BE MONITORED: All audits will be brought to QAPI monthly thereafter.