Egress Door Compliance Failure
Penalty
Summary
The facility failed to maintain their egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 standards. During a facility tour conducted on April 29, 2025, between 1:15 PM and 2:45 PM, it was observed that the delayed egress doors located in the Coconut Grove hallway did not open when tested. This issue was identified in the presence of the Director of Property Management, who was accompanying the surveyors during the inspection. An interview with the Administrator and the Director of Property Management was conducted concurrently with the observations, during which they acknowledged the findings. The deficiency was reviewed with both the Administrator and the Director of Property Management at the exit meeting on the same day at 3:00 PM. The failure to maintain the egress doors in compliance with the NFPA 101 standards was documented as a deficiency, specifically noting the non-compliance with the delayed egress locking arrangements.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. **K222 Egress Doors** Immediate Corrective Action: On 4/29/2025, an emergency purchase order was submitted and service request scheduled for vendor RF Technology to provide service to the egress door located on the west unit adjacent to the Coconut dining room. On 4/30/2025 RF Technology Inc. field service technician repaired the egress door. The door is equipped with delayed egress locking arrangements in accordance with NFPA 101. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. All egress doors were inspected throughout the units to ensure compliance with NFPA 101 standards. No other egress doors were identified out of compliance. Measures: Director of Property Management and Maintenance team members were re-educated on conducting weekly egress door inspection and document on preventative maintenance sheet and report any non-functioning doors to supervisor immediately. Doors must be equipped with delay egress locking arrangements in accordance with NFPA 101. Monitoring: The Director of Property Management and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure compliance with NFPA 101 standards. Director of Property management will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until committee determines substantial compliance.