Delayed Egress Door Locking System Not Maintained per NFPA Standards
Penalty
Summary
The facility failed to maintain the delayed egress door locking system at the main entrance door near nurse's station 1. During an observation on May 7, 2025, it was found that the delayed egress device did not enter an irreversible opening sequence when the panic bar was activated, as required by NFPA 101, 19.2.2.2.4 (2), 7.2.1.6.1. This deficiency was identified through direct observation and confirmed in an interview with the Maintenance Director at the time of the survey. This failure to maintain the delayed egress system in accordance with NFPA standards could affect approximately 15 occupants in the event of a fire emergency. The report does not mention any specific residents or their medical conditions at the time of the deficiency, nor does it provide additional context regarding the individuals present beyond the number of potentially affected occupants.
Plan Of Correction
LSC Annual Survey 5.7.25K 222 Egress Doors Element 1: Main entrance door near station 1 was immediately adjusted and validated as working correctly with irreversible opening sequence triggering as it should. Element 2: A full facility audit was conducted to validate that all other egress doors were functioning properly. No other issues were identified. Element 3: The maintenance director was educated on the regulations of tag K222 in accordance with the NFPA 101 guidance. The regulatory maintenance schedule within TELS was reviewed and deemed appropriate, in addition to all other routine scheduled door inspections. Element 4: The maintenance director will validate the proper functioning of all egress doors daily and indefinitely per TELS schedule. NHA will validate with Maintenance Director weekly that all doors are working correctly. The results of all ongoing audits will be reviewed by the QAPI committee. The NHA is responsible for ongoing compliance.