Missing Required Signage on Delayed Egress Door
Penalty
Summary
A deficiency was identified when surveyors observed that the door from the solarium into the 600 wing, which serves as a posted exit, was equipped with 15-second delayed egress hardware. This door did not display the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS," as mandated by NFPA 101, 7.2.1.6.1.1 (4). The absence of this signage was confirmed during the survey by the Maintenance Director at the time of discovery. The report specifies that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless the special locking arrangements for clinical needs were met according to regulatory standards. This deficiency was noted to potentially affect all occupants in the solarium in the event of a fire or emergency, as the required egress signage and compliance with special locking arrangements were not in place.
Plan Of Correction
Element 1: 600 wing exit needed a PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS sign. Signs were placed on the door on 06/03/2025. Element 2: All residents in the solarium/staff/visitors have the potential to be impacted by this deficiency. Element 3: Sign was placed on the door on 06/03/2025 stating PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. Element 4: Physical Plant Manager will be responsible for sustained compliance.