Missing Delayed Egress Signage on Exit Doors
Penalty
Summary
A deficiency was identified when surveyors observed that the delayed egress double doors located at the south end of the facility did not have the required 15-second delayed egress sign. This observation was made during a walkthrough and was confirmed through an interview with the facility Maintenance Director at the time of the observation. The lack of proper signage on the delayed egress doors means that the doors were not in compliance with the requirements for special locking arrangements as outlined in the applicable codes. The report specifically notes that the door was not identified as a delayed egress door, which is necessary for proper emergency exiting procedures. The deficiency could potentially affect 35 occupants in the area if emergency exiting is required.
Plan Of Correction
Element #1 Signage was added to the emergency egress door that indicates 15 second egress. Element #2 Signage was added to the emergency egress door that indicates 15 second egress. A facility-wide audit was conducted to validate all egress doors have appropriate signage. Element #3 The EVS facility manager will monitor egress doors twice weekly to assure signage remains. The EVS Manager will report findings of missing signage immediately to the Administrator. And will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee monthly, and periodically thereafter. The Administrator will assume responsibility for attained compliance.