Deficient Maintenance of Delayed Egress Doors
Penalty
Summary
During a fire safety tour of the facility, surveyors observed that two of seven sampled delayed egress exits were not maintained in accordance with NFPA 101 requirements. At 11:00 AM, the Southeast Corridor exit, which was equipped with a delayed egress locking arrangement, failed to operate when tested. Later, at 1:04 PM, the Northeast corridor exit near Central Supply, also equipped with a delayed egress locking arrangement, required more than fifteen pounds of force to open the door, exceeding the standard for ease of egress. These deficiencies were confirmed through direct observation and acknowledged by the Maintenance Director during the inspection. The findings were subsequently reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during the exit conference. No information regarding specific residents or their medical conditions was provided in relation to these deficiencies.
Plan Of Correction
Corrective Actions A. The SE corridor exits delayed egress locking arrangement was repaired on 5/28/2025. B. The NE corridor exits delayed egress locking arrangement was adjusted on 5/28/2025 so that it required less than 15 lbs. of force to open the door. Identification of Others Potentially Affected The Maintenance Director, or designee, evaluated all other egress doors with a delayed egress locking arrangement to ensure proper functionality and operating force. Systemic Changes On an ongoing basis as part of the facility's life safety program, the Maintenance Director, or designee, will perform monthly testing of all facility egress doors with a delayed egress locking arrangement to ensure proper functionality. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Results of the monthly testing will be reviewed at the monthly QAPI meetings X 3 months. If substantial compliance is not met after 3 months, results of the ongoing monthly inspections will be brought to QAPI meetings until substantial compliance is met. The statements made on this plan of correction are not an admission to and do not constitute an agreement with alleged deficiencies herein. To remain compliant with all federal and state regulations, the facility has taken actions set forth in the plan of correction. The plan of correction constitutes the facility's allegation of compliance such as the deficiencies cited have been corrected by the date certain. Corrective Actions A. The SE corridor exits delayed egress locking arrangement was repaired on 5/28/2025. B. The NE corridor exits delayed egress locking arrangement was adjusted on 5/28/2025 so that it required less than 15 lbs. of force to open the door. Identification of Others Potentially Affected The Maintenance Director, or designee, evaluated all other egress doors with a delayed egress locking arrangement to ensure proper functionality and operating force. Systemic Changes On an ongoing basis as part of the facility's life safety program, the Maintenance Director, or designee, will perform monthly testing of all facility egress doors with a delayed egress locking arrangement to ensure proper functionality. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Results of the monthly testing will be reviewed at the monthly QAPI meetings X 3 months. If substantial compliance is not met after 3 months, results of the ongoing monthly inspections will be brought to QAPI meetings until substantial compliance is met.