Deficient Delayed Egress Door Signage and Function
Penalty
Summary
Surveyors observed that the facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 requirements. During a fire safety tour, it was found that two delayed egress exit doors—the first floor West Wing Rehabilitation Room door and the Service Hallway door—did not have the required signage with a contrasting background. This signage is necessary to comply with fire safety codes and to ensure that the doors are easily identifiable in an emergency. Additionally, the Service Hallway delayed egress exit door exhibited a malfunction during testing. Specifically, the door automatically reset when it was tested, which is not in accordance with the required operation for delayed egress doors. This issue could potentially interfere with the proper function of the delayed egress system, which is designed to allow safe evacuation during emergencies. The findings were confirmed through direct observation by surveyors and acknowledged by the Regional Maintenance Director during the inspection. The deficiency was reviewed with both the Administrator and the Regional Maintenance Director at the exit conference. Photographic evidence was obtained to document the observed issues. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.