Failure to Maintain Exit Door Latching in Therapy Gym
Summary
The facility failed to maintain exit doors in accordance with NFPA 101 (2012 Edition) during a facility tour conducted on March 12, 2025, between 9:00 a.m. and 3:00 p.m. An exit door in the therapy gym was observed to be not latching properly. This observation was confirmed through an interview with facility maintenance staff who were present during the tour. The deficiency is cited under NFPA 101 (2012 Edition) sections 19.2.2.2.1, 7.2.1, 7.2.1.5.10, and 4.6.
Plan Of Correction
On 3/12/25 the Maintenance Director/Maintenance Assistance evaluated the Exit Door in the therapy gym and made adjustments to the door so it could latch properly. ATTACHMENT #55 See corresponding email sent to area office dated 4/4/25 with attachments. On 3/12/25 the Maintenance Director inspected the other Exit Doors to ensure that the exit doors close and latch properly. During this inspection, there were no other exit doors that did not close and latch properly. ATTACHMENT #56 See corresponding email sent to area office dated 4/4/25 with attachments. On 3/12/25, the Administrator provided an inservice for the Maintenance and Therapy staff on the importance for exit doors to close and latch properly. The inservice included notifying the administrator/designee of any exit doors that do not close and latch properly and a plan to correct as indicated. ATTACHMENT #57 See corresponding email sent to area office dated 4/4/25 with attachments. The facility Maintenance Director/designee will audit facility exit doors weekly to help monitor and maintain proper latching for the facility exit doors. The monthly audit of exit doors will be recorded on a log. ATTACHMENT #58 See corresponding email sent to area office dated 4/4/25 with attachments. The Maintenance Director/designee will provide the monthly QAPI Committee a summary report on the findings from the audits of the facility exit doors for three (3) months. The QAPI committee will evaluate the outcome of the audits and if necessary amend the improvement plan and continue to monitor until sustained improvement has been determined by the committee. ATTACHMENT #59 See corresponding email sent to area office dated 4/4/25 with attachments.
Penalty
The facility failed to maintain accurate evacuation diagrams, as the diagram in the PT corridor did not display two exit routes from the viewer's location, violating NFPA 170 standards. This deficiency was confirmed by the maintenance supervisor.
The facility failed to maintain an exit door in the 100-wing corridor, as it had a sign stating "*DO NOT EXIT" "ALARM WILL SOUND!" and did not close and latch properly. This was observed during a tour with the Maintenance Director and Regional Maintenance Consultant, and acknowledged during an interview and exit conference. Photographic evidence was obtained, and the deficiency is cited under NFPA 101 standards.
The facility failed to maintain proper means of egress requirements as the evacuation diagrams did not include a 'YOU ARE HERE' notation or exit paths. This deficiency was confirmed by the maintenance supervisor, indicating non-compliance with NFPA standards.
The facility failed to maintain proper evacuation diagrams on all building levels. Observations revealed that the diagrams lacked a notation showing the viewer's location, which was confirmed by the maintenance supervisor. This deficiency violates NFPA 170-11.2.4 and 11.4.1 standards.
A Life Safety Code survey found that certain doors in the facility were equipped with locks requiring more than one action to open, violating safety regulations. This issue was observed in the Unit 1/2 Resident Lounge and two basement storage rooms, despite recent inspections documented by the maintenance staff.
Evacuation Diagram Deficiency in PT Corridor
Penalty
Summary
The facility failed to maintain accurate evacuation diagrams, as observed on April 8, 2025. Specifically, the evacuation diagram located in the PT corridor did not display two exit routes from the viewer's location, which is a requirement under NFPA 170 - 11.2.4 and 11.3.2. This deficiency was confirmed during an interview with the maintenance supervisor conducted at the same time as the observation.
Plan Of Correction
Physical Therapy hallway evacuation plan was updated. All other evacuation diagrams reviewed to verify two exit routes on each one. Findings will be reported at Quality Assurance Performance Improvement meeting.
Exit Door Deficiency in 100-Wing Corridor
Penalty
Summary
The facility failed to maintain one of two exits in the corridor of the 100-wing, as observed during a tour conducted by the Maintenance Director and the Regional Maintenance Consultant. The exit door located by resident room 102 had a sign posted on it stating "*DO NOT EXIT" "ALARM WILL SOUND!" Additionally, the exit door did not close and latch properly when tested, which is a violation of the NFPA 101 Life Safety Code requirements. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during an interview conducted concurrently with the record review. The deficiency was further discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. Photographic evidence was obtained to document the deficiency, which is cited under NFPA 101 (2012 and 2021 Editions) sections 19.2.1, 19.2.2.2, 7.1.10.1, 7.1.10.2.1, and 7.2.1.4.5.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The sign was removed from the exit door on 3/31/2025 located by resident room 102 by maintenance staff. The door that failed to latch was repaired by Regional Maintenance Consultant on 3/31/2025 and the door now closes and latches appropriately. 2. Exit doors in facility were audited for removal of any do not exit signs and to ensure doors close and latch by Maintenance Director on 04/01/2025. 3. Education was provided to the Maintenance Director on Means of Egress Requirements. The Maintenance Director or designee will conduct quality assurance checks weekly for 12 weeks ensuring no exit signs on exit doors and doors closing and latching appropriately. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured. Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The sign was removed from the exit door on 3/31/2025 located by resident room 102 by maintenance staff. The door that failed to latch was repaired by Regional Maintenance Consultant on 3/31/2025 and the door now closes and latches appropriately. 2. Exit doors in facility were audited for removal of any do not exit signs and to ensure doors close and latch by Maintenance Director on 04/01/2025. 3. Education was provided to the Maintenance Director on Means of Egress Requirements. The Maintenance Director or designee will conduct quality assurance checks weekly for 12 weeks ensuring no exit signs on exit doors and doors closing and latching appropriately. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Evacuation Diagram Deficiency
Penalty
Summary
The facility failed to maintain proper means of egress requirements in its building component. During an observation on January 29, 2025, it was noted that the evacuation diagrams did not include a notation indicating the location of the viewer on the diagram. This deficiency was confirmed in an interview with the maintenance supervisor, who acknowledged that the diagrams lacked 'YOU ARE HERE' locations and exit paths, as required by NFPA 170-11.2.4 through 11.4.1.
Plan Of Correction
Egress evacuation diagrams have been updated to show two forms of evacuation. Education completed with the maintenance supervisor to have routes of evacuation clearly marked on the evacuation diagrams. Diagrams will be monitored monthly. Results will be reviewed at the QAPI meeting.
Evacuation Diagram Deficiency
Penalty
Summary
The facility was found to be deficient in maintaining proper evacuation diagrams across all three building levels. During an observation conducted on January 15, 2025, between 11:20 a.m. and 12:10 p.m., it was noted that the evacuation diagrams lacked a critical notation indicating the location of the viewer on the diagram. This deficiency was confirmed in an interview with the maintenance supervisor, who acknowledged that the diagrams did not show the viewer's location or the exit paths, as required by NFPA 170-11.2.4 and 11.4.1.
Plan Of Correction
1. Evacuation Diagrams have been updated to contain the notation showing the location of the viewer on the diagram.
Non-compliant Egress Door Locks
Penalty
Summary
During a Life Safety Code survey, it was observed that certain facility doors were not maintained in compliance with safety regulations. Specifically, doors within a means of egress were equipped with locks that required more than one releasing operation to open. On the first floor, the door separating the Unit 1/2 Resident Lounge from the Unit 1 corridor had a thumb turn lock that required two actions to open: turning the thumb lock to the unlocked position and then turning the doorknob. The Maintenance Director confirmed that the maintenance staff had inspected the facility's corridor doors and had documentation for these inspections. Further observations in the basement revealed similar issues with doors leading to storage rooms. The door to the La(NAME) storage room and the Therapy Storage room (A5) both had thumb turn locks requiring two actions to open. These doors were also marked with illuminated exit signs. The facility's Annual Door Audit sheets indicated that the doors were checked in September 2024, but the deficiency persisted, affecting the safety of the egress routes.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. All locks requiring more than one releasing operation were audited on 12/30/2024 by Maintenance Director. The door that separates the first and second unit was audited and the locking mechanism was replaced. The door in the basement by La(NAME) Storage room was audited by the Maintenance Director on 12/30/2024 and the locking mechanism was replaced. The door for therapy storage in the basement was audited by the Maintenance Director on 12/30/2024 and the locking mechanism was replaced. 2. All residents are at risk for deficient practice of doors within a means of egress being equipped with locking mechanisms with more than one releasing mechanism. 3. The policy and procedure for life safety doors with a section on doors within a means of egress was created on 12/30/2024 by the Administrator. 4. An entire building-wide audit will be conducted on all doors within a means of egress having locks with more than one releasing mechanism. All doors with deficient practice will be repaired. 5. The Maintenance Director/Tech will be educated on this issue by the Administrator on 1/10/2025. 6. The Maintenance Director will report completion of lock changes to the QAPI Committee to ensure compliance with K200. An audit will be completed monthly by the Maintenance Director/Tech to ensure this issue is no longer present in the facility. The QAPI Committee will review completion and determine any further changes needed. Person Responsible: Maintenance Director
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