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Missing Signage on Delayed Egress Door

Comprehensive Rehabilitation And Nursing Center AtWilliamsville, New York Survey Completed on 12-06-2024

Summary

During a Life Safety Code survey, it was observed that a door on the first floor of Unit 1/2, equipped with a delayed egress locking mechanism, lacked the required signage indicating how the door could be opened during a fire or other emergency. The door, located near resident rooms, was supposed to have a sign stating, 'Push Unit Alarm Sounds Door Can be Opened in 15 Seconds.' Although an illuminated exit sign was installed near the door, the absence of the specific signage was noted. The Maintenance Director confirmed that the delayed egress mechanism had been installed three months prior, and documentation showed that checks of the doors with such mechanisms were conducted regularly, including on 11/28/24 and 12/2/24. However, the lack of appropriate signage was a deficiency affecting one of the three resident units.

Plan Of Correction

Plan of Correction: Approved December 29, 2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

1. Stairway exit door near resident rooms [ROOM NUMBERS] was equipped with proper signage. Push Unit Alarm Sounds. Door can be opened in 15 seconds.

2. All residents are at risk for deficient practice of not having proper signage for exit door with delayed egress signage explaining functionality of door.

3. All exit doors with delayed egress features will be audited to ensure proper signage by the Maintenance Director/Designee.

4. The Maintenance Tech/Maintenance Director was inserviced by the Administrator that monthly audits have to be completed per the audit tool called Monthly Emergency Exit Doors and Signs. The Maintenance Director/Tech will submit this audit monthly to the QAPI Committee. The QAPI Committee will determine additional process change needed based on findings.

Person Responsible: Administrator

Penalty

No penalty information released