Non-Functioning Internal Door Releases on Walk-In Refrigerator and Freezer
Summary
Surveyors observed that the facility failed to maintain proper means of egress as required by NFPA 101, Life Safety Code. During a tour, it was found that both the walk-in refrigerator and freezer, located towards the back of the walk-in refrigerator, were equipped with deadbolt locks and internal release knobs intended to allow individuals to open the doors from the inside. However, when the Director of Maintenance (DOM) attempted to operate the internal release mechanisms from inside both units, the mechanisms failed to function. The deficiency was identified through direct observation and interview with the DOM, who stated he was unaware that the internal release knobs were not working. This issue was present in one of four smoke compartments within the facility. The report specifically notes that the non-functioning internal door release mechanisms could result in staff becoming trapped inside the walk-in units. No information was provided in the report regarding any residents being directly involved or affected at the time of the deficiency. The findings were limited to the staff's ability to exit the walk-in refrigerator and freezer in the event of an emergency, as observed during the facility tour.
Plan Of Correction
1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. The facility immediately addressed the non-functioning internal door release mechanism in the walk-in refrigerator and freezer doors. The doors were repaired to function properly so that no potential entrapment could occur. 2. How the facility will identify other residents having the potential to be affected. Staff who utilize the walk-in refrigerator and freezers have the potential to be affected. No residents have the potential to be affected. No other negative findings were noted. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the dietary staffs were in-serviced by the Environmental Service Director regarding "Means of Egress requirements." The Dietary Supervisor will monitor the walk-in refrigerator and freezer doors to make sure the locking mechanism is properly functioning so as not to impede egress weekly. Any negative findings will be corrected immediately and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with members of the Safety Committee the weekly monitor in place for the walk-in refrigerator and freezer doors to make sure the locking mechanism is properly functioning so as not to impede egress. The findings will be reported to the QA/QAPI Committee at least quarterly for analysis, review, modification and/or correction. The utilization of portable fire extinguishers and their locations to hazardous areas. The Environmental Services Director and/or designee will verify monthly that the portable fire extinguishers within the building are in compliance and within the appropriate distance of hazardous areas. Any negative findings will be corrected immediately and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor at least quarterly the monthly monitoring conducted by the Environmental Services Director that the portable fire extinguishers within the building comply and are within the appropriate distance of hazardous areas. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction. K711. 1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. The Environmental Services Director immediately discussed with the two staff who were unaware of the protocols for addressing a grease fire and made them aware of the appropriate procedures to address such an occurrence.
Penalty
Surveyors found that two delayed egress exit doors lacked the required signage with a contrasting background, and one door in the Service Hallway automatically reset when tested, both in violation of NFPA 101 standards. These deficiencies were observed during a fire safety tour and acknowledged by facility leadership.
Surveyors observed that a courtyard exit egress door was secured with a combination padlock, which did not meet NFPA 101 requirements. The issue was confirmed by facility leadership and had been previously identified earlier in the year.
Surveyors found that two delayed egress exits were not properly maintained: one exit failed to operate when tested, and another required excessive force to open. These issues were confirmed by the Maintenance Director during the inspection and discussed with facility leadership.
A 15-second delayed egress door by a resident room was found without the required signage indicating the door could be opened after 15 seconds, as required by NFPA 101. This deficiency was confirmed by the Maintenance Director and could affect all occupants in the affected wing.
Surveyors found that a posted exit door from the solarium to the 600 wing was equipped with 15-second delayed egress hardware but lacked the required signage indicating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS," as specified by NFPA 101. The Maintenance Director confirmed the absence of this signage during the survey.
Surveyors found that an emergency egress door required more than one action to unlock due to a turn button lock, affecting 25 residents in one smoke compartment. The Maintenance Director confirmed the door had been in this condition for an extended period.
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.
Improper Locking of Courtyard Exit Egress Door
Penalty
Summary
The facility failed to maintain proper exit egress on one of the courtyard exit doors. During an observation on the first floor, surveyors found that the exit gate door leading to the outside courtyard was secured with a combination padlock. This locking arrangement did not comply with NFPA 101 requirements for egress doors, which prohibit locks that require a tool or key from the egress side unless specific special locking arrangements are met. The deficiency was confirmed during an exit interview with the Administrator, Regional, and Local Maintenance Director, who acknowledged that the combination padlock was discovered during the survey. It was also noted that this was the second time within the same calendar year that the issue had been identified by surveyors.
Plan Of Correction
The combo pad lock on the exit gate door was immediately removed. The facility will replace this with a magnetic locking system. Plans for the magnetic locking system will be forwarded to Life Safety Plan Review for approval. The maintenance director will provide education to all staff on proper egress requirements and emergency access. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly for 2 months on all egress doors to ensure ongoing compliance. Expected date of completion: 2/18/2026
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.
Missing Required Signage on Delayed Egress Door
Penalty
Summary
Surveyors observed that a door in a required means of egress, specifically the 15-second delayed egress door by room 301, did not have the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS" as mandated by NFPA 101, 7.2.1.6.1.1 (4). This observation was made during a facility inspection and was confirmed by the Maintenance Director at the time of discovery. The lack of appropriate signage on the delayed egress door constitutes a failure to comply with regulations regarding special locking arrangements for egress doors. The deficiency was identified on the 300 wing and could potentially affect all occupants in that area in the event of an emergency. No specific residents or patient medical histories were mentioned in the report.
Missing Required Signage on Delayed Egress Door
Penalty
Summary
A deficiency was identified when surveyors observed that the door from the solarium into the 600 wing, which serves as a posted exit, was equipped with 15-second delayed egress hardware. This door did not display the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS," as mandated by NFPA 101, 7.2.1.6.1.1 (4). The absence of this signage was confirmed during the survey by the Maintenance Director at the time of discovery. The report specifies that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless the special locking arrangements for clinical needs were met according to regulatory standards. This deficiency was noted to potentially affect all occupants in the solarium in the event of a fire or emergency, as the required egress signage and compliance with special locking arrangements were not in place.
Plan Of Correction
Element 1: 600 wing exit needed a PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS sign. Signs were placed on the door on 06/03/2025. Element 2: All residents in the solarium/staff/visitors have the potential to be impacted by this deficiency. Element 3: Sign was placed on the door on 06/03/2025 stating PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Emergency Egress Door Required Multiple Actions to Unlock
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed that an emergency egress door near Room 1 was equipped with a door knob featuring a turn button lock. When tested, the door required two separate actions to unlock from the egress side. This configuration does not comply with NFPA 101 Life Safety Code requirements, which mandate that egress doors must be readily openable from the egress side without the use of a tool, key, or more than one action. The Maintenance Director confirmed during the interview that the door had been in this condition for some time. This deficiency affected 25 out of 46 residents located in one of the facility's three smoke compartments. The report does not mention any specific medical history or conditions of the residents involved at the time of the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The egress door near Room 1 was immediately repaired to eliminate the need for more than one action to open. A single-action, code-compliant push bar has been installed. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: All door hardware was checked, and visual checks will be part of the preventive maintenance schedule to inspect egress hardware monthly. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The log will be part of the facility QA program, and any deficient practices identified will have a QAPI developed to monitor and/or correct the deficient practice. Date of Completion of Corrective Action: 05/19/25 How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The log will be part of the facility QA program, and any deficient practices identified will have a QAPI developed to monitor and/or correct the deficient practice. Date of Completion of Corrective Action: 05/19/25 K 222
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