Inadequate Exit Signage at Stairway Door
Penalty
Summary
The facility failed to provide appropriate signage at a stairway door, which was neither an exit nor a way of exit access, as required by NFPA 101: 2012 Edition, Section 19.2.10 and 7.10.8.3.1. During an observation, it was noted that the stairwell door by room 118 was marked with a sign indicating stairs and had an exit sign suspended from the corridor ceiling nearby. The exit sign, positioned approximately 8 inches to the left of the door's opening edge and 7 inches off the corridor wall, featured chevron arrows pointing in both directions. This arrangement made the door likely to be mistaken for an exit, necessitating a "NO Exit" sign on the door. The stairwell serves as an exit from the second floor to the first floor but is not an exit from the first floor, potentially affecting all first-floor residents.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: No Exit sign was placed on stairwell door by room 118 on 12/23/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All 1st floor residents had the potential to be affected. 3. Systemic changes to ensure that deficient practice does not recur: Maintenance has been in service on Exit signage. Maintenance/designee will conduct monthly walking audits of all exit doors outside for compliance and tracking. Findings of audits will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the audit on a Quarterly basis x 12 months to ensure compliance.