Deficiency in Exit Signage Maintenance
Penalty
Summary
The facility failed to maintain proper exit and directional signage throughout the building, as required by NFPA 101 standards. During a survey conducted on January 22, 2025, it was observed that the MIU unit courtyard doors had blinds covering the 'NOT AN EXIT' signs, obstructing visibility. Additionally, the facility was unable to provide documentation for monthly exit sign inspections for the previous 12 months. These deficiencies were confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
A. MIU Courtyard Door: Maintenance immediately removed all blinds that were covering courtyard "NOT AN EXIT" sign. Maintenance completed exit sign inspection and documented findings. No additional negative findings. NHA/Designee to educate maintenance staff by 21MAR2025 on exit signage visibility. Maintenance/designee will complete weekly x 4 audits of exit signage to ensure proper display. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Facility couldn't provide documentation for monthly 12 month exit sign inspection: Maintenance performed immediate exit sign inspection and documented findings. Maintenance will keep proper documentation for monthly exit sign inspection. NHA/Designee will educate Maintenance staff by 21MAR2025 on exit sign inspection and documentation. NHA/Designee will complete exit sign inspection documentation audits monthly x 3 audits to ensure proper inspection and documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.