Failure to Document Monthly Exit Signage Inspections
Penalty
Summary
The facility failed to provide documentation verifying that monthly visual inspections of exit signage had occurred within the previous twelve months. This deficiency was identified during a document review and interview conducted on January 15, 2025. The review revealed that the facility had not documented any visual inspections of exit signs since August 28, 2024. This lack of documentation affects the entire component of the facility's exit signage system. An interview with the Facilities Director on the same day confirmed the absence of documentation for the required monthly visual inspections of exit signage. The failure to maintain records of these inspections indicates non-compliance with the NFPA 101 standards, which require exit and directional signs to be displayed with continuous illumination and to be part of the emergency lighting system. The deficiency impacts the facility's ability to ensure that exit signage is properly maintained and functional.
Plan Of Correction
1. The Maintenance Director will conduct a thorough inspection of all exit signs within the facility to ensure proper functionality and compliance with NFPA 101 Standard - Exit Signage. 2. The Maintenance Director and relevant staff members will be trained on the NFPA 101 Standard - Exit Signage requirements, focusing on the importance of conducting and documenting monthly visual inspections. 3. The Maintenance Director/designee will establish a log or binder specifically for exit signage inspections, where they will document the date and findings of each monthly inspection. The log will be stored in the Life Safety Book located in the NHA's office. The Maintenance Director/designee will perform monthly visual inspections of exit signs and update the log accordingly. The NHA/designee will review the log during monthly audits to verify documentation and compliance with the inspection requirements. 4. Findings will be reviewed at the Quality Assurance Performance Improvement meeting.