Failure to Maintain Exit Signage Documentation
Penalty
Summary
The facility failed to maintain proper exit signage as required by NFPA 101 standards, affecting the entire facility. During a document review on December 23, 2024, it was discovered that the facility lacked documentation of monthly exit sign testing after March 2024. This deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director, who acknowledged the absence of the necessary documentation.
Plan Of Correction
The monthly Exit signage inspection have been completed. NPE/designee will re-educate maintenance staff on maintaining the monthly inspection documentation. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.