Evacuation Diagram Deficiency
Penalty
Summary
The facility failed to maintain proper means of egress requirements in its building component. During an observation on January 29, 2025, it was noted that the evacuation diagrams did not include a notation indicating the location of the viewer on the diagram. This deficiency was confirmed in an interview with the maintenance supervisor, who acknowledged that the diagrams lacked 'YOU ARE HERE' locations and exit paths, as required by NFPA 170-11.2.4 through 11.4.1.
Plan Of Correction
Egress evacuation diagrams have been updated to show two forms of evacuation. Education completed with the maintenance supervisor to have routes of evacuation clearly marked on the evacuation diagrams. Diagrams will be monitored monthly. Results will be reviewed at the QAPI meeting.