Failure to Conduct Monthly Exit Sign Inspections
Penalty
Summary
The facility failed to perform monthly exit sign inspections for five out of the last twelve months, which affected the entire facility. This deficiency was identified during a document review conducted on February 10, 2025, at 8:55 a.m., which revealed the absence of documentation for the required monthly inspections. An interview with the Facility Administrator and Maintenance Director later that day confirmed the lack of documentation at the time of the survey.
Plan Of Correction
1. The Maintenance Director/Designee will conduct monthly exit sign inspections for all exit signs for 12 out of 12 months. 2. The Nursing Home Administrator/designee will educate the maintenance staff on monthly inspection of all exit signs in the facility. 3. The maintenance staff/designee will audit weekly for two months and then monthly for two months to ensure monthly inspections of all exit signs in the facility are being completed. 4. Any concerns will be brought to the Quality Assurance Performance Improvement Committee for review.