Failure to Maintain Exit Signage Documentation
Penalty
Summary
The facility failed to maintain proper exit signage as required by NFPA 101 standards, specifically the 2012 Existing requirements for exit and directional signs. During a document review on January 27, 2025, it was found that the facility did not have documentation of monthly exit sign inspections, which is necessary to ensure compliance with safety regulations. This deficiency affects the entire facility and was confirmed during an exit interview with the Administrator and Maintenance Director. Notably, this is a repeat deficiency from the previous annual survey conducted on March 13, 2024, indicating a continued failure to address the issue.
Plan Of Correction
1. Exit sign inspections were conducted to ensure they are in proper working order. 2. A log was created to document exit sign inspections and ensure compliance. 3. Education provided to ensure proper compliance with this regulation. 4. An audit of five exit signs will be conducted to ensure they are in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.