Exit Signage Deficiency
Penalty
Summary
The facility failed to maintain proper exit signage as required by NFPA 101, Section 7.10, which mandates continuous illumination of exit and directional signs, also served by the emergency lighting system. During an observation conducted on December 18, 2024, between 9:41 a.m. and 12:15 p.m., three deficiencies were noted. A missing directional exit sign was observed in the basement corridor outside the unit clerk room, another was missing in the basement laundry near the sort room, and a third was missing on the second floor near nurse station 2-BD. These missing signs disrupted the continuity of exit signage, which is essential for safe evacuation. The maintenance director confirmed the absence of these signs during an interview conducted at 12:15 p.m. on the same day.
Plan Of Correction
1. Maintenance Director or designee immediately repaired or replaced three exit signs. 2. Education will be provided to the maintenance department by Administrator or designee on the importance of maintaining exit signs with directionals. 3. Maintenance Director or designee will audit weekly x 4 weeks and monthly x 1 month. 4. Results will be discussed with QA committee with monitoring if applicable.