Failure to Maintain and Inspect Exit Signage
Penalty
Summary
The facility failed to maintain and inspect exit signage as required by NFPA 101 standards. During a document review on January 23, 2025, it was discovered that the facility lacked documentation of monthly exit sign inspections prior to April 2024. This deficiency affected nine out of twelve inspections. An exit interview with the Administrator and Maintenance Director confirmed the absence of the necessary documentation, indicating a failure to comply with the continuous illumination and emergency lighting system requirements for exit and directional signs.
Plan Of Correction
1. An inspection of all exit signage was completed on 1/27/2025 to ensure proper functioning. 2. NHA/Designee will in-service maintenance department on requirements for completing monthly exit sign inspection. 3. The Director of maintenance/designee will continue to complete monthly inspections of the exit signage to ensure proper functioning. 4. NHA or designee will do audits of the monthly inspection x 3 months. 5. Results of the inspection to be reported at QA.