Failure to Conduct Monthly Exit Sign Inspections
Penalty
Summary
The facility failed to perform monthly exit sign inspections for the entire year of 2024, as required by NFPA 101 standards for exit signage. This deficiency was identified during a document review and interview conducted on January 7, 2025. The review revealed a lack of documentation for the monthly inspections of exit signs, which are crucial for ensuring safety and compliance with emergency lighting requirements. The absence of these records was confirmed in an interview with the Facility Administrator, Maintenance Director, and staff, indicating a systemic oversight in maintaining the necessary safety protocols for the facility.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Patriot Village OPCO LLC agrees with the allegations and citations listed on the statement of deficiencies. Patriot Village OPCO LLC maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Patriot Village OPCO LLC's written credible allegation of compliance. By submitting this plan of correction, Patriot Village OPCO LLC does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Patriot Village OPCO LLC reserves all rights to raise all possible contentions and defenses in any civil or criminal proceedings. The exit sign inspections were completed, but not documented appropriately. A new exit sign inspection form was developed and includes all exit signs throughout the facility. The Maintenance Director was educated on K 0293 and how it applies to Patriot Village. The Executive Director will review the exit sign inspections monthly for two months to ensure compliance. Results will be reviewed at the Quality Assurance Performance Improvement meeting.