Failure to Conduct Monthly Exit Sign Inspections
Penalty
Summary
The facility failed to perform monthly exit sign inspections for three out of the last twelve months, specifically in October, November, and December 2024. This deficiency was identified during a document review conducted on March 17, 2025, at 8:50 a.m., which revealed the absence of documentation for these inspections. An interview with the Facility Administrator and Maintenance Director later that day confirmed the lack of documentation at the time of the survey. This oversight affected the entire facility, as exit and directional signs are required to be continuously illuminated and served by the emergency lighting system in accordance with NFPA 101 standards.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0293 Exit Signage. The facility is unable to correct the lack of previous month's documentation. The Maintenance Director is currently performing monthly exit sign inspections per regulation. The NHA/designee will randomly audit the Maintenance Director exit signage inspection log monthly.