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NY State Tag
E

Improper Exit Signage and Egress Path Indication

Williamsville, New York Survey Completed on 01-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a Life Safety Code survey, it was observed that required exit signs did not correctly indicate the egress path on two of the four resident use floors, specifically the basement and first floor. On the first floor, an illuminated exit sign in the Main Kitchen was mounted perpendicular to the exit stairway, with both left and right chevrons lit, misleadingly indicating egress through the service elevator or mop closet. A paper sign on the exit stairway door incorrectly stated 'This is no longer an exit,' contradicting the fire evacuation diagram that showed the exit stairway as the primary egress route. Additionally, in the dish wash area of the Main Kitchen, an exit sign incorrectly indicated egress through the dish machine alcove and service elevator lobby, conflicting with the fire evacuation diagram. Further observations on the first floor revealed an exit sign in the service elevator lobby without chevrons, suggesting an incorrect path through a solid wall. In the lobby outside the Atrium, an exit sign incorrectly lit only the chevron pointing into the Atrium, despite both the Atrium and main entrance being valid egress routes. In the basement, an exit sign above double doors in the Boiler Room had chevrons coated with white paint, obscuring the correct egress path. These discrepancies in exit signage were acknowledged by the Director of Facilities Maintenance/Corporate, who noted the need for corrections to align with the appropriate egress routes.

Plan Of Correction

Plan of Correction: Approved February 21, 2025 Corrective action for the deficient exit signs in the kitchen stairway door, the kitchen dish wash area, basement service area, lobby outside of the atrium, and the double doors in the boiler room have been adjusted and are functioning properly. A full building audit will be conducted to verify the accuracy of all facility exit signs; this will be monitored through the TELS system. Education for the maintenance staff will be provided on exit signs operation. Ongoing compliance will be monitored by the Director of Maintenance and reported to the QA committee on a monthly basis. The Administrator will provide education; we will review our tasks in our computerized maintenance system. Exit signs will be checked monthly for 3 months in QA. Responsible designee - Maintenance Director. Policy and Procedure will be reviewed as part of the P(NAME).

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