Egress Illumination Deficiency Due to Manual Switches
Penalty
Summary
The facility failed to ensure that the illumination of means of egress was protected from manual operation, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that the egress passageway on the 1st floor, leading from stair C, was equipped with switches that could turn off all lights in the area. This deficiency was identified through observation and staff interviews, specifically with the Director of Maintenance, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1: Corrective Action: The light switches from stair C that shut off all lights in the 1st floor egress passageway were disconnected. The light source was reconnected to ensure that egress lighting is permanently powered and cannot be manually deactivated during building occupancy. Element 2: All residents have the potential to be affected by this practice. No residents were found to be harmed by this practice. All means of egress were inspected for similar deficiencies. None were found. Element 3: The policy for means of egress will be revised to reflect this new revision. Maintenance staff will be educated on this new revision. Element 4: Monitoring: The maintenance director will monitor all the stairwells monthly to ensure the handrails and landings are marked per NFPA 101 Illumination means of egress. The audit results will be reported to the administrator, and any areas of non-compliance will be immediately corrected. The maintenance director will report for one quarter the results of the audit to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5: Person responsible: Maintenance Director.