Improper Exit Signage in Facility
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101: Life Safety Code during a recertification survey. Specifically, the surveyors observed that exit signs did not properly indicate the direction of egress in two of the seven resident units and in the basement. In the (NAME) unit, an exit sign near the Oxygen storage and soiled utility room had directional arrows pointing towards a wall instead of an egress route. In the Kipp unit, two non-delayed egress emergency exit doors were incorrectly marked with delayed egress signage, and an emergency door between two sets of entrance doors lacked a directional sign pointing to the emergency exit. Additionally, in the basement, one of the required means of egress from the Dental/exam room lacked exit signage to indicate the path of egress. The Engineering Manager acknowledged the findings, noting that the dental exam room is used for residents' dental services once a week, and residents are always accompanied when visiting the room. The Senior Director of Operations, present during the observations in the (NAME) and Kipp units, confirmed that there are no delayed egress doors in the facility and committed to removing the incorrect signage and fixing the other exit signs. These deficiencies indicate a failure to ensure that exit signs were displayed in accordance with the NFPA 101: Life Safety Code, potentially impacting the safety and evacuation procedures within the facility.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 Plan of Correction for affected areas: On (MONTH) 9, 2024 the maintenance staff permanently repositioned the Emergency exit light on the (NAME) unit by the Oxygen storage and soiled utility room, so the directional arrows pointed to the egress route. On (MONTH) 9, 2024 the maintenance staff permanently removed the delayed egress signs on the identified exit doors on the Kipp unit corridor along the Adult Day Care Center. The maintenance staff will permanently install Emergency Exit signage with directional arrows in the Kipp unit at the emergency door located between the two set of entrance doors to the unit showing the egress route. The maintenance staff will permanently install Emergency Exit signage with directional arrows to indicate the path of egress for the second required means of egress from the Dental/exam room in the basement. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiency. No other deficiencies were found. Plan of Correction for system measures to prevent reoccurrence: All maintenance staff will receive additional education, and all participants will understand the life safety issues with Exit signage in accordance with the requirements of NFPA 101, 2012 Edition section 7.10.1.5.1. The In-Service Coordinator/designee has been assigned the responsibility for the education of staff. This education will also be provided to all new Maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all areas for Exit signs and directional arrows showing egress routes monthly and utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions: The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Operations Compliance Date: January 27, 2025