Incorrect Exit Signage in Egress Path
Penalty
Summary
The facility failed to ensure that the means of egress was clearly marked to indicate the direction of travel to the nearest exit. Specifically, the exit sign with directional arrows between the elevator and the recreation room on the B wing indicated a path of travel through a separate occupied space, the daycare. This issue was observed on one of the four resident floors during a survey conducted on February 25, 2025, at 1:55 PM. The Director of Maintenance acknowledged the incorrect signage during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 K293 – Exit Signage I. Immediate Corrections The facility removed the directional arrow on the exit sign installed between the elevator and recreation room on the B wing indicating the path of travel through the Daycare Center. Work completed (MONTH) 12, 2025 II. 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 the same deficiency. None were identified. Work completed: (MONTH) 14, 2025 III. Systematic Changes The facility maintenance and repairs were reviewed; it was determined that no changes were needed to the policy. The Director of Plant Operations will provide in-service education to all maintenance staff. All participants will understand the safety issues with NFPA Life Safety Code 2012 7.10.2, with a focus on exit signs, maintenance, and inspections. Work completed: (MONTH) 14, 2025 IV. QA Monitoring The Director of Plant Operations or Designee will develop an audit tool to verify that exit and directional signs are displayed in accordance with NFPA Life Safety Code 2012 7.10.2. 1. Audits will be completed by the Director of Plant Operations monthly x 3 months, then complete quarterly thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to QA Committee monthly x 3 months then quarterly thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee