Deficiency in Egress Illumination
Summary
During a Life Safety Code recertification survey, it was observed that the facility failed to ensure proper illumination of the means of egress in accordance with NFPA 101 standards. Specifically, on the basement level, the emergency exit discharge located by the Dry Storage Room and the exit leading to the loading dock were both found to be without light fixtures above the doors. Additionally, there were no light fixtures along the path leading to a public way, compromising the continuity of the egress path. These observations were made between 9:30 AM and 2:00 PM, and the findings were acknowledged by the Chief Executive Officer and the Director of Maintenance present during the survey.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 K281 Illumination of Means of Egress 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice Light fixtures were installed above the emergency exit discharge. Light fixtures were installed above the emergency exit discharge located by the Dry Storage Room on the basement level. Light fixtures were installed above the emergency exit discharge leading to the loading dock on the basement level. Additional light fixtures were installed along the path leading to a public way to ensure continuity in the path of egress. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The following corrective actions will be implemented to identify other residents who may be affected by the same practice: all areas of egress were assessed to ensure proper illumination is in place. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Hospital Police will add inspection of proper illumination of the means of egress to daily building rounds. Hospital Police has been educated on this new responsibility, on confirming illumination of egress. Regular maintenance checks will be conducted to ensure that all light fixtures are functioning properly and that the means of egress remain illuminated in accordance with NFPA 101. All maintenance staff were in-serviced regarding illumination of means of egress. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice All egress areas will be monitored for proper illumination and functionality of the light fixtures monthly for a period of 3 months or until compliance is achieved. The results from the monitoring will be reported to the QAPI Committee. 5. Responsible Individual: Director of Maintenance
Penalty
The facility did not maintain continuous illumination in the Rehab corridor, as required by NFPA 101 standards. During a survey, it was found that turning off the wall-mounted light switches extinguished all lights in the corridor leading to an emergency stairwell exit. The Director of Maintenance confirmed the issue, noting that the lights would be continuous.
The facility did not provide proper illumination for egress pathways, as required by NFPA 101. Observations revealed that exit doors from the French Quarter wing, the main entrance, and the Spanish Villa wing lacked necessary lighting for safe egress during darkness. These findings were confirmed by the Maintenance Director and acknowledged by the Administrator.
A Life Safety Code Survey found that the facility did not ensure proper illumination of egress pathways for four of seven exits. Observations revealed a lack of exterior lighting on several sections of the pathways. The Environmental Services Director was unaware of the deficiency but acknowledged the need for additional lighting.
The facility did not maintain continuous illumination in the means of egress as required by NFPA 101. During a survey, it was found that turning off the wall-mounted light switches in the fifth-floor dining room also turned off all lights, including those needed for an emergency stairwell exit. This issue was identified on one of the three resident floors, and the Director of Maintenance confirmed the lights would be continuous.
The facility did not maintain continuous illumination of the means of egress in one of five stair towers. Light fixtures failed to illuminate the exit by Component 1, as observed and confirmed by the Director of Maintenance.
The facility failed to maintain proper illumination in the exit stairways, affecting one of three floors. An observation revealed that the lights in the first floor South main stair tower were not illuminating. This was confirmed during an exit interview with the Administrator and the Maintenance Director.
Failure to Ensure Continuous Illumination in Egress Pathway
Penalty
Summary
The facility failed to ensure continuous illumination in the means of egress as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the wall-mounted light switches in the Rehab corridor, when turned off, extinguished all the lights in the corridor leading to an emergency stairwell exit. This issue was identified on one of the two resident floors. The Director of Maintenance acknowledged the finding during an interview, stating that the corridor lights would be continuous.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K281 I. Immediate Corrective Action: 1. Rehab Corridor Lighting: - The Maintenance director immediately contacted an electrician to address the lighting issue in the Rehab corridor, powering every other light for clear illumination of egress. - The wall-mounted light switches that were controlling the lights leading to the emergency stairwell exit have been re-wired to ensure that the illumination in the means of egress is continuous, even when the light switches are turned off. II. Identification of Others: - All residents have the potential to be affected. However, none were. - All other egress routes were found to be compliant. - The Director of Maintenance conducted a review of all light switches and emergency exit routes on both residents’ floors to ensure compliance with NFPA 101, identifying and addressing any similar concerns. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's Life Safety procedures, ensuring maintenance staff are trained in NFPA 101 requirements for the illumination of means of egress. The training included instructions on how to ensure continuous illumination for safe exits. - Maintenance staff were re-educated on the importance of maintaining proper lighting on all exit routes, with an emphasis on the emergency stairwell. 2. Regular checks on all emergency lighting systems during routine inspection were added to the routine maintenance checklist ensuring all corridors and exits are properly illuminated and compliant with NFPA 101. IV. Quality Assurance: 1. A tracking tool was developed by the Director of Maintenance to ensure ongoing compliance with lighting and means of egress standards. 2. Monthly audits of all exit routes will begin to ensure that lighting remains compliant with NFPA 101, and any identified issues will be corrected promptly. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: - Director of Maintenance
Failure to Illuminate Egress Pathways
Penalty
Summary
The facility failed to provide proper illumination for means of egress walkways and exit passageways leading to the public way, as required by NFPA 101. During a tour conducted with the Director of Maintenance, it was observed that several exit areas lacked the necessary egress lighting. Specifically, the exit doors from the French Quarter wing to the courtyard and smoking patio, the exit doors to the left of the main entrance and administrative hallway, and the exit doors at the end of the Spanish Villa wing did not have adequate lighting to ensure safe egress during hours of darkness. These deficiencies were confirmed by the Maintenance Director during an interview and acknowledged by both the Administrator and the Director of Maintenance at the exit conference.
Inadequate Illumination of Egress Pathways
Penalty
Summary
During a Life Safety Code Survey conducted from February 24 to February 28, 2025, it was observed that the facility failed to ensure proper illumination of the means of egress for four of seven exits. Specifically, the outdoor exit discharge pathways lacked sufficient lighting to the public way. Observations made on February 24, 2025, between 1:11 PM and 1:24 PM revealed that there was no exterior lighting present to illuminate several sections of the exterior egress pathways. These included a 100-foot-long section between the exits from the A1 and D2 corridors, a 50-foot-long section between the exits from the D2 corridor and physical therapy, a 100-foot-long section between the exits from the D1 and C2 corridors, and a 50-foot-long section between the exits from the C2 corridor and the main entrance. During an interview conducted on the same day at 1:24 PM, the Environmental Services Director stated they were unaware of the lack of lighting between exits or the need for additional lighting. The director acknowledged the presence of lighting at the exits but indicated that additional lighting could be added for the pathways.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K281 Corrective Action - To ensure the facility meets the requirements of illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall either be continuously in operation or capable of automatic operation without manual intervention. 1) The facility will install lighting: in the 100 foot long section of exterior egress pathway between the exits from A1 and D2 corridors; the 50 foot long section of exterior egress pathway between the exits from D2 and D2 physical therapy; the 100 foot long section of exterior egress pathway between the exits from D1 and C2 corridors; and the 50 foot long section of exterior egress pathway between the exits from the C2 corridors and the main entrance so that the egress paths are illuminated in compliance with the Life Safety Code. 2) The Director of maintenance will conduct a complete inspection of all means of egress to identify any additional areas that may require increased lighting in compliance with the Life Safety Code. Annual inspection of egress path lighting will be added to the facility’s electronic work order system. 3) The Administrator will oversee in-services to all maintenance department staff in regard to the life safety requirements for means of egress lighting. 4) All means of egress will be audited monthly for 3 months and as needed based on the audits findings. Audits will verify all egress lighting meets the requirement of the Life Safety Code. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K281.
Failure to Ensure Continuous Illumination in Egress Pathway
Penalty
Summary
The facility failed to ensure continuous illumination in the means of egress as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the wall-mounted light switches in the fifth-floor dining room, when turned off, extinguished all lights in the room. This room contained an emergency stairwell exit, which should have been continuously illuminated. This deficiency was noted on one of the three resident floors. During an interview, the Director of Maintenance acknowledged the issue and stated that the lights in the rooms would be continuous.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 K281 – NFPA 101 Illumination of Means of Egress I. Immediate Corrections: The manual operated wall mounted light switches in fifth floor dining room were removed, allowing all lights in the room to be on continuously. Work completed (MONTH) 4, 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 Plant Operations inspected all areas throughout the facility for the same deficiencies. No additional instances of non-compliant were found. Work completed (MONTH) 6, 2025. III. Systemic Changes The Policy relating to Illumination of Means of Egress was reviewed and it was determined that no changes were needed to the policy. All maintenance staff will be provided with in-service education by the Director of Plant Operations on the policy relating to Illumination of Means of Egress with a focus on the importance of ensuring that Illumination of the Means of Egress were installed and maintained in accordance with 7.8. Work completed: (MONTH) 6, 2025. IV. QA Monitoring The Director of Plant Operations will develop an audit tool to verify that Means of Egress were installed and maintained in accordance with 7.8. 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
Failure to Maintain Continuous Egress Illumination
Penalty
Summary
The facility failed to maintain continuous illumination of the means of egress for one of five stair towers. During an observation on February 12, 2025, at 2:30 PM, it was noted that the light fixtures did not illuminate the exit by Component 1. This was confirmed in an interview with the Director of Maintenance at the same time.
Plan Of Correction
1. Stairwell exit light was repaired. 2. Facility audited stairwell lighting to ensure proper illumination. 3. Maintenance director/ designee will conduct monthly audits of stairwell lighting to ensure proper illumination. Audits will be reviewed at QAPI to ensure compliance.
Failure to Maintain Illumination in Exit Stairways
Penalty
Summary
The facility failed to maintain proper illumination of the exit stairways, specifically affecting one of the three floors. During an observation on January 30, 2025, at 9:20 a.m., it was noted that the lights in the first floor South main stair tower were not illuminating as required. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director later that morning at 11:30 a.m., where it was acknowledged that the exit stair tower lights did not illuminate.
Plan Of Correction
Step 1 Lights on the first-floor South main stair tower repaired. Step 2 The maintenance team completed a facility-wide audit of all stairways to ensure that all exit stairways had adequate illumination. Step 3 The maintenance team was educated on the requirement to maintain the illumination of the exit stairways. Step 4 The maintenance director or designee will audit monthly x4 to ensure that the illumination of the exit stairways is properly maintained. Findings will be reviewed in QAPI.
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