Deficiency in Egress Lighting Maintenance
Summary
The facility failed to ensure that lighting in all means of egress was continuously maintained, as required by safety regulations. During a life safety survey conducted over two days, it was observed that a manual switch on the wall in the basement storage room (B23) could disable all lights, leaving the area in total darkness. Additionally, a ramp area leading to the public way on the exterior of the facility, measuring approximately 20-30 feet, was found to lack egress lighting. These deficiencies were confirmed during an interview with the Maintenance Director, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action Maintenance removed the light switch and replaced it with a metal plate for the basement in order to prevent the light from being turned off. Lights were added to the ramp area to ensure continuous illumination. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. An audit of facility lighting in all means of egress was conducted. No outstanding issues were found. III. Systemic Changes The Maintenance department was in-serviced and educated about Illumination of Means of Egress. Continuous illumination was added to the monthly environmental rounds. IV. QA Monitoring The facility will conduct a review of all lighting by means of egress on a quarterly basis. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for review. On a quarterly basis, the Director of Maintenance or designee will report findings to the QAPI Committee to determine if further action is required. Responsible Party: Director of Maintenance
Penalty
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