Improper Labeling of Exit Signs
Summary
The facility failed to ensure proper labeling of exit signs in accordance with the National Fire Protection Association (NFPA) 101 standards. During the Life Safety Code recertification survey, it was observed that the double doors to the upper courtyard and the single door from the second-floor lounge area to the upper courtyard were not labeled as either an exit or a non-exit. This lack of labeling could lead to confusion, as these doors might be mistaken for exits. The Director of Facility Services acknowledged during an interview that the doors should have been labeled 'No Exit' to ensure the safe egress of residents and staff.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 (Exit Signage) The Facility Services Director has installed the proper signage to read (No Exit) on the following doors: The double doors to the upper courtyard, second-floor lounge, and 3 east middle hall door to the roof. The Facility Services Director or designee will conduct a Facility wide audit of all (No Exit) doors throughout the facility to ensure that there are no other non-exit doors that are out of compliance and if there are any other doors found to be deficient they will be corrected in a timely manner. The Facility Services Director or designee will conduct a Facility wide audit of all Non Exit doors throughout the facility on a quarterly basis to ensure that signage remains on the doors. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/25. The Facility Services will be responsible for this plan of correction.
Penalty
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