Lack of Directional Signage in Emergency Exits
Penalty
Summary
During a Life Safety recertification survey, it was observed that the facility failed to ensure proper directional signage in accordance with NFPA 101 standards. Specifically, the enclosed courtyard, which serves as an emergency discharge route from the Weinberg and Nursing home buildings, lacked directional signage leading to a public way. This deficiency was identified during a tour of the courtyard, where it was noted that 2 out of 3 buildings did not have the required signage. The Director of Plant Operations acknowledged the absence of the signs during an interview conducted at the time of the survey.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance staff will permanently install Exit Signage from the exit doors through the enclosed exterior courtyard ensuring clear identification and direction for egress in case of fire or emergency. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). 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. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. 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 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 monthly and utilize an audit tool to document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) 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 QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted.