Deficient Illumination of Emergency Exit
Penalty
Summary
The facility failed to ensure proper illumination of the means of egress in accordance with NFPA 101 standards. During a Life Safety recertification survey, it was observed that a wall-mounted light switch could turn off the exterior lighting above an emergency exit door in the Stairwell on South West 1. Additionally, there was no light installed directly above the emergency discharge exit from the resident unit on South West 1. Instead, illumination was provided by a light fixture installed on the building directly opposite the exit. These deficiencies were noted in 1 of 3 emergency exits from the Nursing Home building.
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 a dual lamp light fixture over the exterior of the exit door from the resident unit on South West 1 in accordance with the requirements of NFPA 101, 2012 Edition, Section 19.2.8 and 7.8. The maintenance permanently removed the wall light switch for the egress lighting to South West 1 Stairwell. The required egress lights will not be switchable. 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 deficiencies. 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 lighting in the means of egress and egress lighting must be continuously on or automatic without manual intervention in accordance with the requirements of NFPA 101, 2012 Edition, Section 19.2.8 and 7.8. 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 egress lighting 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.