Inoperative Exit Signage and Noncompliance with Emergency Lighting Requirements
Penalty
Summary
The facility failed to ensure that exit and directional signs were displayed in accordance with regulatory requirements, specifically 7.10 and 19.2.10.1, which mandate continuous illumination and connection to the emergency lighting system. During observations on April 14, 2025, multiple ceiling-mounted exit signs were found to be inoperative: one on the 3rd floor Lakeland Hall by stairway "C," several in the 3rd floor corridor at the Jefferson Central Stairway door and the remainder of the 3rd floor, and one on the 2nd floor Jefferson Hall. These deficiencies were confirmed by the facility Maintenance Director at the time of observation. All 175 residents in the facility could be affected by the lack of properly functioning exit signage in the event of a fire, as the required continuous illumination and emergency lighting backup were not provided for these exit signs.
Plan Of Correction
K293 - Exit Sign 1. The Facility failed to ensure exit and directional signs are displayed in accordance with 7.10, continuously illuminated and served by the emergency lighting system as required by 19.2.10.1. a. Ceiling mounted exit sign 3rd floor Lakeland Hall by stairway "C" is now operative. b. Ceiling mounted exit signs 3rd floor in the corridor at Jefferson Central Stairway door and the remainder of the 3rd floor are now operative. c. Ceiling mounted exit sign 2nd Floor Jefferson Hall is now operative. 2. The maintenance director and staff will be educated on the importance of exit signs/emergency lighting to be continuously activated and working properly. 3. To ensure continued compliance is maintained with the exit sign lighting/emergency lighting, the Maintenance Director/Designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.