Failure to Maintain Illuminated Emergency Exit Signage
Penalty
Summary
The facility failed to maintain emergency exit signage as required by NFPA 101, specifically section 19.2.10.1, which mandates that exit and directional signs be continuously illuminated and served by the emergency lighting system. During a facility tour and staff interviews, surveyors observed that the battery-backup emergency exit signs above the southeast fire doors and the northwest wall of the corridor by Nurse Station A did not remain illuminated when tested. Staff present at the time confirmed the findings and indicated they were not aware of the non-functioning exit signs. This deficiency affected 27 of 92 residents and one of six smoke compartments within the facility. The lack of illuminated exit signage was directly observed during the survey, and no information was provided regarding the medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
Corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly fire barrier inspections, with results reviewed in QAPI meetings. Any deficiencies identified will be corrected immediately and documented. Date of Compliance 4/18/25 Tag K 293: Exit Signage How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility replaced the batteries in the emergency exit signs above the southeast fire doors and the northwest wall of the corridor by Nurse Station A on 4/21/25. The signs are now fully operational and compliant with NFPA 101 requirements. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A facility-wide audit was conducted to check all emergency exit signs. No additional faulty signs were identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur.