Missing Evacuation Map in Corridor
Penalty
Summary
The facility failed to provide the required evacuation map in the Maple Ridge corridor, as observed during a survey. The evacuation map is necessary to identify locations within the facility and to highlight designated evacuation routes to the exterior of the building. This deficiency was confirmed through observation and interview with the Maintenance Director. The lack of an evacuation map could affect 26 of 64 residents in the event of a fire or other emergency requiring area evacuation. Employees were not periodically instructed in their duties under the evacuation plan as required by regulatory standards, and the written plan for the protection and evacuation of all residents was not fully implemented in this area.
Plan Of Correction
ELEMENT 1 On 6/27/25 an evacuation map was placed on Autum Ridge to identify the current location within the facility and highlight designated evacuation routes to the exterior of the facility. ELEMENT 2 Rounds were conducted by the Maintenance Director and/or designee on all fire corridors to ensure there are evacuation maps present. ELEMENT 3 The Maintenance Director has been reeducated on maintaining evacuation maps throughout the building in all fire corridors. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 1 month to ensure all fire corridors have the required evacuation maps. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.