Failure to Maintain Continuous Illumination of Exit Sign
Penalty
Summary
Surveyors observed that the facility failed to maintain continuous illumination of an exit sign as required by NFPA 101 standards. Specifically, during an inspection, the exit sign located above the door leading to grade from the stairtower near the Elevator Lobby on one of the four floors was found to be unlit. This deficiency was confirmed during an interview with the Administrator, Regional Director, Regional Maintenance Director, and the Environmental Services Director, who acknowledged that the exit sign was not illuminated at the time of the survey. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The facility failed to maintain exit signs to be continuously illuminated, on one of four floors. No residents were identified. All residents have the potential to be affected. The exit sign, above the door leading to grade from the stair tower near the Elevator Lobby, was repaired to ensure it is continuously illuminated as required. Facility-wide audit was completed by the Maintenance Director to ensure that there are no other open areas in walls. The Maintenance Director was educated on the requirement by the Administrator. The Maintenance Director/Designee will conduct compliance audits to ensure that exit signs meet the requirement. The audits will be weekly for four weeks, then monthly ongoing thereafter. The administrator will conduct quarterly random audits thereafter to spot check. The results of the audits will be discussed monthly and quarterly by the Quality Assurance and Performance Improvement Committee for the duration of the audit process (3 months). Based on the results of these audits, a decision will be made regarding the need for continued submissions and reporting.