Inadequate Illumination of Egress Pathways
Summary
The facility failed to maintain continuous illumination of egress pathways, as required by the Life Safety Code. On the first floor, the corridor lighting in the Administrative wing was controlled by two light switches, and when these were turned off, no lighting remained on between the reception desk and the west end, which forked into two corridors. This area, approximately 96 feet in each branch, served as egress routes between the west stairway and the main entrance, as indicated by illuminated exit signs. This lack of continuous illumination could impede safe evacuation in the event of an emergency. Additionally, the exterior of the facility lacked adequate lighting above certain exit doors. Specifically, there was no light fixture above the C Stairway exit door, with the closest light being approximately six feet away, and no light fixture above the Physical Therapy exit door, with the closest light being a pole light approximately 25 feet away. During a second observation before sunrise, it was noted that the closest lights to these exits were not lit at certain times, although inside lighting was visible through the glass doors and walls. The Director of Facilities Maintenance indicated that new pole lights had been added and electricians were testing the exterior lighting, which may have caused the observed inconsistencies.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 Corrective action for the deficient areas of lighting was performed by outside vendor. Contractor installed wall pack lights with 2 bulbs above affected doors. The first-floor administrative corridor will have seven corridor lights which will be wired to be on at all times. The exterior lighting issues at both the C stairway exit and the physical therapy exit have been corrected. Education will be provided to the Director of Maintenance to maintain compliance with proper lighting throughout the facility, as required by this regulation. A weekly audit will be completed to check for illumination throughout the inside and exterior of the facility. Any deficient lighting systems will be entered into the TELS system and corrected at that time. The results of the audit will be reported to the QA committee on a monthly basis. This will be monitored monthly in QA for 3 months. Administrator will provide education to the Maintenance Director and maintenance team. Responsible Designee: Maintenance Director
Penalty
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