Deficiency in Egress Lighting
Summary
The facility failed to maintain proper illumination of means of egress, as observed during a Life Safety Code survey. Specifically, the survey revealed that continuous egress lighting capable of automatic operation without manual intervention was not provided on the exterior of the building at exit doors. This deficiency affected Unit 6 and the Therapy room located between Unit 5 and Unit 6. Observations on the exterior of the First Floor on Unit 6 showed that there were no light fixtures installed above exit doors (13) and (10), with existing light fixtures positioned too far away and only partially illuminating the doors. Similarly, the Therapy Room's exit door (6) also lacked an exterior light fixture. Interviews with the Maintenance Director confirmed the absence of exterior light fixtures above the mentioned exit doors. The facility's Monthly Outdoor Light Check sheets indicated that the last check of outdoor lights was conducted on 11/22/24, suggesting a lapse in regular maintenance checks. The lack of proper egress lighting is a violation of the 2012 NFPA 101 standards and New York Codes, Rules, and Regulations (NYCRR), which require adequate illumination for safe evacuation routes.
Plan Of Correction
Plan of Correction: Approved January 1, 2025 1. Exterior of the First Floor on Unit 6 had light fixture installed with two light fixtures above exit door by Maintenance Director on 1/17/2025. Exterior of the First Floor on the Unit 6 had two light fixture installed above exit door located by Resident lounge by Maintenance Dir on 1/17/2025. Exterior of the First Floor between Unit 5 and Unit 6 had two light fixture installed by Maintenance Director on 1/17/2025. 2. All residents are at risk for deficient practice of not having proper illumination above means of egress. 3. Administrator reviewed policy and procedure for life safety illumination of egress doors and no change to the policy was institute. 4. Administrator educated Maintenance Director/Maintenance Tech on illumination above egress doors. 5. All egress doors were audited by Maintenance for proper illumination. Any deficient practices were corrected immediately and brought to QAPI for further review. Weekly audits will occur for 8 weeks then monthly for 6 months. Person Responsible: Maintenance Director
Penalty
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