Inoperative Exit Signage and Noncompliance with Emergency Lighting Requirements
Summary
The facility failed to ensure that exit and directional signs were displayed in accordance with regulatory requirements, specifically 7.10 and 19.2.10.1, which mandate continuous illumination and connection to the emergency lighting system. During observations on April 14, 2025, multiple ceiling-mounted exit signs were found to be inoperative: one on the 3rd floor Lakeland Hall by stairway "C," several in the 3rd floor corridor at the Jefferson Central Stairway door and the remainder of the 3rd floor, and one on the 2nd floor Jefferson Hall. These deficiencies were confirmed by the facility Maintenance Director at the time of observation. All 175 residents in the facility could be affected by the lack of properly functioning exit signage in the event of a fire, as the required continuous illumination and emergency lighting backup were not provided for these exit signs.
Plan Of Correction
K293 - Exit Sign 1. The Facility failed to ensure exit and directional signs are displayed in accordance with 7.10, continuously illuminated and served by the emergency lighting system as required by 19.2.10.1. a. Ceiling mounted exit sign 3rd floor Lakeland Hall by stairway "C" is now operative. b. Ceiling mounted exit signs 3rd floor in the corridor at Jefferson Central Stairway door and the remainder of the 3rd floor are now operative. c. Ceiling mounted exit sign 2nd Floor Jefferson Hall is now operative. 2. The maintenance director and staff will be educated on the importance of exit signs/emergency lighting to be continuously activated and working properly. 3. To ensure continued compliance is maintained with the exit sign lighting/emergency lighting, the Maintenance Director/Designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Penalty
Surveyors found that an exit sign above the door leading to grade from the stairtower near the Elevator Lobby was not illuminated as required. This lack of illumination was confirmed by facility leadership during the inspection.
A deficiency was identified when an exit sign near a resident room in one smoke compartment was found to be unilluminated, as confirmed by the Director of Maintenance.
Surveyors found that the facility did not have documentation to verify that monthly visual inspections of exit signs were completed over the past year. This was confirmed by the DON and Director of Maintenance during the survey.
Exit signs in the older section of the facility failed to illuminate when tested for battery back-up, indicating they were not transferring to emergency power as required. The maintenance director believed the signs were working, but testing and observation confirmed the deficiency, which could affect 50 occupants during a power outage.
An exit sign with a battery backup near the kitchen corridor failed to illuminate when tested, as observed during a facility tour and confirmed by the Environmental Supervisor. This deficiency affected 15 residents and one smoke compartment, indicating the exit sign was not maintained in accordance with NFPA 101 requirements.
Exit and directional signs were not properly displayed or configured, with the emergency exit sign outside the Saginaw Room Dining space set up incorrectly. This left the North side of the facility without an emergency exit from resident spaces, and the exit configuration did not match the emergency placards in the corridors. These issues were confirmed by the maintenance director during the survey.
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.
Failure to Maintain Illuminated Exit Signage
Penalty
Summary
The facility failed to maintain the required illumination of exit signage in accordance with NFPA 101 standards. During an observation, it was found that the exit sign located in Zone 11, near Resident Room 319, was not illuminated. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the exit sign was not functioning as required. The issue affected one of twelve smoke compartments within the component.
Plan Of Correction
The light bulb for the Exit Signage in Zone 11 by Resident room 319 has been replaced. Maintenance staff will be educated on ensuring all exit signage is illuminated moving forward. Maintenance Director/Designee to perform random quarterly audits on exit signage to ensure all exit signage is illuminated. Results of audits will be forwarded to the QAPI Committee.
Lack of Documentation for Monthly Exit Sign Inspections
Penalty
Summary
Surveyors determined that the facility failed to provide documentation verifying that monthly visual inspections of exit signs had been conducted over the past 12 months. During a document review, it was found that there was no record of these required inspections. This finding was confirmed in an interview with the DON and the Director of Maintenance, who acknowledged that the facility could not produce the necessary documentation for exit sign inspections. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
1. The facility is unable to retroactively perform this testing. 2. A monthly exit sign inspection was completed in July. 3. The Environmental Services Director was re-educated on the requirements of K0293. Monthly exit sign inspections are scheduled. 4. The NHA or designee will complete an audit of exit sign inspection documentation monthly x 6 months. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Exit Signs Not Illuminated on Emergency Power
Penalty
Summary
During an inspection, it was observed that exit signs in the older section of the facility did not remain illuminated when the battery back-up test button was pressed. This indicated that the exit signs were not transferring from regular power to emergency battery power as required. The maintenance director, when interviewed, believed that the signs were functioning properly, but the test demonstrated otherwise. These findings were confirmed through direct observation and interview with the maintenance director at the time of the inspection. The deficiency was noted to potentially affect 50 occupants in the event of a power loss, as the exit signs would not be illuminated during an outage. No specific residents or their medical conditions were mentioned in the report.
Exit Sign with Battery Backup Failed to Illuminate During Test
Penalty
Summary
During a facility tour and interview with the Environmental Supervisor, it was observed that an exit sign with a battery backup located in the corridor near the exit to the Back Walkway by the kitchen failed to illuminate when tested. The deficiency was identified on 6/10/25 at 8:46 a.m. when the exit sign did not function as required during a test. The Environmental Supervisor confirmed that the exit sign had been tested the week prior to the survey. This failure affected 15 of 35 residents and one of two smoke compartments. The report cites that exit and directional signs must be displayed and continuously illuminated in accordance with NFPA 101, Life Safety Code, 2012 Edition, and that battery-powered exit signs must be tested and maintained as specified. The facility did not maintain the exit sign in accordance with these requirements, as evidenced by the failed test and the lack of continuous illumination.
Plan Of Correction
1. Corrective Action: The battery powered exit sign located in the corridor near the exit to the Back Walkway near the kitchen is now illuminating when tested. A new battery was installed on 06/11/2025. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: Battery powered exit signs will be checked monthly by the Maintenance Supervisor. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of Correction: 06/11/2025
Deficient Exit Signage and Egress Configuration
Penalty
Summary
Exit and directional signs in the facility were not displayed in accordance with regulatory requirements, as observed during a survey. Specifically, the emergency exit sign outside the Saginaw Room Dining space had an incorrect emergency egress configuration, resulting in the North side of the facility lacking an emergency exit from resident spaces. Additionally, the exit configuration did not match the emergency placards displayed in the corridors. These findings were confirmed through an interview with the maintenance director at the time of observation. This deficiency could affect 35 occupants in the event of an emergency evacuation, as noted in the report.
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