Kitchen Illumination Deficiency
Penalty
Summary
The facility failed to ensure continuous illumination in the kitchen area, as manual switches were observed that could disable all lighting. This deficiency was noted during a Life Safety Code Survey on one of the four resident units. Specifically, on the first floor kitchen area wall, manual switches were found that, when tested, turned off all illumination in the kitchen area. This was confirmed through observation and an interview with the facilities director, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved January 22, 2025 K291 Plan of Correction for affected areas: The facility reconfigured the manual switches on the first-floor kitchen wall allowing for continuous illumination in the kitchen area when switches are turned off. Work completed 01/12/24. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Plant Operations inspected all kitchen areas throughout the facility for similar deficiencies. No deficiencies were identified. Work completed by 01/21/24. Plan of Correction for system measures to prevent reoccurrence: All maintenance staff will receive additional education, and all participants will understand the life safety issues relating to continuous illumination in the kitchen. The Director of Plant Operations has been assigned the responsibility for the education of staff. The facility will check for continuous illumination in the kitchen on a monthly basis. The Director of Plant Operations will utilize an audit tool to document and report kitchen continuous illumination lighting findings. Plan of Correction for monitoring corrective actions: The Director of Plant Operations or Designee will review monthly Kitchen continuous illumination audit for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of the kitchen continuous illumination lighting audits to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Plant Operations