Emergency Back-Up Lighting Deficiency
Penalty
Summary
The facility failed to maintain battery back-up lighting in operable condition, affecting one of three floors. During an observation on January 30, 2025, from 10:50 a.m. to 10:55 a.m., deficiencies were noted in the emergency back-up lighting system on the second floor South. Specifically, at 10:50 a.m., the emergency back-up lights next to resident room 230 failed to illuminate when tested. Additionally, at 10:55 a.m., the emergency back-up lights next to resident room 238 failed to turn off after being tested. These deficiencies were confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m.
Plan Of Correction
Step 1 Back-up lighting on the second floor South next to resident room 230 was repaired. Back-up lighting on the second floor South next to resident room 238 was repaired. Step 2 A facility-wide audit of all emergency battery backup lights was completed to ensure that they operate as required. Step 3 The maintenance team was educated on the requirement to ensure that Emergency lighting of at least 1-1/2-hour duration is provided automatically. Step 4 The maintenance director/ designee will complete a random audit of backup lighting monthly x 4 to ensure safe operation. Findings will be reviewed during QAPI meeting.