Emergency Lighting Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper documentation for emergency lighting testing, as required by NFPA 101. During a documentation review on February 10, 2025, it was found that the facility did not have records of monthly 30-second tests for battery backup lighting for the past 12 months. Additionally, there was no documentation of an annual 90-minute test of the battery backup lighting conducted within the last year. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged the absence of the necessary testing documentation at the time of the survey.
Plan Of Correction
1. The facility will conduct the monthly 30 second testing of the battery back-up lighting for 12 out of the 12 months. 2. The facility will conduct an annual 90-minute test of the battery backup lighting. 3. The Nursing Home Administrator/designee will educate maintenance staff to ensure all battery back-up lighting. 4. The maintenance staff/designee will audit weekly for two months and then monthly for two months to ensure the monthly back-up lighting for the facility is completed. 5. Any concerns will be reviewed during the Quality Assurance Performance Improvement committee.