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K0291
E

Deficiency in Emergency Lighting Maintenance

Gettysburg, Pennsylvania Survey Completed on 02-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to be deficient in maintaining emergency lighting as required by NFPA 101. During a document review, it was discovered that the facility did not conduct the necessary functional monthly and annual testing of battery-powered emergency lighting sources. This was confirmed through an interview with the Acting Administrator and Director of Maintenance. Additionally, an observation revealed that the battery back-up lighting unit in the Maintenance Mechanical Room failed to operate, indicating a lack of proper maintenance and testing of emergency lighting fixtures throughout the facility.

Plan Of Correction

Annual testing and monthly testing of battery powered emergency lighting will occur. Maintenance mechanical room battery will be replaced. Annual lighting check will occur by 3/15/25. Maintenance staff will be educated on completing monthly and annual testing of battery powered emergency lighting. A quarterly audit will occur to ensure that monthly testing of battery powered emergency lighting is occurring. Audit results will be reported at the next QAPI meeting.

See complete original report
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