Failure to Ensure Continuous Illumination of Egress
Penalty
Summary
The facility failed to ensure continuous illumination of the means of egress, specifically affecting one of two levels. During an observation on December 16, 2024, at 11:25 a.m., it was noted that a ceiling light fixture inside the exit vestibule of the basement laundry was not illuminated. This deficiency was confirmed during an exit interview with the Administrator and the Regional Maintenance Director on the same day at 12:45 p.m.
Plan Of Correction
This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The missing ceiling light fixture was replaced and the light is now working. 2. Maintenance Director, or designee will conduct an initial audit of all lights in exit egresses are working. 3. Maintenance Director will educate maintenance staff to check all egress exit lights during monthly Life Safety Rounds to ensure they are working. 4. Maintenance Director, or designee will conduct audit of exit egress lighting, weekly x 4 weeks then monthly x2 months to ensure that all exit egress lighting is working. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action.