Failure to Maintain Emergency Lighting Documentation
Penalty
Summary
The facility failed to maintain emergency lighting as required by NFPA 101, affecting the entire facility. During a document review on January 27, 2025, it was found that the facility could not provide documentation that emergency lighting had been tested for 30 seconds on a monthly basis and for 90 minutes on an annual basis. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Notably, this is a repeat deficiency from the March 13, 2024, annual survey, indicating a continued failure to comply with the emergency lighting requirements.
Plan Of Correction
1. An audit of emergency lighting was conducted to ensure all units are in proper working order. 2. A log was created to document emergency lighting inspections and ensure compliance. 3. Education provided to ensure proper compliance with this regulation. 4. An audit of five emergency lights will be conducted to ensure they are in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.