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K0291
C

Failure to Maintain Emergency Lighting Documentation

Brookville, Pennsylvania Survey Completed on 12-23-2024

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 failed to maintain emergency lighting in accordance with regulations, affecting the entire facility. During a document review on December 23, 2024, at 10:00 a.m., it was revealed that the facility could not provide documentation for a 90-minute annual emergency lighting test over the past 12 months. An interview with the maintenance supervisor at the same time confirmed the absence of this documentation.

Plan Of Correction

1. Maintenance Director completed and properly documented the required 90 minute annually emergency lighting test on 1-2-25. 2. Education will be provided to maintenance staff regarding the required testing and documentation for the yearly 90 minute emergency lighting test by 2-10-25. 3. From this point forward, the yearly emergency lighting testing will be completed and properly documented every January. 4. Process will be monitored in QAPI meeting to ensure this process is sustained.

See complete original report
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