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K0291
E

Failure to Conduct Annual Emergency Lighting Test

Quakertown, Pennsylvania Survey Completed on 02-10-2025

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 failed to ensure that emergency lighting was tested annually, as required by NFPA 101 standards. During a document review on February 10, 2025, it was found that the facility could not provide documentation of a 90-minute annual test for their emergency lighting over the past 12 months. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.

Plan Of Correction

1) Maintenance was able to find paperwork after the audit was completed. 2) Maintenance was educated on how to find Emergency Lighting documentation. 3) Maintenance will audit the online monitoring system weekly to monitor regulatory tasks three times a week for 8 weeks, then monthly x2. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.

See complete original report
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