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K0291
E

Failure to Maintain Emergency Lighting

Shenandoah, Pennsylvania Survey Completed on 12-11-2024

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 battery-powered emergency lighting in two locations, affecting two of four floors. During an observation on December 11, 2024, between 10:28 a.m. and 10:43 a.m., it was noted that the battery back-up emergency lights did not illuminate when tested. Specifically, at 10:28 a.m., Emergency Light #10 on the 3rd floor near Resident room 308 failed to function. Similarly, at 10:43 a.m., Emergency Light #21 at the Nurse's station on the 2nd floor also did not illuminate. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:15 a.m.

Plan Of Correction

This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. 1. Batteries in Emergency Lights #10 & #21 were replaced. 2. Whole house test of Emergency Lights completed and addressed accordingly. 3. Education to the Maintenance Director and Maintenance staff on ensuring testing and maintenance of the Emergency Lights in the facility. 4. Weekly testing of Emergency Lights for 4 weeks; monthly testing of Emergency Lights for 2 months. Results of audit(s) to be submitted to the QA Committee Meeting monthly.

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