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K0291
C

Failure to Test Emergency Lighting

Mechanicsburg, Pennsylvania Survey Completed on 01-23-2025

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 meet the requirement for emergency lighting as outlined in NFPA 101. Specifically, the facility did not perform functional tests of the battery-powered emergency lighting source located in the Generator Room, which serves the entire component. During a document review conducted on January 23, 2025, it was revealed that there was no documentation verifying that the Generator Room's battery back-up emergency lighting was tested for 90 minutes annually. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged the lack of recorded annual testing.

Plan Of Correction

1. The Generator Room battery back-up emergency lighting was tested 90 minutes to ensure lighting during power outage. 2. Back up lighting unit will be added to the facility Preventative Maintenance log to ensure the working condition and will be audited monthly. 3. Maintenance Director will report findings to the QAPI committee.

See complete original report
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