Emergency Lighting Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper documentation for emergency lighting testing and inspection on one of its two levels. During a review conducted on March 12, 2025, it was observed that the facility did not have records verifying that emergency backup lights were tested monthly and that a 90-minute test was performed annually. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged the lack of documentation for the emergency backup lighting tests.
Plan Of Correction
1. Facility will resume testing monthly test and completed a 90-minute test. 2. 4/28/25 3. The new director of maintenance will create a new PM binder. Maintenance staff educated on testing. 4. Audits will be conducted monthly x 3.