Failure to Test Emergency Lighting and Exit Signs
Penalty
Summary
The facility failed to periodically test emergency lighting equipment and exit signs in accordance with NFPA 101 (2012). During a record review with the Maintenance Director, it was found that the facility did not provide written documentation supporting the maintenance of emergency lighting and exit signage. The required functional test, which should be conducted on every emergency lighting system at 30-day intervals for not less than 30 seconds, was not performed. Additionally, the annual test for battery-powered emergency lighting systems, which should last not less than 1 1/2 hours, was also not conducted. The Maintenance Director acknowledged during an interview that these inspections were not carried out, and he had no further comments. These findings were verified by both the Maintenance Director and the Administrator during the exit conference.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483. 1. On 3/17/25, the 30 second and 1 1/2 hour functional test of the emergency lighting system and exit signage was completed by the Maintenance Director. 2. The Maintenance Director identified further concerns with the emergency lighting system and exit signage during the functional tests. On 3/20/25, the replacement parts were ordered and were installed on 4/1/25. Current facility residents have the potential to be affected by the deficient practice. 3. On 3/24/25, the facility Administrator/designee provided education for maintenance employees regarding NFPA 101 emergency light and exit sign testing requirements. 4. On 3/25/25, an alert was added to the facility TELS system to remind maintenance staff of the required 30-day interval and annual testing of emergency and exit sign lighting. Maintenance Director/designee to complete the 30 second required functional testing of the emergency lighting system and exit signage every 30 days for 3 months, or until substantial compliance is achieved. The Findings to be reviewed during the monthly QAPI Committee Meeting. Modifications implemented if indicated.