Lack of Documentation for Emergency Lighting Testing
Penalty
Summary
The facility failed to provide documentation verifying the testing of battery back-up emergency lighting, which is required to be tested monthly for 30 seconds and annually for 90 minutes. This deficiency was identified during a document review conducted on March 13, 2025, between 8:45 AM and 10:45 AM. The review revealed that the facility lacked the necessary documentation to confirm that these tests had been conducted within the previous twelve months. During an exit conference on the same day at 1:45 PM, the Administrator and Maintenance Director confirmed the absence of documentation verifying the testing of battery back-up lighting fixtures. This deficiency affects the entire component of the facility's emergency lighting system.
Plan Of Correction
Battery back-up lighting annual 90 minute test will be performed on 4/2/25. Going forward, the lighting will be tested monthly for 30 seconds and annually for 90 minutes. Record of testing will be maintained in the Life Safety Book. All battery back-up lighting has been identified for testing. The Maintenance Director has been re-educated on the need to test the back up lighting monthly for 30 seconds and annually for 90 minutes. The NHA or designee will audit the recording of testing monthly and the documentation is filed in the Life Safety Book.