Deficient Lighting in Egress Path
Summary
The facility failed to ensure that the lighting in the path of egress was fully functional. During a life safety code survey, it was observed that the egress path in a stairwell leading to Anthony Avenue had two lighting tubes that were only partially illuminated. This issue was noted on one out of four units. The observation was made on two consecutive days, and the Maintenance Director was informed immediately after the finding.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Corrective Action: The Maintenance Director and Facilities Supervisor on 12.04.2024 effectively replaced the two identified lightbulbs/lighting tubes that were partially illuminated in stairwell egress to (NAME) Avenue - in accordance with NFPA 101 section 7.9. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Maintenance Director and facility team were re-in-serviced on 12.09.2024 for state requirements regarding Means of Egress and TAG K-291: Emergency Lighting specificities by the compliance officer. The Maintenance Director will continue to perform Monthly emergency Lights test - 30 seconds per month hold button; and annual checks of 90 minutes unplugged. In addition, the maintenance team are now required to observe, record and ensure the path of egress is functionally illuminated during daily environmental rounds. Quality Assurance Monitoring: The Maintenance Director will complete the updated daily compliance facilities testing tracker and immediately provide replacement or work order(s) for TAG K291 on the tracker in the event illumination is affected. The Internal Record of Inspection and Testing reports are then reviewed by the facilities Manager and the compliance team. Any deficient practice/findings will be reported for reconciliation during the QA monthly meetings. Responsible Party: Maintenance Director
Penalty
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility did not perform and/or could not document the required annual 90‑minute test of battery-powered emergency lighting as required by NFPA 101 (2012 and 2021). During a record review with the Maintenance Director, no records were available to show that the annual 90‑minute emergency lighting test had been completed, and the Maintenance Director acknowledged the absence of this documentation, resulting in a cited deficiency affecting all occupants of the building.
Surveyors found that the facility failed to maintain and document required testing of emergency battery backup lighting in accordance with NFPA 101. During record review with the Maintenance Director, no documentation was available for the monthly 30-second tests or the annual 90-minute tests for all sampled battery backup emergency lights. The Maintenance Director acknowledged the absence of these records, and the deficiency was determined to affect all residents and staff.
Surveyors found that the facility did not perform and/or document required monthly and annual inspections of battery back-up emergency and exit lighting in accordance with NFPA 101 standards. During record review, no evidence was available to show that emergency lights throughout the building had been tested for the required 90-minute annual duration, despite multiple requests for documentation. The Maintenance Director confirmed that the documentation could not be produced, and this deficiency potentially affected all residents in the facility.
The facility did not provide documentation to verify that required monthly and annual tests of battery-powered emergency lighting were performed, as confirmed by both document review and interviews with the DON and Director of Maintenance.
Surveyors determined that the facility did not conduct or document the required annual 90-minute test of battery backup emergency lighting. This was confirmed by facility leadership during the survey process.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual 90‑Minute Emergency Battery Lighting Test
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual 90‑minute testing of battery-powered emergency lighting in accordance with NFPA 101 (2012 and 2021 editions), Sections 18.2.9.1 and 19.2.9.1. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors were unable to locate documentation showing that the annual 90‑minute emergency battery lighting test had been completed. The Maintenance Director acknowledged that the facility could not provide documentation that this required annual 90‑minute testing of the battery lighting was performed. The deficiency was cited as affecting all occupants of the building under NFPA 101 2012 and 2021, 19.2.9.1, Class III. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the findings were limited to the facility’s emergency lighting testing and documentation practices as observed during the surveyor’s record review and staff interview.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions 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. The 90 minute battery lighting test was completed and documentation is placed in the maintenance director book. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for three months random checks of completed documentation. Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions 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. The 90 minute battery lighting test was completed and documentation is placed in the maintenance director book The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Failure to Maintain and Document Required Emergency Battery Backup Lighting Tests
Penalty
Summary
The deficiency involves the facility’s failure to maintain and document required testing of emergency battery backup lighting in accordance with NFPA 101 standards. During a record review conducted with the Maintenance Director, surveyors requested documentation for the required monthly 30-second functional tests and the annual 90-minute tests of the facility’s battery backup emergency lights. For all 3 of 3 sampled battery backup emergency lights, no documentation was provided to show that the monthly 30-second tests had been performed. Similarly, no documentation was available to demonstrate that the required annual 90-minute battery backup lighting tests had been conducted for the same 3 of 3 emergency lights. The Maintenance Director, interviewed concurrently with the record review, acknowledged the lack of documentation. The deficiency was determined to affect all residents and staff in the facility and was discussed with the Administrator and the Maintenance Director during the exit conference.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K291 Emergency Lighting It is the practice of this facility to maintain emergency battery backup lighting. Immediate Corrective Action: The Maintenance Director was in-serviced on the required monthly and annual testing for emergency battery backup lighting. The 3 of 3 emergency battery backup lights were tested. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants on the required monthly and annual testing for emergency battery backup lighting. Monitoring: Maintenance Director will complete monthly audits for three months, to ensure that the monthly test is being completed. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance. K0291 The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K291 Emergency Lighting It is the practice of this facility to maintain emergency battery backup lighting. Immediate Corrective Action: The Maintenance Director was in-serviced on the required monthly and annual testing for emergency battery backup lighting. The 3 of 3 emergency battery backup lights were tested. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants on the required monthly and annual testing for emergency battery backup lighting. Monitoring: Maintenance Director will complete monthly audits for three months, to ensure that the monthly test is being completed. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance.
Failure to Perform and Document Required Emergency and Exit Lighting Tests
Penalty
Summary
The facility failed to perform and document required monthly and annual inspections of emergency and exit lighting in accordance with NFPA 101, 2012 Edition, sections 19.2.9.1 and 7.9.3.1.2, affecting all 69 residents in the building. During record review on 03/25/26 beginning at 8:45 A.M., surveyors found no documentation verifying that the battery back-up emergency lights located throughout the facility had been tested for the required 90-minute annual duration. Documentation of these tests was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no records were provided by the time of exit. The Maintenance Director confirmed during interview that the requested documentation was not available, verifying the deficiency in required emergency lighting testing and recordkeeping. No specific residents, medical histories, or clinical conditions were described in the report beyond the statement that 69 residents were potentially affected.
Plan Of Correction
1.Based on record review and staff interview, no residents experienced negative outcomes related to failure to perform and document required emergency lighting testing. 2.The Medical Director was notified on 03/26/2026 by LNHA that the facility failed to provide documentation verifying battery back-up emergency lights were tested annually for 90 minutes as required. 3.Emergency lighting testing [for 90 minutes] will be completed by Maintenance Director/designee on or before 04/30/2026. Testing will be added to an annual automatically recurring schedule by Administrator/designee. 4.Documentation will be maintained and reviewed. Compliance will be reviewed in QAPI quarterly and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining emergency lighting.
Lack of Documentation for Emergency Lighting Testing
Penalty
Summary
The facility failed to provide documentation verifying that monthly and annual testing of battery-powered emergency lighting had been performed, as required by NFPA 101 standards. During a document review, it was found that there was no record of these required tests for the emergency lighting sources. This was confirmed in an interview with the DON and Director of Maintenance, who acknowledged that documentation for the testing of installed back-up emergency lighting could not be provided. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
1. The facility is unable to retroactively perform this testing. 2. Monthly and annual battery-powered emergency lighting tests were completed in July. 3. The Environmental Services Director was re-educated on the requirements of K0291. Monthly battery-powered emergency lighting tests are scheduled. Annual testing will occur in July of each year. 4. The NHA or designee will complete an audit of the battery-powered emergency lighting testing monthly x 6 months. Annual testing will be confirmed in July. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Document Annual Emergency Lighting Test
Penalty
Summary
The facility failed to ensure that annual 90-minute testing of battery backup emergency lighting was conducted and documented as required. During a document review, surveyors found that the facility could not provide documentation showing that the required annual testing of emergency lighting had been performed. This deficiency was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged the absence of the annual testing report. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
90-minute test of battery backup lighting completed and on file. Facility will ensure that proof of testing is available for survey team during all inspections.
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