Deficient Lighting in Egress Path
Penalty
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