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K0291
F

Deficiency in Emergency Lighting Maintenance and Installation

Chambersburg, Pennsylvania Survey Completed on 04-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to be deficient in maintaining and installing emergency lighting as required by NFPA 101. During a document review and observation, it was discovered that the facility lacked documentation verifying the annual maintenance of battery-powered emergency lighting sources. Additionally, it was observed that there was no installed battery-powered emergency lighting at the automatic transfer switch, affecting all six smoke compartments within the component. These findings were confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director.

Plan Of Correction

1. and 2. Maintenance Director has completed annual maintenance of battery-powered emergency lighting and installed battery-powered emergency lighting at the automatic transfer switch. 3. Maintenance department will be educated on the standards of ensuring the facility has completed the annual maintenance of battery-powered emergency lighting and ensuring there is a battery back-up emergency lighting at the automatic transfer switch. 4. Maintenance or facility designee will audit the facilities battery-powered emergency lighting weekly x2 for 2 months, then every 60 days throughout the year and results of the audit will be reported to the QA Committee.

See complete original report
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