Failure to Test and Maintain Emergency Lighting in Generator Room
Summary
The facility failed to ensure that the emergency lighting in the basement generator room was tested and maintained as required. Specifically, the annual 90-minute run test for the battery-operated emergency light was not completed in 2023 and 2024, and the monthly 30-second run tests were not documented from an unspecified month in 2023 to an unspecified month in 2024. During an observation, it was noted that the basement generator room contained a battery-operated emergency light. The Maintenance Director confirmed in an interview that the required tests had not been conducted and stated they were unaware of the testing requirements for the emergency light.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 The Maintenance staff was trained on the importance of emergency lighting in the generator room and the importance of monthly and annual testing of the emergency lighting and correctly documenting it on a newly revised form. Ninety Minute test run on (MONTH) 9, 2025, 30 second tests were run on (MONTH) 12, 2025 & 3/3/2025. The Director of Environmental Services will monitor compliance with an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Penalty
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