Deficiency in Emergency Lighting Compliance
Penalty
Summary
The facility was found to be deficient in providing emergency illumination in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This deficiency was observed during a recertification survey conducted on March 28, 2025. The surveyors noted that the facility did not have emergency lighting or lighting that would operate automatically without manual intervention along the means of egress to the public way in Building #2. This lack of compliance with the required safety standards was evident during observations made at 12:00 PM in the den area. During the survey, it was further revealed through an interview with Facilities Manager #1 that the facility had not installed the necessary emergency lighting in the dens. The manager acknowledged the absence of such lighting and indicated plans to address the issue. However, at the time of the survey, the deficiency remained uncorrected, posing a potential risk to the safety of residents and staff in the event of an emergency requiring evacuation. The deficiency was not isolated to Building #2, as similar issues were identified in multiple other buildings within the facility, including Buildings #3, #4, #5, #6, #7, #8, #10, #12, #14, #16, #19, #21, #22, #24, and #31 (House #1). In each case, the facility failed to provide emergency lighting that would function automatically without manual intervention, as required by the NFPA 101 Life Safety Code. This widespread non-compliance highlights a systemic issue within the facility's emergency preparedness measures.
Plan Of Correction
Plan of Correction: Approved May 3, 2025 Element 1: Vendor has been contacted to install required emergency lighting in the den in accordance with National Fire Protection Association 101 safety code to illuminate means of egress. Work to be completed by (MONTH) 13, 2025. Element 2: All residents have potential to be impacted by this practice. Element 3: Facilities manager will educate maintenance staff on the emergency lighting installed and addition of lights to the Preventative maintenance schedule. Element 4: Emergency lighting audits will be completed monthly. Audits will be checking the functionality of the emergency lights to ensure they are in good working order. Results of audits will be provided monthly to the Quality Assurance Committee. Results will be reported for three months with the Quality Committee making recommendations as to ongoing frequency. Facilities Manager responsible for compliance.