Failure to Maintain and Inspect Emergency Lighting
Penalty
No penalty information released
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 failed to maintain and inspect emergency lighting as required by NFPA 101, affecting the entire facility. During a document review on May 1, 2025, it was found that the facility could not provide documentation for monthly testing and annual 90-minute testing of emergency lighting. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day.
Plan Of Correction
The facility will maintain and inspect emergency lighting, affecting the entire facility. The Director of Maintenance or designee will audit emergency lighting of at least 1-1/2-hour duration, monthly testing for 30 seconds and annual 90-minute testing weekly x4 then monthly x2. All findings will be brought to QAPI for review.