Failure to Document Emergency Lighting Inspection and Maintenance
Summary
The facility failed to provide documentation of the required 30-second test, inspection, and maintenance for the battery-powered emergency light located in the building. This deficiency was identified during a record review conducted on March 13, 2025, at approximately 10:00 AM. The absence of this documentation indicates that the facility did not ensure automatic emergency lighting was provided in accordance with the applicable code section 7.9. The Facility Maintenance Director and Administrator confirmed the lack of documentation during the exit interview and at the time of record review. This deficiency could potentially affect all 70 occupants in the event of a fire emergency, as noted in the findings.
Penalty
Surveyors found that the facility did not perform and/or document required monthly and annual inspections of battery back-up emergency and exit lighting in accordance with NFPA 101 standards. During record review, no evidence was available to show that emergency lights throughout the building had been tested for the required 90-minute annual duration, despite multiple requests for documentation. The Maintenance Director confirmed that the documentation could not be produced, and this deficiency potentially affected all residents in the facility.
The facility did not maintain documentation of annual 90-minute testing for seven emergency lights as required by NFPA 101, with a staff member confirming unawareness of the requirement. This deficiency had the potential to affect 46 residents.
The facility did not maintain proper emergency lighting documentation, failing to record the duration of monthly tests and omitting the required annual 90-minute test, potentially affecting 39 residents. Additionally, the facility did not ensure that cooking facilities met NFPA fire protection and ventilation standards, as observed during the survey and confirmed by staff interviews.
Failure to Perform and Document Required Emergency and Exit Lighting Tests
Penalty
Summary
The facility failed to perform and document required monthly and annual inspections of emergency and exit lighting in accordance with NFPA 101, 2012 Edition, sections 19.2.9.1 and 7.9.3.1.2, affecting all 69 residents in the building. During record review on 03/25/26 beginning at 8:45 A.M., surveyors found no documentation verifying that the battery back-up emergency lights located throughout the facility had been tested for the required 90-minute annual duration. Documentation of these tests was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no records were provided by the time of exit. The Maintenance Director confirmed during interview that the requested documentation was not available, verifying the deficiency in required emergency lighting testing and recordkeeping. No specific residents, medical histories, or clinical conditions were described in the report beyond the statement that 69 residents were potentially affected.
Plan Of Correction
1.Based on record review and staff interview, no residents experienced negative outcomes related to failure to perform and document required emergency lighting testing. 2.The Medical Director was notified on 03/26/2026 by LNHA that the facility failed to provide documentation verifying battery back-up emergency lights were tested annually for 90 minutes as required. 3.Emergency lighting testing [for 90 minutes] will be completed by Maintenance Director/designee on or before 04/30/2026. Testing will be added to an annual automatically recurring schedule by Administrator/designee. 4.Documentation will be maintained and reviewed. Compliance will be reviewed in QAPI quarterly and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining emergency lighting.
Failure to Maintain Required Emergency Lighting Documentation
Penalty
Summary
The facility failed to maintain emergency lighting in accordance with NFPA 101-2012 Edition, Section 19.2.9.1 and Section 7.9.3.1.1. During a review of the life safety documentation, it was found that there was no record of the required annual 90-minute test for seven emergency lights. This lack of documentation was discovered in the facility's life safety binder during a survey. An interview with a staff member confirmed that the required testing had not been performed, as the staff member was unaware of the specific requirements. The deficiency had the potential to affect 46 residents, as emergency lighting is necessary for safe egress in the event of a power failure. The report does not mention any specific incidents involving residents or their medical conditions at the time of the deficiency.
Plan Of Correction
K291 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to complete the annual 90-minute emergency light test. Step 1: Director of Maintenance to complete the 90-minute test by (7/18/25). Step 2: Potential to affect all residents. Power outage on 4/29/25 for 1 hour, with no negative outcomes. The generator worked properly. Step 3: NHA educated Maintenance Director on NFPA 101 Emergency Lighting 90 Minute Annual Testing by 7/15/25. Step 4: NHA to monitor emergency lighting test logs for continued compliance weekly x4 then monthly x2. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.
Deficiencies in Emergency Lighting and Cooking Facility Safety Standards
Penalty
Summary
The facility failed to maintain emergency lighting in accordance with NFPA 101-2012 requirements. A review of the life safety documentation revealed that while twenty-three emergency lights were listed as "OK" on the emergency lighting log, the records did not indicate the duration of the monthly tests. Additionally, the section of the log designated for the required annual 90-minute test was not utilized. During an interview, the Regional Maintenance Director confirmed that the maintenance director was likely unaware of the specific testing requirements. This deficiency had the potential to affect 39 residents. The report also notes a failure to maintain cooking facilities in compliance with NFPA 101-2012 and related standards. The facility did not meet the requirements for protecting cooking equipment as outlined in the relevant NFPA codes. The observations and staff interviews indicated that the necessary fire protection and ventilation controls for cooking operations were not properly maintained, as required by the standards cited.
Plan Of Correction
Tag: K 0291 On 6/20/25, all 23 emergency lights were tested and found to be functional. All emergency lights will be appropriately tested and documented by the maintenance director or designee monthly. The administrator provided the maintenance director with education regarding emergency lighting requirements on 6/16/25. The maintenance director or designee will submit the emergency lighting log to the QAPI committee for review and recommendation for the next 3 months.
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