Failure to Maintain Annual Emergency Lighting Testing
Penalty
Summary
The facility failed to maintain yearly testing of the emergency battery back-up exit lighting as required by NFPA 101. During a record review, surveyors found that the most recent documented test of the emergency lighting was performed on 7/12/23, and there was no evidence of a more recent annual test. This deficiency was confirmed through interviews with the Assistant Director of Maintenance, who acknowledged the lack of complete records for the required testing. The absence of up-to-date annual testing records for the emergency lighting was further reconfirmed with both the Administrator and the Assistant Director of Facilities during the exit conference. The deficiency was supported by photographic evidence, and no specific individual was identified as solely responsible for the deficient practice.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents, employees, and visitors have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents, employees, and visitors have the potential to be affected by this practice. On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. The Administrator Consultant developed a tracking schedule for the yearly testing of the emergency battery back-up exit lighting. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule noted the date on which the Maintenance Director is to complete the yearly testing of the emergency battery back-up exit lighting. The Maintenance Director is to provide documentation to the Administrator of the date of the inspection and testing. Upon completion of the inspection and testing, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of yearly testing of the emergency battery back-up exit lighting to the QA and QAPI committee monthly x 12 months.