Failure to Provide Emergency Lighting at Main Electrical Room Transfer Switch
Penalty
Summary
During an observation on April 24, 2025, at approximately 10:29 am, it was found that the facility did not provide a battery pack emergency light at the transfer switch located in the main electrical room. This was identified as a failure to ensure automatic emergency lighting in accordance with section 7.9. The deficiency was confirmed through an interview with the facility's environmental supervisor at the time of the observation. This deficiency could affect all occupants, staff, and visitors in the event that the emergency power systems fail to operate as designed during an electrical utility power outage.
Plan Of Correction
K291 Emergency Lighting SS=F 1. A battery pack emergency light was installed at the transfer switch located in the main electrical room on 5/15/25. 2. Residents residing within the facility have the potential to be affected. 3. Facility administrator has re-educated the maintenance director on the regulatory requirement for an emergency backup light at the transfer switch. The facility preventative maintenance system (TELS) has been updated to ensure that back up lighting is testing per regulatory standards. 4. Facility Administrator and/or designee will verify regulatory compliance with emergency backup lighting monthly x4. Findings will be reported to the QAPI committee for further review and/or recommendations. The Administrator is responsible for sustained compliance.