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.