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.