Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on June 4, 2026, at Beacon Light Adult Residential Services, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID 44021100
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on June 4, 2026, it was determined Beacon Light Adult Residential Services was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type V (000), unprotected, wood frame building, that is not sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - MAIN BUILDING 01 Component - 01
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on document review, observation, and interview, the facility failed to maintain general requirements of the life safety code that are not addressed by specific K-tags, but are deficient, for three of three building components.
Findings include:
Document review on June 4, 2026, at 11:00 a.m., revealed the facility failed to provide documentation of obtaining Department of Health State Plan Review approval and a granted occupancy from the Life Safety Division for the renovation of the bathroom in cottage #1-3.
Interview with the director of maintenance on June 4, 2026, at 11:00 a.m., confirmed the facility could not provide approval documentation for the renovation project.
Plan of Correction:The Director of Facilities Management has begun the plan review for Cottage 1. New plan review document submission will be completed by 6/26/2026. The Director of Facilities Management will provide weekly updates to the Executive Director as to the status of the approval process until the updated occupancy has been provided. This will ensure the review is complete finalized.
To prevent this deficiency from recurring, each time there is a project identified that will require plan review, a request will be placed to the agency's Space Planning Committee to begin the process of developing plan review. The Space Planning Committee will provide weekly updates to the Executive Director on the status of the plan review until final approval. This process will formally begin on 7/1/26.
Additionally, there will be a section of the "Monthly Life Safety Check Sheet" that includes projects and plan review submittals. This form is completed monthly by the maintenance staff and submitted to the Executive Director for his review. This process will begin in July 2026.
The Executive Director will be responsible for monitoring this area in conjunction with the Director of Facility Management.
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - MAIN BUILDING 01 Component - 01
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on observation, document review, and interview, the facility failed to maintain fire alarm system maintenance and testing requirements, affecting three of three building components.
Findings include:
Observation on June 4, 2026, at 11:40 a.m., revealed the main fire panel room failed to have a smoke detector installed within the immediate vicinity of fire system control equipment.
Interview with the director of maintenance on June 4, 2026, at 11:40 a.m., confirmed the fire panel failed to have a smoke detector installed within the immediate vicinity of the equipment.
Plan of Correction:A quote to instill a smoke detector in the immediate vicinity of the fire panel in cottage 1 (fire panel room) was received on 6/17/26 from Johnson Controls. The work order with Johnson Controls is in the process of being scheduled. The Director of Facility Management will ensure that Johnson Controls has completed the smoke detector by 7/15/26
To prevent/monitor this from occurring in the future (to assure that there is always a smoke detector in the immediate vicinity of the fire panel), this area will be added to the monthly life safety checks conducted by the maintenance department. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. This process will begin In July 2026.
The Director of Facility Management is responsible for monitoring this area.
NFPA 101 STANDARD
Building Services - Other
Name - MAIN BUILDING 01 Component - 01
Building Services - Other
List in the REMARKS section any LSC Section 32.2.5 and 33.2.5 Building Services that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on document review and interview, the facility failed to meet receptacle testing requirements, affecting three of three building components.
Findings include:
Observation on June 4, 2026, at 11:10 a.m., revealed the facility was unable to provide documentation for the annual receptacle testing of patient care areas.
Reference NFPA 99 6.3.3.2
Interview with the director of maintenance on June 4, 2026, at 11:10 a.m., confirmed the facility was unable to provide documentation for annual receptacle testing at the time of the survey.
Plan of Correction:The Director of Facility Management contacted Minich Electric on 6/16/26 to inquire about their ability to conduct the receptacle testing for the cottages; this would include their documentation of the testing. Completion of this initial testing will occur by 7/17/2026 or sooner per the contractor.
To monitor and prevent this issue from occurring in the future, this area will be added to the "Monthly Review of Life Safety" form to include the stipulated month of July of each year for the testing to occur. The maintenance department are responsible for conducting the life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office.
The Director of Facility Management is responsible for monitoring this area.
NFPA 101 STANDARD
Maintenance, Inspection and Testing - Doors
Name - MAIN BUILDING 01 Component - 01
Maintenance, Inspection & Testing - Doors
Door assemblies where the door leaf is required to swing in the direction of egress travel are inspected and tested annually per 7.2.1.15.
Fire door assemblies are inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Smoke door assemblies are inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
Door assemblies are visually inspected on both sides and the requirements under 7.2.1.15.7 are verified.
Individuals performing the door inspection and testing have an understanding of the operating components of the doors.
Written records of inspection and testing are maintained and are available for review.
33.7.7, 7.2.1.15 (LSC)
5.2. 5.2.3 (NFPA 80)
5.2.1 (NFPA 105)
Observations:
Based on document review, observation, and interview, the facility failed to maintain door maintenance, testing, and inspections, affecting three of three building components.
Findings include:
Document review on June 4, 2026, at 11:06 a.m., revealed the facility failed to provide documentation for annual fire door inspections.
Interview with the director of maintenance on June 4, 2026, at 11:06 a.m., confirmed the facility could not provide the inspection documentation at the time fo the survey.
Plan of Correction:The agency's maintenance department will utilize the ASHE form provided to assess and document the proper functionality of each door per code requirement. This documentation will be completed and forwarded by 7/17/2026.
To monitor and prevent this issue from occurring in the future, this area will be added to the "Monthly Review of Life Safety" form to include the stipulated month of July of each year for the door inspections to occur. The maintenance department is responsible for conducting the life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. This process will be initiated in July 2026
The Director of Facility Management is responsible for monitoring this area.
Initial Comments:
Name - BUILDING 02 Component - 02
Facility ID 440211
Component 02
Cottage 02
Based on a Medicaid Recertification Survey completed on June 4, 2026, it was determined that Beacon Light Adult Residential Services was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type V (000), unprotected, wood frame building, that is not sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - BUILDING 02 Component - 02
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on document review, observation, and interview, the facility failed to maintain general requirements of the life safety code that are not addressed by specific K-tags, but are deficient, for three of three building components.
Findings include:
Document review on June 4, 2026, at 11:00 a.m., revealed the facility failed to provide documentation of obtaining Department of Health State Plan Review approval and a granted occupancy from the Life Safety Division for the renovation of the bathroom in cottage #1-3.
Interview with the director of maintenance on June 4, 2026, at 11:00 a.m., confirmed the facility could not provide approval documentation for the renovation project.
Plan of Correction:The Director of Facilities Management has begun the plan review for Cottage 1. New plan review document submission will be completed by 6/26/2026. The Director of Facilities Management will provide weekly updates to the Executive Director as to the status of the approval process until the updated occupancy has been provided. This will ensure the review is complete finalized.
To prevent this deficiency from recurring, each time there is a project identified that will require plan review, a request will be placed to the agency's Space Planning Committee to begin the process of developing plan review. The Space Planning Committee will provide weekly updates to the Executive Director on the status of the plan review until final approval. This process will formally begin on 7/1/26.
Additionally, there will be a section of the "Monthly Life Safety Check Sheet" that includes projects and plan review submittals. This form is completed monthly by the maintenance staff and submitted to the Executive Director for his review. This process will begin in July 2026.
The Executive Director will be responsible for monitoring this area in conjunction with the Director of Facility Management.
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - BUILDING 02 Component - 02
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on observation, document review, and interview, the facility failed to maintain fire alarm system maintenance and testing requirements, affecting three of three building components.
Findings include:
Observation on June 4, 2026, at 11:40 a.m., revealed the main fire panel room failed to have a smoke detector installed within the immediate vicinity of fire system control equipment.
Interview with the director of maintenance on June 4, 2026, at 11:40 a.m., confirmed the fire panel failed to have a smoke detector installed within the immediate vicinity of the equipment.
Plan of Correction:A quote to instill a smoke detector in the immediate vicinity of the fire panel in cottage 2 (fire panel room) was received on 6/17/26 from Johnson Controls. The work order with Johnson Controls is in the process of being scheduled. The Director of Facility Management will ensure that Johnson Controls has completed the smoke detector by 7/15/26
To prevent/monitor this from occurring in the future (to assure that there is always a smoke detector in the immediate vicinity of the fire panel), this area will be added to the monthly life safety checks conducted by the maintenance department. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. This process will begin In July 2026.
The Director of Facility Management is responsible for monitoring this area.
NFPA 101 STANDARD
Building Services - Other
Name - BUILDING 02 Component - 02
Building Services - Other
List in the REMARKS section any LSC Section 32.2.5 and 33.2.5 Building Services that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on document review and interview, the facility failed to meet receptacle testing requirements, affecting three of three building components.
Findings include:
Observation on June 4, 2026, at 11:10 a.m., revealed the facility was unable to provide documentation for the annual receptacle testing of patient care areas.
Reference NFPA 99 6.3.3.2
Interview with the director of maintenance on June 4, 2026, at 11:10 a.m., confirmed the facility was unable to provide documentation for annual receptacle testing at the time of the survey.
Plan of Correction:The Director of Facility Management contacted Minich Electric on 6/16/26 to inquire about their ability to conduct the receptacle testing for the cottages; this would include their documentation of the testing. Completion of this initial testing will occur by 7/17/2026 or sooner per the contractor.
To monitor and prevent this issue from occurring in the future, this area will be added to the "Monthly Review of Life Safety" form to include the stipulated month of July of each year for the testing to occur. The maintenance department are responsible for conducting the life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office.
The Director of Facility Management is responsible for monitoring this area.
NFPA 101 STANDARD
Utilities - Gas and Electric
Name - BUILDING 02 Component - 02
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NPFA 70, National Electric Code.
32.2.5.1, 33.2.5.1, 9.1.1, 9.1.2
Observations:
Based on observation and interview, the facility failed to maintain electrical equipment, in accordance with the National Fire Protection Association (NFPA) 70, on one of two building levels.
Findings include:
Observation on June 6, 2026, at 10:35 a.m., revealed the fire alarm panel room had two open junction boxes.
Interview with the maintenance supervisor on June 6, 2026, at 10:35 a.m., confirmed the electrical deficiency.
Plan of Correction:The maintenance department placed covers on the open junction boxes in cottage 2 on 6/5/2026 bringing them into compliance.
To monitor and prevent this issue from occurring in the future, this area will be added to the "Monthly Review of Life Safety" form to include monthly checks of junction boxes in all three cottages. The maintenance department is responsible for conducting the life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office.
The Director of Facility Management is responsible for monitoring this area.
NFPA 101 STANDARD
Maintenance, Inspection and Testing - Doors
Name - BUILDING 02 Component - 02
Maintenance, Inspection & Testing - Doors
Door assemblies where the door leaf is required to swing in the direction of egress travel are inspected and tested annually per 7.2.1.15.
Fire door assemblies are inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Smoke door assemblies are inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
Door assemblies are visually inspected on both sides and the requirements under 7.2.1.15.7 are verified.
Individuals performing the door inspection and testing have an understanding of the operating components of the doors.
Written records of inspection and testing are maintained and are available for review.
33.7.7, 7.2.1.15 (LSC)
5.2. 5.2.3 (NFPA 80)
5.2.1 (NFPA 105)
Observations:
Based on document review, observation, and interview, the facility failed to maintain door maintenance, testing, and inspections, affecting three of three building components.
Findings include:
Document review on June 4, 2026, at 11:06 a.m., revealed the facility failed to provide documentation for annual fire door inspections.
Interview with the director of maintenance on June 4, 2026, at 11:06 a.m., confirmed the facility could not provide the inspection documentation at the time fo the survey.
Plan of Correction:The agency's maintenance department will utilize the ASHE form provided to assess and document the proper functionality of each door per code requirement. This documentation will be completed and forwarded by 7/17/2026.
To monitor and prevent this issue from occurring in the future, this area will be added to the "Monthly Review of Life Safety" form to include the stipulated month of July of each year for the door inspections to occur. The maintenance department is responsible for conducting the life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. This process will be initiated in July 2026
The Director of Facility Management is responsible for monitoring this area.
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID 44021100
Component 03
Building 03
Based on a Medicaid Recertification Survey completed on June 4, 2026, it was determined that Beacon Light Adult Residential Services was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type V (000), unprotected, wood frame building, that is not sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - BUILDING 03 Component - 03
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on document review, observation, and interview, the facility failed to maintain general requirements of the life safety code that are not addressed by specific K-tags, but are deficient, for three of three building components.
Findings include:
Document review on June 4, 2026, at 11:00 a.m., revealed the facility failed to provide documentation of obtaining Department of Health State Plan Review approval and a granted occupancy from the Life Safety Division for the renovation of the bathroom in cottage #1-3.
Interview with the director of maintenance on June 4, 2026, at 11:00 a.m., confirmed the facility could not provide approval documentation for the renovation project.
Plan of Correction:The Director of Facilities Management has begun the plan review for Cottage 1. New plan review document submission will be completed by 6/26/2026. The Director of Facilities Management will provide weekly updates to the Executive Director as to the status of the approval process until the updated occupancy has been provided. This will ensure the review is complete finalized.
To prevent this deficiency from recurring, each time there is a project identified that will require plan review, a request will be placed to the agency's Space Planning Committee to begin the process of developing plan review. The Space Planning Committee will provide weekly updates to the Executive Director on the status of the plan review until final approval. This process will formally begin on 7/1/26.
Additionally, there will be a section of the "Monthly Life Safety Check Sheet" that includes projects and plan review submittals. This form is completed monthly by the maintenance staff and submitted to the Executive Director for his review. This process will begin in July 2026.
The Executive Director will be responsible for monitoring this area in conjunction with the Director of Facility Management.
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - BUILDING 03 Component - 03
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on observation, document review, and interview, the facility failed to maintain fire alarm system maintenance and testing requirements, affecting three of three building components.
Findings include:
Observation on June 4, 2026, at 11:40 a.m., revealed the main fire panel room failed to have a smoke detector installed within the immediate vicinity of fire system control equipment.
Interview with the director of maintenance on June 4, 2026, at 11:40 a.m., confirmed the fire panel failed to have a smoke detector installed within the immediate vicinity of the equipment.
Plan of Correction:A quote to instill a smoke detector in the immediate vicinity of the fire panel in cottage 3 (fire panel room) was received on 6/17/26 from Johnson Controls. The work order with Johnson Controls is in the process of being scheduled. The Director of Facility Management will ensure that Johnson Controls has completed the smoke detector by 7/15/26
To prevent/monitor this from occurring in the future (to assure that there is always a smoke detector in the immediate vicinity of the fire panel), this area will be added to the monthly life safety checks conducted by the maintenance department. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. This process will begin In July 2026.
The Director of Facility Management is responsible for monitoring this area.
NFPA 101 STANDARD
Building Services - Other
Name - BUILDING 03 Component - 03
Building Services - Other
List in the REMARKS section any LSC Section 32.2.5 and 33.2.5 Building Services that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on document review and interview, the facility failed to meet receptacle testing requirements, affecting three of three building components.
Findings include:
Observation on June 4, 2026, at 11:10 a.m., revealed the facility was unable to provide documentation for the annual receptacle testing of patient care areas.
Reference NFPA 99 6.3.3.2
Interview with the director of maintenance on June 4, 2026, at 11:10 a.m., confirmed the facility was unable to provide documentation of annual receptacle testing at the time of the survey.
Plan of Correction:The Director of Facility Management contacted Minich Electric on 6/16/26 to inquire about their ability to conduct the receptacle testing for the cottages; this would include their documentation of the testing. Completion of this initial testing will occur by 7/17/2026 or sooner per the contractor.
To monitor and prevent this issue from occurring in the future, this area will be added to the "Monthly Review of Life Safety" form to include the stipulated month of July of each year for the testing to occur. The maintenance department are responsible for conducting the life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office.
The Director of Facility Management is responsible for monitoring this area.
NFPA 101 STANDARD
Maintenance, Inspection and Testing - Doors
Name - BUILDING 03 Component - 03
Maintenance, Inspection & Testing - Doors
Door assemblies where the door leaf is required to swing in the direction of egress travel are inspected and tested annually per 7.2.1.15.
Fire door assemblies are inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Smoke door assemblies are inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
Door assemblies are visually inspected on both sides and the requirements under 7.2.1.15.7 are verified.
Individuals performing the door inspection and testing have an understanding of the operating components of the doors.
Written records of inspection and testing are maintained and are available for review.
33.7.7, 7.2.1.15 (LSC)
5.2. 5.2.3 (NFPA 80)
5.2.1 (NFPA 105)
Observations:
Based on document review, observation, and interview, the facility failed to maintain door maintenance, testing, and inspections, affecting three of three building components.
Findings include:
Document review on June 4, 2026, at 11:06 a.m., revealed the facility failed to provide documentation for annual fire door inspections.
Interview with the director of maintenance on June 4, 2026, at 11:06 a.m., confirmed the facility could not provide the inspection documentation at the time fo the survey.
Plan of Correction:The agency's maintenance department will utilize the ASHE form provided to assess and document the proper functionality of each door per code requirement. This documentation will be completed and forwarded by 7/17/2026.
To monitor and prevent this issue from occurring in the future, this area will be added to the "Monthly Review of Life Safety" form to include the stipulated month of July of each year for the door inspections to occur. The maintenance department is responsible for conducting the life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. This process will be initiated in July 2026
The Director of Facility Management is responsible for monitoring this area.
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