Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 19, 2025, it was determined that Beacon Light Adult Residential Services was not in compliance with the requirements of 42 CFR 483.475.
Plan of Correction:
483.475(d) STANDARD
EP Training and Testing
Name - Component - --
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.
Findings include:
Document review on May 19, 2025, at 11:55 a.m., revealed the facility lacked annual staff emergency preparedness plan training at the time of the survey.
Interview with the maintenance supervisor on May 19, 2025, at 11:55 a.m., confirmed the training documentation was unavailable at the time of the survey.
Plan of Correction:Although the Emergency Preparedness training sign offs were not available during the onsite survey which took place on 5/19/25, they were, in fact, completed in March 2025. The Beacon Light Adult Residential Services administrative team as well as the Direct Support Professionals all were trained in March. Sign off sheets are available for these trainings.
Moving forward, all of these Emergency Preparedness trainings that take place annually will be stored in a "Life Safety" binder and this will be stored in the Executive Director's office (which will be up-to-date and available for all future surveys). This binder will be formalized and complete by 7/1/25
The Executive Director is responsible for monitoring this area for compliance and for assuring this information is available for future surveys.
483.475(d)(2) STANDARD
EP Testing Requirements
Name - Component - --
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.
Findings include:
Document review on May 19, 2025, at 11:58 a.m., revealed the facility lacked an emergency preparedness plan that included the following annual exercises:
A. Full-scale exercise (including test, evaluation, and changes as needed).
B. Second full-scale or table top exercise.
Interview with the maintenance supervisor on May 19, 2025, at 11:58 a.m., confirmed the documentation was unavailable at the time of the survey.
Plan of Correction:Although the Full-Scale exercise and table top exercise were not available during the onsite survey which took place on 5/19/25, they were, in fact, completed. The Full-Scale exercise was completed on 7/22/24 and the Table Top was completed on 12/13/24.
Moving forward, all emergency drills that take place on an annual basis will be stored in a "Life Safety" binder and this will be stored in the Executive Director's office (which will be up-to-date and available for all future surveys). This binder will be formalized and complete by 7/1/25
The Executive Director is responsible for monitoring this area for compliance and for assuring this information is available for future surveys.
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID 44021100
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on May 19, 2025, 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
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 document review and interview, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:
Document review on May 19, 2025, at 11:46 a.m., revealed the facility could not provide documentation for the following:
A. Fire alarm annual inspection/testing;
B. Semi-annual visual inspection;
C. Smoke detector sensitivity testing.
Interview with the maintenance supervisor on May 19, 2025, at 11:46 a.m., confirmed the documentation was unavailable at the time of the survey.
Plan of Correction:Regarding Cottage 1, although the fire alarm annual inspection/testing and the smoke detector sensitivity testing were not available during the onsite survey which took place on 5/19/25, they were, in fact, completed. This testing was completed on 11/11/24 by Johnson Controls. The semi-annual visual inspections were completed in July of 2024 and again in January of 2025. These semi-annual inspections are completed as part of the monthly life safety inspections completed by the maintenance department.
Moving forward, the fire alarm annual inspections, semi-annual visual inspections and the smoke detector sensitivity testing will all be stored in a "Life Safety" binder and this will be stored in the Executive Director's office (which will be up-to-date and available for all future surveys). This binder will be formalized and complete by 7/1/25
The Executive Director is responsible for monitoring this area for compliance and for assuring this information is available for future surveys.
Initial Comments:
Name - BUILDING 02 Component - 02
Facility ID 44021100
Component 02
Building 02
Based on a Medicaid Recertification Survey completed on May 19, 2025, 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
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 document review and interview, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:
Document review on May 19, 2025, at 11:46 a.m., revealed the facility could not provide documentation for the following:
A. Fire alarm annual inspection/testing;
B. Semi-annual visual inspection;
C. Smoke detector sensitivity testing.
Interview with the maintenance supervisor on May 19, 2025, at 11:46 a.m., confirmed the documentation was unavailable at the time of the survey.
Plan of Correction:Regarding Cottage 2, although the fire alarm annual inspection/testing and the smoke detector sensitivity testing were not available during the onsite survey which took place on 5/19/25, they were, in fact, completed. This testing was completed on 11/11/24 by Johnson Controls. The semi-annual visual inspections were completed in July of 2024 and again in January of 2025. These semi-annual inspections are completed as part of the monthly life safety inspections completed by the maintenance department.
Moving forward, the fire alarm annual inspections, semi-annual visual inspections and the smoke detector sensitivity testing will all be stored in a "Life Safety" binder and this will be stored in the Executive Director's office (which will be up-to-date and available for all future surveys). This binder will be formalized and complete by 7/1/25
The Executive Director is responsible for monitoring this area for compliance and for assuring this information is available for future surveys.
NFPA 101 STANDARD
Fire Drills
Name - BUILDING 02 Component - 02
Fire Drills
1. The facility must hold evacuation drills at least quarterly for each shift of personnel and under varied conditions to:
a. Ensure that all personnel on all shifts are trained to perform assigned tasks;
b. Ensure that all personnel on all shifts are familiar with the use of the facility's emergency and disaster plans and procedures.
2. The facility must:
a. Actually evacuate clients during at least one drill each year on each shift;
b. Make special provisions for the evacuation of clients with physical disabilities;
c. File a report and evaluation on each drill;
d. Investigate all problems with evacuation drills, including accidents and take corrective action; and
e. During fire drills, clients may be evacuated to a safe area in facilities certified under the Health Care Occupancies Chapter of the Life Safety Code.
3. Facilities must meet the requirements of paragraphs (i) (1) and (2) of this section for any live-in and relief staff that they utilize.
42 CFR 483.470(i)
Observations:
Based on document review and interview, the facility failed to maintain fire drills, in accordance with regulations, affecting three of three work shifts.
Findings include:
Document review on May 19, 2025, at 11:35 a.m., revealed the facility failed to provide fire drill documentation for cottage #2, for the first, second, and third shifts, all quarters.
Interview with the maintenance supervisor on May 19, 2025, at 11:35 a.m., confirmed the fire drill documentation was unavailable at the time of the survey.
Plan of Correction:Regarding the fire drill documentation, although the fire drill reports were not available during the onsite survey which took place on 5/19/25, they were, in fact, completed as required. All of the monthly drills that are done quarterly for each shift are available upon request.
Moving forward, the monthly fire drills will all be stored in a "Life Safety" binder and this will be stored in the Executive Director's office (which will be up-to-date and available for all future surveys). This binder will be formalized and complete by 7/1/25
The Executive Director is responsible for monitoring this area for compliance and for assuring this information is available for future surveys.
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID 44021100
Component 03
Building 03
Based on a Medicaid Recertification Survey completed on May 19, 2025, 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
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 document review and interview, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:
Document review on May 19, 2025, at 11:46 a.m., revealed the facility could not provide documentation for the following:
A. Fire alarm annual inspection/testing;
B. Semi-annual visual inspection;
C. Smoke detector sensitivity testing.
Interview with the maintenance supervisor on May 19, 2025, at 11:46 a.m., confirmed the documentation was unavailable at the time of the survey.
Plan of Correction:Regarding Cottage 3, although the fire alarm annual inspection/testing and the smoke detector sensitivity testing were not available during the onsite survey which took place on 5/19/25, they were, in fact, completed. This testing was completed on 11/11/24 by Johnson Controls. The semi-annual visual inspections were completed in July of 2024 and again in January of 2025. These semi-annual inspections are completed as part of the monthly life safety inspections completed by the maintenance department.
Moving forward, the fire alarm annual inspections, semi-annual visual inspections and the smoke detector sensitivity testing will all be stored in a "Life Safety" binder and this will be stored in the Executive Director's office (which will be up-to-date and available for all future surveys). This binder will be formalized and complete by 7/1/25
The Executive Director is responsible for monitoring this area for compliance and for assuring this information is available for future surveys.
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