Incomplete Fire Drill Records and Improper Use of Electrical Equipment
Summary
The facility failed to maintain complete fire drill records, as evidenced by the absence of documentation for fire drills conducted during the AM shift in the fourth quarter of 2024. During a record review and interview, the Administrator was unable to provide the required fire drill records and could not locate them in the designated binders. The facility was given an opportunity to submit the missing records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. Additionally, the facility did not maintain electrical equipment in accordance with regulatory requirements. Observations revealed the use of extension cords and daisy-chained power strips in several areas, including the Main Entrance, Kaiser Room, and Dietary Supervisor's Office. Specifically, extension cords were used to power a wander guard detector and a portable air conditioning unit, while a power strip was found powering another power strip for computers and monitors. The Maintenance Director confirmed these setups were due to insufficient outlets and the need to power specific equipment.
Plan Of Correction
Systemic Changes As a new system, the safety committee monthly meeting will review the documentation to ensure the plan of correction is sustained and completed. Any discrepancy will be addressed to the maintenance supervisor and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025. Corrective Action Maintenance director removed the yellow extension cord at the main entrance. Wander guard system is directly connected to the main power. Facility immediately removed the power strip from the kaiser room. The maintenance director will make sure that all electrical equipment is connected directly to the power outlet in the wall. Maintenance director and dietary manager removed the extension cord from the dietary manager's office and the portable air conditioner connected directly to the wall outlet. Identify other residents Maintenance director will do walk through the facility to make sure that this deficiency is not repeating in any other rooms. Any similar violations will be corrected immediately. Safety committee members will assist the maintenance director to identify any similar violations at the facility. Systemic Changes As a systemic change, the DSD and maintenance director will conduct an in-service to housekeeping and maintenance staff to re-educate them about the importance of not having any extension cords in the rooms & hallway. Housekeeping will assist and report to the maintenance director if they see any similar violations anywhere in the facility, and maintenance will correct it immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025.
Penalty
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
A three-to-one outlet multiplier was found in use in the first floor salon, with a hair dryer, hair straightener, and hair curler plugged into it, in violation of electrical equipment requirements. The maintenance director confirmed this setup during an interview.
A power strip not meeting required UL standards was found in use at a bedside, resulting in an electrical fire. The device had been brought in by a family member for charging a phone, and the facility could not verify its compliance with safety standards. This deficiency affected multiple residents and a smoke compartment.
Surveyors found that multiple window AC units throughout the facility were retrofitted by removing factory GFCI power cords and attaching extension cords, eliminating original electrical protections. One AC unit in the Dietary Director's office was also plugged into a power strip, contrary to regulations. Facility leadership confirmed these modifications, which violated electrical safety standards.
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Outlet Multiplier in Salon
Penalty
Summary
The facility failed to comply with electrical equipment requirements as outlined by NFPA 101 and related standards. During an observation, it was found that in the first floor salon, a three-to-one outlet multiplier was plugged into the wall, with a hair dryer, hair straightener, and hair curler all connected to it. This setup does not meet the specified requirements for the use of power strips and outlet multipliers in patient care areas, as only certain types of equipment and UL-listed devices are permitted, and extension cords or outlet multipliers are not to be used as substitutes for fixed wiring. The maintenance director confirmed the use of the three-to-one outlet multiplier in the salon during an interview. The report does not mention any specific residents or patients involved, nor does it provide details about their medical history or condition at the time of the deficiency. The deficiency was identified based on direct observation and staff interview, indicating a failure to adhere to established electrical safety protocols in the facility.
Plan Of Correction
The systematic change was removing the three-to-one outlet immediately. The Director of Maintenance will monitor the beauty shop for appropriate use of electrical outlets. The Director of Maintenance will report this findings to the Administrator and Monthly Quality Assurance meeting.
Unapproved Power Strip Causes Electrical Fire at Bedside
Penalty
Summary
A deficiency was identified when a power strip was found in use at a patient bedside location that did not meet the required approval standards. During a facility tour, it was observed that a power strip was located approximately one foot away from a resident's bed on the ground in Resident Room 34. The Maintenance Supervisor confirmed that an electrical fire had occurred at this location in the early morning hours, and the resident occupying the bed reported that the power strip had been brought in by a family member for charging a phone. The facility was unable to verify whether the power strip in question met the necessary UL 1363A or UL 60601-1 standards required for use with patient-care-related electrical equipment in a patient care vicinity. This deficiency affected 47 out of 116 residents and one of four smoke compartments, as noted during the survey. The report does not provide additional details regarding the medical history or condition of the resident at the time of the incident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: A: Power strips and extension cords were immediately removed from the rooms. Both family and resident were notified of power cord safety and the importance of using medical-grade approved cords and safety of surroundings around the power cords. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A: All residents have the potential to be affected by the deficient practice. Facility-wide audit conducted on 12/08/25 and all other power cords identified were noted and removed. Education was provided on 12/08/25 to the Maintenance Director on appropriate power cords within the facility. Facility-wide audit to be completed weekly for 12 weeks and then PRN as needed. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A: 1) Resident education on proper equipment usage (i.e., hospital graded extension cords only) 2) Staff In-Serviced on fire safety and prevention in regards to outlets and proper power cord identification—importance of keeping residents' belongings away from outlets and bringing concerns related to storage of belongings to facility leadership team 3) Daily resident room round sheet updated and to be conducted by assigned department managers. Weekly facility rounds will be conducted and every room and common area checked to ensure approved hospital grade extension cords are in place and outlet integrity is compliant by the maintenance supervisor or designee. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: A: Room round sheets will be turned in weekly. The Maintenance Director or designee will complete a facility-wide audit weekly for 12 weeks and report the results of the audit to the Safety Committee and QA meeting for compliance evaluation x4 months and then PRN as needed. Include dates when corrective action will be completed. The corrective action completion dates must be acceptable by the State Agency: Completion date: 12/11/2025
Improper Use of Extension Cords and Power Strips for Window AC Units
Penalty
Summary
Surveyors observed that throughout the facility, on each floor, multiple window air conditioning (AC) units were being used in place of the originally installed P-Tec units. These window AC units had been retrofitted by removing the factory-supplied GFCI power cords, then cutting, splicing, and attaching extension cords. This modification eliminated the AC units' original electrical protections. Additionally, one window AC unit in the Dietary Director's office was found plugged into a power strip, which is not permitted for this type of equipment. Interviews with the Administrator, Regional and local Maintenance Director, and the VP of Building Operations confirmed that power strips and extension cords were used to modify window AC units, resulting in the removal of the AC units' electrical protections and the attachment of heat-drawing equipment to power strips. These actions were found to be in violation of NFPA 101 and related standards, as extension cords and power strips were improperly used as substitutes for fixed wiring and permanent outlets.
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