Deficient Maintenance of Sprinkler Systems and Improper Storage in Electrical Panel Room
Summary
Surveyors observed multiple deficiencies related to the maintenance of fire safety equipment and electrical panel access. During several walkthroughs with the maintenance supervisor (MS), it was noted that sprinkler deflectors in various rooms, including resident rooms, a restroom, and a shower room, had significant buildups of dust and, in one case, a green mildew-like substance. The MS acknowledged these findings during the observations. The facility's maintenance policy states that the maintenance department is responsible for keeping the building and equipment in a safe and operable manner and in compliance with applicable regulations. Additionally, the electrical panel room was found to be used for storage and as an office space for the case manager. Items such as binders, blank paper, and a floor polishing machine were stored within three inches of the electrical panel, which is not compliant with NFPA 70 requirements for clear working space around electrical panels. The MS confirmed that the room had been used in this manner for years due to limited space in the building and acknowledged the findings during the survey.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding electrical safety requirements as specified in NFPA 101 Life Safety Code (2012 Edition) and NFPA 70 National Electrical Code (2011 Edition), specifically regarding maintaining clear working spaces around electrical panels. Corrective Action Taken: On 05/20/2025, the Maintenance Supervisor immediately removed all stored items, including binders, paper, and floor polishing machine from the electrical panel room. The Case Manager's office was relocated to an alternative space within the facility. The electrical panel room was secured with appropriate signage indicating "Electrical Room - No Storage Permitted." The Maintenance Supervisor conducted a complete inspection of all electrical panel rooms facility-wide to ensure compliance with NFPA requirements for clear working spaces. Identification of Other Areas with Potential to be Affected: The Maintenance Supervisor, in conjunction with the Safety Committee, completed a facility-wide assessment on 05/20/2025 to identify any other electrical panels or utility rooms that could potentially be affected by improper storage or space utilization. This assessment included all four smoke compartments and documentation of current space utilization near all electrical equipment. Systemic Changes and Measures Implemented: 1. The facility's Maintenance Service Policy and Procedure has been revised to specifically address electrical room safety requirements, including: • Prohibition of storage within 36 inches of electrical panels • Required monthly inspections of all electrical rooms and panels 2. Implementation of a facility-wide space utilization assessment to ensure appropriate allocation of office and storage areas. Monitoring and Quality Assurance: The Maintenance Director will conduct weekly inspections of all electrical rooms for the first month, then monthly thereafter. The Director of Maintenance will conduct independent monthly audits to ensure continued compliance. Results will be documented and reviewed during monthly Safety Committee meetings and quarterly QAPI meetings. The QAPI Committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive quarters. Any identified issues will
Penalty
Surveyors found that a circuit breaker panel cover in one smoke compartment was improperly fastened with sheet metal screws instead of appropriate blunt-end fasteners, in violation of NFPA 70 requirements. The maintenance director acknowledged the use of sheet metal screws on the panel cover, and the report notes that this noncompliance could result in electric or fire hazards.
Surveyors identified that the facility’s electrical system was not maintained according to NFPA 101 and NFPA 70. In the kitchen electrical panel, breakers labeled for the dishwasher were in the off position while the dishwasher continued to run with power. In generator sub panel B, a breaker was labeled for a sprinkler pump even though no sprinkler pump existed, and there was an open breaker position without a blank cover. These issues were confirmed by the Maintenance Director and had the potential to affect all residents.
Surveyors observed that an electrical outlet in Nursing Station 1's med room was installed 18 inches from a sink and was not equipped with a required ground-fault circuit interrupter (GFCI), as mandated by NFPA 70, National Electrical Code. The DES confirmed during the survey that this outlet lacked GFCI protection, resulting in a cited deficiency related to utilities and electrical safety in one of the facility’s smoke compartments.
An electrical junction box above the Zone 8 suspended ceiling, near the smoke barrier doors by the Unit Scheduler's Office, was found without a cover plate, leaving electrical wiring exposed. The Director of Maintenance confirmed the issue during the inspection.
Surveyors observed multiple deficiencies including broken light bulb bases left in ceiling sockets, combustible materials stored too close to electrical panels, and exposed wiring behind a boiler. These issues were confirmed by facility leadership during the inspection.
An electrical outlet at Nurse Station #2 was found with a broken faceplate, exposing metal terminals. The CMO confirmed the damage had not been previously noticed. Facility policy assigns the Maintenance Director responsibility for maintaining safe equipment, but the exposed outlet was not addressed as required by NFPA 70.
Improper Fastening of Circuit Breaker Panel Cover with Sheet Metal Screws
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of electrical utility equipment in accordance with NFPA 70. During an observation at 3:15 PM, they noted that the cover of a circuit breaker panel was fastened using sheet metal screws instead of appropriate fasteners. This condition was found in 1 of 7 smoke compartments. The facility’s maintenance director, present during the observation, acknowledged that sheet metal screws were being used on the circuit breaker panel cover. The report states that this failure to comply with NFPA 70 could result in electric or fire hazards. No residents or specific patient conditions were mentioned in the report, and no additional events beyond the improper fastening of the circuit breaker panel cover were described.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0511 and assure continued compliance, the following plan has been put in place. K0511 - Electrical Panel Fasteners Immediate Correction: Unauthorized sheet metal screws were removed from the cited circuit breaker panel and replaced with OEM-approved, blunt-end machine screws to prevent internal wire damage. Identification of Others: A facility-wide audit of all electrical panels, sub-panels, and pull boxes was conducted. Any non-compliant fasteners found were immediately replaced with blunt-end hardware. Systemic Changes: The Electrical Safety Policy was updated to prohibit self-tapping or pointed screws. Maintenance staff were trained on NFPA 70 hardware requirements to maintain equipment integrity. Monitoring (QA): "Panel Fastener Integrity" was added to the Monthly Life Safety Walkthrough. Audit logs will be reviewed during quarterly QAPI meetings.
Improperly Labeled and Maintained Electrical Panels
Penalty
Summary
Surveyors found that the facility failed to maintain its electrical system in accordance with NFPA 101-2012 and NFPA 70-2011, potentially affecting all 69 residents. During a tour of the facility, surveyors observed in the kitchen electrical panel that the breakers labeled for the facility’s dishwasher were in the off position while the dishwasher itself was running and had power. Later, in generator sub panel B, surveyors noted a breaker labeled as a sprinkler pump even though the facility did not have a sprinkler pump, as well as an open breaker space without a blank installed. The Maintenance Director confirmed these findings at the time they were discovered. No specific residents, medical histories, or clinical conditions were mentioned in relation to these deficiencies.
Plan Of Correction
1.Based on observation and staff interview, no residents experienced negative outcomes related to electrical system deficiencies. The facility's kitchen dishwasher breakers were in the off position; the dishwasher was running and had power. It was also noted that in generator sub panel B there was a breaker listed as sprinkler pump as well as an open breaker that has no blank, while the facility has no sprinkler pump. 2.The Medical Director was notified by LNHA on 03/26/2026 of deficiencies including improper breaker configuration and labeling. 3.Electrical deficiencies will be corrected by licensed electrician on or before 04/30/2026. 4.Monthly inspections will be conducted and compliance reviewed in QAPI. 5.LNHA educated 03/26/2026 regarding the requirements for maintaining the facility's electrical equipment, including the requirements for the facility's kitchen dishwasher breakers' requirements in power being active and breaker reflecting that it is on, and vice versa. Also, Maintenance Direct was educated in the importance of ensuring the appropriate labeling of breakers.
Non-GFCI Electrical Outlet Near Sink in Medication Room
Penalty
Summary
Surveyors found that the facility failed to ensure electrical safety in accordance with NFPA 70, National Electrical Code, 2011 Edition, Section 210.8. During an observation in Nursing Station 1's medication room, an electrical outlet was identified 18 inches from a sink that was not equipped with the required ground-fault circuit interrupter (GFCI). The Director of Environmental Services (DES) was present during the observation and confirmed that the outlet, located near the sink, did not have a GFCI. This deficiency affected one of four smoke compartments and was cited as noncompliance with NFPA 101 requirements for utilities, gas, and electric systems. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the report focused solely on the physical environment and the noncompliant electrical installation near the sink in the medication room.
Plan Of Correction
K511 - Utilities - Gas and Electric (NFPA 70) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately removed the outlet from use and implemented interim safety measures. A licensed electrician was contacted to install a GFCI-protected outlet at Nursing Station 1 medication room sink area. The GFCI outlet was installed on 3/12/2026 to ensure compliance with NFPA 70 requirements and reduce risk of electrical shock. 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. On 3/12/2026, the Director of Environmental Services (DES) conducted a facility-wide audit of all electrical outlets located within proximity to water sources, including medication rooms, kitchen areas, and resident care areas. Any outlets identified as not GFCI-protected were immediately removed from service and scheduled for correction by a licensed electrician. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a preventive maintenance program that includes routine inspection of all electrical outlets near water sources for GFCI compliance. On 3/13/2026, the DES re-educated staff on NFPA 70 requirements, specifically related to GFCI installation near sinks and wet locations. The facility will ensure that all future electrical work is reviewed for compliance with applicable codes and completed by licensed professionals. 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. The DES or designee will conduct weekly environmental rounds for 3 months to ensure all outlets near water sources are GFCI-protected and functioning properly. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any deficiencies will be corrected immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Exposed Electrical Wiring Due to Missing Junction Box Cover
Penalty
Summary
During an inspection, it was observed that an electrical junction box located above the Zone 8 suspended ceiling, near the smoke barrier doors by the Unit Scheduler's Office, was missing a cover plate. This resulted in exposed electrical wiring. The Director of Maintenance confirmed the presence of the exposed wiring at the time of the observation. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The electrical junction box cover plate was replaced above the suspended ceiling in Zone 8. Maintenance staff will be educated on ensuring cover plates are in place for junction boxes moving forward. The Maintenance Director/Designee will perform an audit on junction box cover plates when work is completed above the ceiling to ensure the junction boxes have a cover plate in place. Results of audits will be forwarded to the QAPI Committee.
Noncompliance with Gas and Electrical Safety Standards
Penalty
Summary
The facility failed to ensure that equipment using gas or gas-related piping complied with NFPA 54 and that electrical wiring and equipment complied with NFPA 70. During observations, surveyors found two ceiling-mounted light sockets with the bases of broken light bulbs still inside the sockets in the Business/Activities Supply Cage. Combustible stock items were stored within three feet of electrical panels in both the Laundry and Sump Pump Room. Additionally, a Greenfield conduit was found displaced, exposing inner wires at the plug to the relay in the back of a boiler in the North Boiler Room. These deficiencies were confirmed through interviews with the facility Maintenance Director and the Corporate Operations Director at the time of observation.
Plan Of Correction
K 511 Element # 1 The (2) ceiling mounted light sockets in the Business/activities Supply cage with broken light bulbs, were repaired. The items stored in the Laundry Room within 3 of the electrical panel were removed. The Greenfield Conduit in the North Boiler Room was repaired. The combustible items within 3 of electrical panel in the sump pump room were removed. Element # 2 Current residents have the potential to be affected by the deficient practice. The facility's electrical equipment was evaluated to ensure proper maintenance. Any deficiencies found were corrected. Element # 3 The Maintenance Department was re-educated on properly maintained electrical equipment. Element # 4 The Administrator and/or designee will conduct random audits of the emergency preparedness plan x1/week for 1 month, then weekly for 1 month and then monthly for 3 months to ensure substantial compliance with a geographically specific risk assessment. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Broken Electrical Outlet Faceplate at Nurse Station
Penalty
Summary
A deficiency was identified when an electrical outlet at Nurse Station #2 was observed to have half of its faceplate cover broken, exposing metal terminals. This observation was made during a walkthrough with the Chief Medical Officer (CMO), who stated he had not previously noticed the broken faceplate. The facility's policy and procedure for the Preventative Maintenance Program, dated 12/19/2022, assigns responsibility to the Maintenance Director for ensuring that buildings and equipment are maintained in a safe and operable manner. The exposed outlet was not protected as required by NFPA 70, 2011 Edition, Article 406.6, and this lapse was found to affect one of five smoke compartments in the facility.
Plan Of Correction
K511 Utilities - Gas and Electric CFR(s) NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice Upon notification of the deficient practice on 05/28/2025, the MS changed the faceplate of the electrical outlet at Nurse Station #2 on 05/28/2025. (Exhibit #3) 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. There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring all electrical receptacles were maintained free of damage. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified. An observational audit of the electrical receptacles will be done once a month by MS for 3 months. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability.
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