Improper Use of Outlet Multipliers for Heat Tape
Summary
The facility failed to maintain electrical system requirements in one of four smoke compartments. During an observation, heat tape installed on the building was found to be plugged into outlet multipliers located outside the main entrance. This setup was directly observed by surveyors, and the maintenance supervisor confirmed the deficiency at the time of the survey. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract obligation or position. Bradford Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Bradford Manor's credible allegation of compliance. Education was provided to the Maintenance department by the Nursing Home Administrator regarding safety concerns with using outlet multipliers and its unacceptable practice. Heat tape was unplugged from outlet multiplier on day of survey. All other areas where heat tape is used were checked to ensure that no outlet multipliers were being used, none were identified. Ongoing compliance will be monitored through daily rounding by the Environmental Service Supervisor or designee 3x weekly for 2 weeks.
Penalty
Surveyors observed that the generator room contained an electrical breaker panel labeled "Panel HC" with an open breaker slot, indicating the electrical system was not maintained per NFPA 70 and NFPA 99 requirements. During an interview, the maintenance supervisor confirmed this electrical system deficiency in one of the facility’s smoke compartments.
An electrical panel inside the nurse station supply closet was found to be blocked by a large cart, making it inaccessible in violation of NFPA 70 requirements. This was confirmed by facility leadership during the survey.
Surveyors identified multiple deficiencies in the protection of electrical wiring, including broken receptacle cover plates, open junction boxes, open wires not ending in a junction box, and unsecured electrical outlets in two smoke compartments. These issues were confirmed by facility leadership and cited as non-compliant with NFPA 70 and NFPA 99 standards.
Surveyors found that a receptacle near an A-bed was missing a cover and a reading light over another A-bed had exposed, non-terminated wiring hanging from the underside of the cover. These electrical system deficiencies were confirmed by facility leadership during the inspection.
Surveyors identified deficiencies in electrical system maintenance, including an open junction box with exposed wiring and electrical panels blocked by storage or with a broken latch, which remained unresolved upon revisit.
The facility failed to maintain electrical system requirements, with unsecured junction boxes found above the ceiling on the first floor and exposed wiring in the Hood Mechanical Room. These deficiencies were confirmed during an exit interview with the Administrator.
Open Breaker Slot Found in Generator Room Electrical Panel
Penalty
Summary
The facility failed to maintain and inspect its electrical system in accordance with NFPA 70 and NFPA 99 requirements in one of four smoke compartments. During an observation of the generator room on April 30, 2026, at 1:00 p.m., surveyors identified an open breaker slot in the electrical breaker panel labeled "Panel HC." This condition was noted as a deficiency under NFPA 70-408.7, which requires proper closure of unused openings in electrical equipment. In an interview conducted at the same time, the maintenance supervisor confirmed the existence of this electrical system deficiency. No residents or patient-specific information was provided in the report, and no additional events beyond the observed open breaker slot and the maintenance supervisor’s confirmation were described.
Plan Of Correction
Maintenance department was educated on the need to maintain and inspect electrical system per NFPA 70 and NFPA 99 with respect to having no open breakers slots in the panel box. The open breaker was replaced 4/30/2026 following the identification of the missing breaker. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that there are no open breakers in the panel boxes. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Electrical Panel Blocked by Cart in Nurse Station Supply Closet
Penalty
Summary
During an observation on the second floor of the facility, it was found that an electrical panel located inside the nurse station supply closet was blocked by a large cart. This observation was made on December 22, 2025, at 12:25 p.m. The presence of the cart obstructed access to the electrical panel, which is a violation of NFPA 70 2011 Section 110.26, requiring electrical panels to be accessible. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director later that day. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The obstructing cart was removed immediately, freeing the 2nd floor electrical panel of blockage. The maintenance director will re-educate all staff on maintaining clear access to all electrical panels. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility is maintaining clear access to all electrical panels. Date of completion: 2/16/2026
Electrical Wiring Protection Deficiencies Identified
Penalty
Summary
Surveyors observed multiple electrical deficiencies in the facility, specifically related to the protection of electrical wiring in two of six smoke compartments. During a walkthrough, they identified a broken receptacle cover plate in the second floor dining room, several open junction boxes in various locations including above double doors near the first floor elevator room, above ceiling tiles across from the first floor mechanical room, above double doors near room 101, and above the suspended ceiling in the first floor elevator room. Additionally, open wires were found where a PAC unit had been removed in the first floor service hall corridor near the kitchen entrance, and an electrical outlet was not securely mounted to the wall in the first floor corridor across from the mechanical room. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director. The findings reference non-compliance with NFPA 70, National Electric Code, and NFPA 99, section 6.3.2.1, which require proper protection and enclosure of electrical wiring and components. No information about residents or their medical conditions was included in the report.
Plan Of Correction
Maintenance director replaced the receptacle protective cover plate to second floor dining room. Open conjunction boxes closed on 8/13/2025 near first floor elevator and across from mechanical room. Exposed wires in PAC unit in back hallway near kitchen placed back inside the unit 8/13/2025. Electrical outlet securely mounted to wall on first floor corridor 8/13/2025.
Electrical System Maintenance Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain components of the electrical system on one of four floors. Specifically, on the 2nd floor in Room 224, a receptacle near the A-bed was missing a cover, and in Room 226, the reading light over the A-bed had non-terminated, exposed wiring hanging from the underside of the cover. These deficiencies were identified during an inspection and confirmed in an interview with the Administrator, Regional Director, Regional Maintenance Director, and the Environmental Services Director.
Plan Of Correction
0911 The facility failed to maintain components of the electrical system, on one of four floors. No residents were affected. All residents have the potential to be affected. The 2nd floor Room 224, a receptacle near the A-bed was repaired and a cover was installed as required. 2nd floor Room 226, the reading light over the A-bed had non-terminated, exposed wiring hanging from the underside of the cover. An audit was completed by the Maintenance Director to ensure that all receptacles are installed as required and that all lights are installed as required. Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. Also, maintenance director and maintenance staff were educated on the requirement to audit the receptacles when installed. They were also educated that bedside lights must be inspected frequently for physical integrity. Education of floor staff (Certified nursing assistants, professional nurses, housekeepers) was initiated to report any damaged receptacles and overhead lights to maintenance for repair. The Maintenance Director/Designee will conduct one weekly audit of random receptacles for four weeks, then monthly for two months and then quarterly thereafter. In addition, auditing will occur for any newly installed receptacles and during room deep cleaning. The Maintenance Director/Designee will conduct one weekly audit for overhead lamps for four weeks and then monthly for two months. Additionally, overhead lamps will be audited when a repair or replacement is put in place. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Electrical System Deficiencies: Exposed Wiring and Inaccessible Panels
Penalty
Summary
Surveyors observed that the facility failed to maintain proper protection of electrical wiring in multiple areas. Specifically, an open junction box with exposed wiring was found in the basement phone room. Additionally, in the storage room across from the Health Care Administrator's office, two electrical panels (DP 2 and DP 4) were blocked by storage items within three feet, and one of the panels (DP 4) had a broken latch, making it difficult to open. During a follow-up onsite revisit, it was determined that the issue with the missing latch on the DP 4 electrical panel door had not been corrected, and the panel was still not secured properly. These deficiencies were confirmed during exit interviews with the Administrator and Maintenance Director. No information about residents or their medical conditions was included in the report.
Plan Of Correction
1) The electrical panel labeled DP 4 has been repaired so that it can latch and be easily opened. Storage has been removed from in front of electrical panel DP 2 and DP 4. 2) Other electrical panels have been checked to ensure that there is no storage and that the latch can close and be easily opened. 3) The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the electrical panels can latch and easily open, and that there is no storage within three feet of the panels. Results of the audits will be reported to QAPI.
Electrical System Deficiencies Found in Facility
Penalty
Summary
The facility failed to maintain electrical system requirements as per NFPA 70 and NFPA 99, affecting one of two levels of the facility. During an observation on April 17, 2025, between 9:05 a.m. and 9:08 a.m., two unsecured junction boxes were found above the ceiling on the first floor, near the rehab area and in front of the laundry. Additionally, at 10:05 a.m. on the same day, an observation inside the Hood Mechanical Room revealed a metal clad conduit wire with exposed wiring. These deficiencies were confirmed during an exit interview with the Administrator on April 17, 2025, at 11:15 a.m.
Plan Of Correction
The junction boxes will be secured on or by 5/23/2025. The exposed wire will be correct on or by 5/23/2025. Above ceiling audits for unsecure junction boxes will be made part of the Maintenance Quarterly Safety inspections by 5/23/2025. All maintenance mechanics will be inserviced on this by 5/23/2025. The exposed wire will be replaced on or by 5/30/2025 by Dunwoody's contracted electrician. This will be inspected quarterly by the Maintenance Manager or Designee and made part of the Maintenance Quarterly Safety inspections by 5/30/2025. All maintenance mechanics will be inserviced on this by 5/30/2025.
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