Medication Refrigerator Not Connected to Critical Branch and EES Maintenance Documentation Lacking
Summary
The facility failed to ensure that electrical receptacles serving medication preparation areas, specifically those used for medication refrigerators, were connected to the critical branch of the Essential Electrical System (EES) and were not distinctly marked as required by NFPA 99. During a fire safety tour, it was observed that a medication refrigerator was not plugged into a receptacle powered by the critical branch, and the required distinctive color or marking was absent. This deficiency was acknowledged by the Regional Maintenance Director during the observation and was reviewed with facility leadership at the exit conference. Photographic evidence was obtained to document the finding. Additionally, the facility did not maintain proper documentation for the maintenance and testing of the EES, including the generator and associated equipment. Required records for weekly inspections, monthly load exercises, and other scheduled maintenance activities were not provided during the record review with the Regional Director of Plant Operations. The lack of documentation means that the facility could not demonstrate compliance with NFPA 99, NFPA 110, and related standards for ensuring the reliability of emergency power systems. These deficiencies affect all residents who receive refrigerated medications from the affected medication room, as well as all residents and staff who rely on the facility's emergency electrical systems. The findings were based on direct observation, staff interviews, and record reviews conducted by surveyors during the inspection.
Plan Of Correction
Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: Weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in [date] and will be conducted annually, with the next test due [date], and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due [date], and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Penalty
Surveyors found that a medication refrigerator in the South Wing medication room was plugged into a receptacle that was not distinctly marked or supplied from the critical branch of the essential electrical system, as required by NFPA 99. This issue was identified for 1 of 5 sampled medication refrigerators and affected residents whose medications were stored in that unit. The Administrator and Maintenance Director observed and acknowledged the noncompliant receptacle configuration during the fire safety tour, and the findings were later reviewed with them along with photographic evidence.
A facility failed to maintain the required distinctive color markings on an emergency electrical receptacle in the dining room, as most of the red coloring had been worn off by residents' wheelchairs. The Maintenance Supervisor confirmed the deficiency, noting the receptacle should be red to indicate its connection to the life safety emergency system.
Surveyors found that electrical outlets supplied by the emergency generator in one area of the facility were not marked with a distinctive color as required by NFPA 99. The maintenance director confirmed that some corridor outlets on emergency power were not properly identified, which could lead to staff not using them during a power outage.
Medication Refrigerator Not Connected to Critical Branch Receptacle
Penalty
Summary
Surveyors identified a deficiency involving the electrical supply to a medication refrigerator in the South Wing medication room. During a fire safety tour conducted with the Administrator and the Maintenance Director at 4:00 PM, it was observed that the South Wing medication room refrigerator was not plugged into a distinctly marked receptacle that was supplied from the critical branch of the essential electrical system, as required by NFPA 99. The receptacle serving this refrigerator lacked the distinctive color or marking that indicates connection to the life safety or critical branch. This issue was noted for 1 of 5 sampled medication refrigerators and was determined to affect residents residing in the South Wing, whose medications are stored in that refrigerator. The Administrator and the Maintenance Director were interviewed at the time of observation and acknowledged the findings. The deficiency and supporting photographic evidence were reviewed again with them during the exit conference at 5:30 PM. No additional resident-specific clinical details or medical histories were provided in the report.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K917 Electrical Systems - Essential Electric System It is the practice of this facility to ensure the critical branch supplied power to select receptacles serving medication refrigerator. Immediate Corrective Action: The Maintenance Director was in-services regarding all refrigerators that store medicine in the medication room need to be plugged into a critical branch supplied power receptacle, identified by red cover. The Maintenance Director contacted the vendor to ensure the critical branch supplied power was properly identified. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants regarding the facilities practice ensuring that critical branch supplied power to select receptacles serving medication refrigerator are properly identified by a red cover. Maintenance Director and/or designee will complete a House-wide audit of all the medication room to ensure that the medication refrigerator are plugged into the correct receptacle. Monitoring: Maintenance Director will random monthly audits of the refrigerators in the medication room to ensure that it is plugged into the red cover receptacle. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance. The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K917 Electrical Systems - Essential Electric System It is the practice of this facility to ensure the critical branch supplied power to select receptacles serving medication refrigerator. Immediate Corrective Action: The Maintenance Director was in-services regarding all refrigerators that store medicine in the medication room need to be plugged into a critical branch supplied power receptacle, identified by red cover. The Maintenance Director contacted the vendor to ensure the critical branch supplied power was properly identified. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants regarding the facilities practice ensuring that critical branch supplied power to select receptacles serving medication refrigerators are properly identified by a red cover. Maintenance Director and/or designee will complete a House-wide audit of all the medication room to ensure that the medication refrigerator are plugged into the correct receptacle. Monitoring: Maintenance Director will random monthly audits of the refrigerators in the medication room to ensure that it is plugged into the red cover receptacle. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance.
Emergency Electrical Receptacle Markings Worn Off
Penalty
Summary
The facility failed to ensure that all emergency electrical receptacles supplied from the life safety and critical branches had distinctive color markings, as required by NFPA 99 standards. During an observation in the dining room, a receptacle located next to the exit sliding door was found to be missing most of its red coloring, which is used to indicate its connection to the emergency power system. The Maintenance Supervisor confirmed that the outlet was designated as an emergency outlet and should be red in color, but stated that the red coloring had been worn off due to contact with residents' wheelchairs. A review of the facility's Maintenance Service Policy and Procedure indicated that the Maintenance Department is responsible for maintaining the building and equipment in compliance with federal, state, and local regulations. The policy also outlines that maintenance personnel are tasked with ensuring the building remains safe and operable at all times. Despite these requirements, the emergency receptacle in question was not properly marked, resulting in noncompliance with regulatory standards.
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 systems and essential electric system receptacles as specified in NFPA 99 codes 6.4.2.2.6, 6.5.2.2.4.2, and 6.6.2.2.3.2. Corrective Action Taken: On 5/20/2025, the Maintenance Director immediately replaced the emergency receptacle located in the dining room next to the exit sliding door with a new red-colored receptacle that clearly identifies it as being connected to the life safety emergency system. Additionally, all emergency receptacles throughout the facility were inspected for proper color identification and marking. Identification of Other Areas with Potential to be Affected: The Maintenance Director conducted a facility-wide assessment on 5/20/2025 of all emergency receptacles connected to life safety and critical branches to identify any other receptacles with worn or missing distinctive color markings. This assessment included all four smoke compartments of the facility. Systemic Changes and Measures Implemented: 1. A preventive maintenance schedule has been implemented requiring monthly inspections of all emergency receptacles for proper color identification. Monitoring and Quality Assurance: The Maintenance Director will conduct monthly audits of all emergency receptacles to ensure proper identification markings are maintained. Results will be documented on the Emergency Receptacle Inspection Log. The Director of Maintenance will review these logs monthly and report findings to the quarterly Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for a minimum of three consecutive quarters. Date of Completion: 5/20/2025
Failure to Distinctly Mark Emergency Power Outlets
Penalty
Summary
Surveyors observed that electrical receptacles or cover plates supplied from the life safety and critical branches in the original side of the facility were not marked with a distinctive color or marking as required by NFPA 99 standards. During the inspection, it was noted that the emergency generator provided power only to dedicated outlets, and some outlets in the corridors were on emergency power but lacked the required distinctive color marking. The maintenance director confirmed during the interview that these outlets were not properly identified, which could result in staff not recognizing or using them during a power outage. These findings were confirmed at the time of observation with the maintenance director present. No specific residents or patient medical histories were mentioned in the report, and the deficiency was based solely on facility infrastructure and staff interviews.
Plan Of Correction
Electrical receptors that are connected to the back up generator were changed to red cover plates. Audit completed of all electrical receptors connected to the back up generator to ensure those receptacles are identified with a red cover plate. Corrections made as needed. Administrator/Designee completed education to Maintenance Department on requirement that all electrical receptacles connected to the back up generator must have a distinctive red cover plate so it is easily identified by staff during an emergency situation. Maintenance Director/Designee will complete random audits of electrical receptacles to ensure emergency receptacles are identified with a red cover plate with findings submitted to QAPI for review and recommendations. Maintenance Director is responsible for maintaining compliance.
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