Generator Set Maintenance Deficiency
Summary
The facility failed to maintain the generator set, as evidenced by an observation on February 4, 2025, at 11:50 a.m., which revealed that the low fuel level lamp was illuminated at the remote annunciator location. This deficiency affected both floors of the facility. During an exit interview with the Facility Administrator and the Facilities Manager on the same day, between 12:30 p.m. and 12:40 p.m., the emergency generator set deficiency was confirmed.
Plan Of Correction
K-0919 Generator Low Fuel Light was corrected. Maintenance Director job description reviewed and signed to ensure knowledge of expectation and responsibilities clear. Maintenance Director/designee will perform generator check to ensure no issues on Panel or with Unit weekly X4, then monthly X2 with results reviewed in QAPI.
Penalty
Surveyors found that an electrical panel labeled 'Fire Alarm Panel Inside' was obstructed by a desk, boxes, and a backpack in the Director of Staff Development Room, with items placed about one foot from the panel. The Maintenance Director confirmed the desk was recently added for new staff. This obstruction affected 36 residents in one smoke compartment and did not meet NFPA requirements for clear workspace around electrical equipment.
The facility failed to maintain electrical equipment as required by NFPA 70, with two electrical panels obstructed by wheelchairs in a storage room, affecting one smoke compartment. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the electrical system on one floor, as items were stored within 36 inches of electrical components in the 3rd floor storage room near the nurse's station. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain its electrical systems, as evidenced by an unsecured junction box located above the suspended ceiling assembly in Room 104. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Surveyors found that two electrical panels in mechanical rooms had several circuits missing required identifiers, with staff either unaware of their purpose or identifying them as spares. This failure to label circuits affected a portion of the facility and did not comply with NFPA 70 standards.
An electrical panel in the Biohazard Storage Room was found with an exposed opening due to a missing cover on one of the breaker spaces. Staff confirmed the issue and were previously unaware of the gap, which affected a portion of the facility and did not comply with required electrical safety codes.
Obstructed Electrical Panel in Staff Development Room
Penalty
Summary
A deficiency was identified when surveyors observed that an electrical panel labeled 'Fire Alarm Panel Inside' was obstructed by a desk, boxes, and a backpack in the Director of Staff Development Room. The items were positioned approximately one foot away from the panel, impeding clear access. This situation was noted during a facility tour and confirmed in an interview with the Maintenance Director, who stated that the desk was recently placed due to new staff and had not been there for long. The obstruction of the electrical panel affected 36 out of 120 residents in one of four smoke compartments. The report cites specific requirements from NFPA 101, NFPA 99, and NFPA 70, which mandate that sufficient workspace must be maintained around electrical equipment to allow for safe operation and maintenance. The observed obstruction did not comply with these standards, as it limited the required clear workspace around the panel.
Plan Of Correction
K919- Electrical Equipment - Other 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/07/2025, the desk and boxes obstructing electrical panel "D" in the DSD office were removed, restoring the required 36 inches of clearance. 2. Identification of other residents having the potential to be affected was accomplished by: On (date), the Maintenance Director conducted a facility-wide audit of all electrical panels and determined that no other panels were obstructed. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/2025 the Maintenance Director was educated by the Administrator on the requirements and documentation for maintaining a 36-inch clearance around all electrical panels in accordance with NFPA 70. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly inspection of all electrical panels to ensure required clearance is maintained. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Obstructed Electrical Panels in Storage Room
Penalty
Summary
The facility failed to maintain electrical equipment in accordance with NFPA 70, National Electric Code, as required by NFPA 101 (2012 Ed.). During an observation on April 30, 2025, at 9:20 a.m., it was noted that two electrical panels were obstructed by wheelchairs in the B-2 storage room on the second floor of the B wing. This deficiency affected one out of 27 smoke compartments in the facility. An interview with the Facility Administrator and Maintenance Director on May 1, 2025, at 11:00 a.m., confirmed the presence of the electrical equipment deficiency. The obstruction of the electrical panels by wheelchairs indicates a failure to ensure clear access to electrical equipment, which is necessary for safety and compliance with the relevant codes.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Maintenance removed the wheelchairs in the second-floor b-wing storage room that were obstructing the electrical panels on 5/1/2025. The Director of Maintenance/designee will conduct random weekly audits throughout the facility two times per week for two weeks then weekly for two weeks to ensure there are no electrical panels obstructed by wheelchairs. The results of these audits will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.
Electrical System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the electrical system properly in one location, specifically affecting one of the three floors. During an observation on April 8, 2025, at 12:02 pm, it was noted that items were stored within 36 inches of electrical components in the 3rd floor storage room near the nurse's station. This proximity of stored items to electrical components constitutes a deficiency in maintaining the electrical system as per NFPA 99 Chapter 10 requirements. The deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager on the same day at 1:15 pm, where they acknowledged the issue with the electrical systems in the specified location.
Plan Of Correction
1. Storage items have been moved away from all electrical panel's components in the third floor storage room near the nurses' station. 2. Items have been moved to at least 36 inches of electrical components in facility storage rooms. 3. Maintenance/Designee will educate all staff about maintaining a 3 foot clearance from all electrical panels. 4. Maintenance/Designee will complete audits weekly x4, then monthly x3. Audits will be reported to QAPI.
Unsecured Junction Box Found in Room 104
Penalty
Summary
The facility failed to maintain its electrical systems, as evidenced by an unsecured junction box located above the suspended ceiling assembly in Room 104. This deficiency was observed on March 31, 2025, at 11:55 a.m. During an exit interview with the Facility Administrator and the Facilities Manager, the deficiency was confirmed, indicating a lapse in maintaining the electrical systems on the floor.
Plan Of Correction
Facility cannot retroactively correct deficiency. Facility audit of all junction boxes completed by maintenance director. All junction boxes were secured. Junction box cited during survey corrected at time of survey. Education provided to maintenance staff on security of junction boxes. Maintenance director/designee to audit junction boxes monthly X 3 months with results sent to the QA committee to ensure compliance.
Electrical Panel Circuits Missing Required Identification
Penalty
Summary
Surveyors observed that the facility failed to maintain proper identification of electrical circuits in two separate electrical panels located in mechanical rooms. Specifically, Panel A was found to have two out of forty-two circuits (circuits 13 and 27) missing identifiers, and Panel F had three out of forty-two circuits (circuits 26, 28, and 30) without labels. During interviews, staff indicated that the unlabeled circuits in Panel A were considered spares, while for Panel F, staff were unaware of the purpose of the unlabeled circuits. These deficiencies were identified during a facility tour and staff interviews, affecting 23 of 103 residents in one of five smoke compartments. The lack of proper labeling on the electrical panels was found to be non-compliant with NFPA 70 National Electrical Code requirements, which mandate that each circuit be clearly and legibly identified as to its specific purpose or use.
Plan Of Correction
How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, that solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly fire drill reports to ensure compliance with varying times and shift compliance. Any findings will be corrected within the month by way of a separate drill if required. The Facilities Maintenance Director will report compliance and findings of fire drills to the Quality Assurance Committee monthly for 12 months for integration and recommendations if indicated. K 919: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? No residents were found to be affected by the deficient practice in regard to the unlabeled circuits. The Maintenance Lead inspected and identified that circuits 13 and 27 in Panel A and confirmed them to be "spares". They were correctly labeled as "SPARE" on 03/27/2025. The maintenance lead inspected and identified that circuits 26, 28, and 30 on Panel F and confirmed them to be "spares". They were correctly labeled as "SPARE" on 03/27/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other residents were found to have been affected by the deficient practice and the corrective action taken above ensures that no residents will be affected. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Facilities Maintenance Director in-serviced all Maintenance Personnel in regard to the requirements of K919, specifically ensuring all circuit breakers are labeled. The Facility Maintenance Lead will inspect the electrical panels for proper circuit labeling monthly for three months. After this, the Facilities Maintenance Director added an annual "Inspect and Document the Main and Feeder Circuit Breakers" task to the TELS system to
Exposed Opening in Electrical Panel
Penalty
Summary
During a facility tour and staff interview, an electrical panel located in the Biohazard Storage Room near Room 27 was observed to have an exposed opening. Specifically, one of the 42 breaker spaces, labeled as '24', was missing a cover, resulting in an open gap in the panel. Staff present at the time confirmed the observation and indicated they were unaware of the missing cover. This deficiency affected 27 out of 92 residents and one of six smoke compartments. The finding was cited as a failure to maintain electrical equipment in accordance with NFPA 101 and NFPA 70 requirements, which mandate that unused openings in electrical panels be properly closed.
Plan Of Correction
The EVS Director was trained by the Administrator on 4/9/25 on the importance of electrical panel safety. 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 EVS Director will conduct quarterly inspections of all electrical panels and wiring to ensure compliance. These inspections will be documented, and corrective actions will be taken as necessary. Results will be reviewed in the QAPI meetings for ongoing compliance oversight.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.