Failure to Conduct Annual Electrical Receptacle Inspection
Summary
The facility failed to conduct the required annual electrical receptacle inspection in resident care areas within one of two smoke zones. During a document review on October 8, 2024, it was found that there was no documentation verifying that electrical receptacles had been tested within the last 12 months. This was confirmed in an interview with the Director of Maintenance, who acknowledged that the receptacles in patient care areas had not been tested in the past year. Further observation on December 9, 2024, revealed that the issue had not been corrected, as confirmed again by the Director of Maintenance. The lack of testing and documentation indicates a failure to comply with the NFPA 101 Electrical Systems - Maintenance and Testing requirements, specifically regarding the testing of hospital-grade receptacles in patient care areas.
Plan Of Correction
1. Facility is unable to retroactively conduct annual electrical receptacle inspection in resident care areas. 2. A facility-wide audit of electrical receptacles will be completed. Maintenance Staff will be educated on the requirement to perform annual receptacle inspections. 3. Maintenance Director will complete annual electrical receptacle inspections by 01/27/2025. 4. NHA or designee will audit Life Safety Book semi-annually to confirm completion of annual inspections and that the documentation has been completed. The results of monitoring will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.
Penalty
Surveyors found that the facility did not perform or could not document required annual testing of electrical receptacles for tension and polarity in patient care areas, as mandated by NFPA 99. During record review with the Maintenance Director, no evidence was produced to show that hospital‑grade and other required receptacles had been tested at the specified intervals, and the Maintenance Director acknowledged this lack of documentation. This noncompliance with NFPA 99 Section 6.3.4 was cited as a deficiency affecting all occupants who rely on the facility’s electrical systems.
Surveyors identified that the facility did not fully comply with NFPA 99 requirements for electrical receptacle maintenance and testing. Review of the electrical receptacle testing log showed that only tension testing was documented, with no evidence of polarity testing being conducted. During interview, the Maintenance Director confirmed that staff had never tested receptacle polarity. This deficiency was cited as affecting the entire facility and was noted as potentially causing faulty electrical equipment which can result in fire.
The facility did not provide documentation verifying that annual inspections and testing of electrical receptacles in resident care areas were completed, as required by NFPA 99. This deficiency was confirmed by both the Administrator and the Director of Maintenance, and affected all smoke zones within the component.
The facility did not perform required testing of electrical receptacles at resident bed locations, including both hospital-grade and non-hospital grade outlets, as mandated by regulations. Documentation and interviews confirmed that testing for physical integrity, polarity, and grounding blade retention force was not conducted throughout the facility.
Multiple hospital-grade electrical outlets in resident rooms failed inspection, and there was no documentation showing that these outlets were repaired or replaced as required. This deficiency was confirmed by the Maintenance Director.
The facility failed to accurately test electrical receptacles in resident care areas and lacked documented performance data. Additionally, improper installation of a power cord passing through the ceiling into interstitial space was observed, with a power strip used as permanent wiring above the fire sprinkler system, posing a potential fire hazard. These issues were confirmed by the Director of Maintenance and acknowledged by the Administrator.
Failure to Perform and Document Required Annual Receptacle Testing
Penalty
Summary
The deficiency involves the facility’s failure to comply with NFPA 99 requirements for electrical systems maintenance and testing, specifically related to receptacle testing for tension and polarity. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that hospital‑grade and other required receptacles at patient care locations had been tested at the required intervals. The facility was unable to provide documentation that annual testing for receptacle tension and polarity had been performed as required by NFPA 99 (referenced as both the 2012 and 2021 editions in the report). The Maintenance Director acknowledged that the facility failed to provide documentation demonstrating that the required annual receptacle testing for tension and polarity had been completed. The report notes that this failure to maintain and document testing of electrical receptacles could affect all occupants in the facility in the event of a fire or other emergency. No specific residents, clinical conditions, or individual patient events are described in the report; the deficiency is based solely on the absence of required testing records and the associated noncompliance with NFPA 99 Section 6.3.4 for Class III electrical systems.
Plan Of Correction
The Tension and Polarity test was performed throughout the building and completed on .The facility has determined that all residents have the potential to be affected.An in-service education program will be conducted by the administrator.The administrator will conduct for a period of three months a random audit of completed documentation. The Tension and Polarity test was performed throughout the building and completed on [R] . The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Perform Required Polarity Testing of Electrical Receptacles
Penalty
Summary
The facility failed to properly maintain and test electrical receptacles in accordance with NFPA 99 requirements for electrical systems maintenance and testing. During record review, surveyors found that the facility’s electrical receptacle testing log documented only tension testing of receptacles and did not include any indication that polarity testing was performed. In a concurrent interview, the Maintenance Director acknowledged that facility staff had never tested the polarity of the receptacles. The deficiency was cited as affecting the whole facility and was noted as potentially causing faulty electrical equipment which can result in fire.
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 K0914 and assure continued compliance, the following plan has been put in place. K0914 - Electrical Receptacle Testing Immediate Correction: Re-testing of electrical receptacles in affected patient care areas was performed. Outlets were verified for polarity and grounding continuity in addition to tension requirements. Identification of Others: A comprehensive re-testing of all receptacles in resident care areas was initiated. The Testing Log was revised to include dedicated columns for Polarity, Grounding integrity, and Tension.Systemic Changes: The facility procured UL-listed polarity analyzers. Staff were trained on NFPA 99, Section 6.3.4.1 regarding hospital-grade electrical verification.Monitoring (QA): The Maintenance Supervisor will audit 10% of testing logs monthly. Findings will be reported to the QAPI Committee to ensure all data points are consistently recorded.
Failure to Document Annual Electrical Receptacle Inspections
Penalty
Summary
Surveyors determined that the facility failed to provide documentation verifying that annual inspections and testing of electrical receptacles in resident care areas had been completed. During a document review, it was found that there was no evidence to confirm that electrical receptacles had been tested within the last 12 months in any of the twelve smoke zones of the component. This lack of documentation was identified during a review conducted between 9:30 AM and 10:35 AM on December 18, 2023. At the exit conference, both the Administrator and the Director of Maintenance confirmed that there was no documentation available to show that the required annual electrical inspections had been performed. The deficiency specifically relates to the absence of records for the testing of electrical receptacles in resident care areas, as required by NFPA 99 standards.
Plan Of Correction
Facility will ensure documentation of annual inspections of electrical receptacles in resident care areas is completed and will include in building Management Software task list as an annual inspection. Education on the inspection of and documentation of electrical receptacles utilizing the annual inspection report in building Management Software task list will be provided to the appropriate staff. Audits will be completed semi-annually to check on schedule and confirm results are filed in life safety book. Findings will be reviewed in monthly QAPI meetings.
Failure to Test Electrical Receptacles at Resident Bed Locations
Penalty
Summary
The facility failed to ensure that electrical receptacles at resident bed locations were tested according to required intervals. Specifically, document review revealed that non-hospital grade receptacles were not tested at intervals not exceeding 12 months, and hospital-grade receptacles were not tested based on documented performance data, with a minimum frequency of at least every 12 months. The required testing includes visual inspection of physical integrity, verification of correct polarity of hot and neutral connections, and measurement of the retention force of the grounding blade, except for locking-type receptacles. These requirements apply to all resident care rooms throughout the facility. During the survey, the Maintenance Director confirmed in an exit interview that testing of electrical receptacles at resident bed locations had not been performed. The deficiency affects the entire facility, as the lack of testing was not limited to a specific area or group of residents. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
Electrical receptacle testing documentation not provided at survey was obtained. Electrical receptacle testing of hospital and non-hospital grade receptacles was completed in November 2024. Hospital and non-hospital grade receptacles testing will occur again in November 2025 so as not to exceed the 12-month requirement. Inspection will be entered in the electronic preventative maintenance program as a task to be completed as required. Monitored by Director of Maintenance or designee.
Failure to Test and Repair Hospital-Grade Electrical Receptacles
Penalty
Summary
The facility failed to ensure that hospital-grade electrical receptacles at patient bed locations and areas where deep sedation or general anesthesia is administered were tested after initial installation, replacement, or servicing, as required by NFPA 99. During a record review, it was found that multiple outlets in resident rooms throughout the building failed inspection in 2024, and there was no documentation or evidence provided to show that these outlets were repaired or replaced. This deficiency was confirmed by the Maintenance Director at the time of discovery. No information was provided regarding the specific medical history or condition of the residents affected at the time of the deficiency.
Plan Of Correction
Element 1: Multiple outlets in resident rooms failed inspection and documentation did not indicate repair or replacement. Documentation now includes date and type of corrective action. Element 2: This deficient practice has the potential to impact the 30 residents near those outlets in the event of a fire. Element 3: Physical Plant Manager instructed maintenance personnel to document the date and type of corrective action on 06/03/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done monthly and brought to QAPI.
Deficiencies in Electrical System Testing and Installation
Penalty
Summary
The facility failed to conduct accurate testing of electrical receptacles in resident care rooms and bed locations, as well as failed to provide documented performance data for these receptacles. This deficiency was identified during a record review, which revealed that the testing report did not include individual testing of receptacles in resident rooms, bed locations, and GFCI outlets in resident restrooms. The Director of Maintenance confirmed these findings during an interview, acknowledging the lack of proper documentation and testing. Additionally, during a facility tour, it was observed that a power cord was improperly installed, passing through the ceiling into the interstitial space, where a power strip was being used as permanent wiring above the fire sprinkler system. This improper installation could potentially result in a fire hazard. The Director of Maintenance also confirmed these observations, and the findings were acknowledged by the Administrator during the exit conference.
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