Failure to Perform Emergency Lighting Tests at Generator
Summary
The facility failed to perform the required functional tests of the battery-powered emergency lighting source at the generator, which serves the entire component. During an observation on October 8, 2024, it was noted that the facility did not conduct the battery back-up emergency lighting test at the generator for 30 seconds monthly and 90 minutes annually. Additionally, the emergency light was found not mounted and was instead laying on an electrical duct. This deficiency was confirmed through an interview with the Director of Maintenance on the same day. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected. The emergency lighting test had still not been performed, and the light fixture remained unmounted. The Director of Maintenance confirmed during interviews on December 9, 2024, that the deficiency identified in the initial observation had not been addressed.
Plan Of Correction
1. The facility is unable to retroactively conduct a 30-second monthly test or 90-minute annual test of the battery backup emergency lighting in the generator room before the survey. 2. The facility had a new Maintenance Director that started on 12/09/24. Maintenance or Designee will conduct a 30-second monthly test and a 90-minute annual test of the battery backup emergency lighting. The 90-minute test will be completed by 01/27/2025. Battery will be replaced as necessary. 3. Education will be provided to Maintenance staff regarding testing of the battery backup emergency lighting. Documentation of testing will be maintained in the Life Safety Book per regulation. 4. Maintenance Director or Designee will complete audits of routine testing monthly until substantial compliance has been achieved and quarterly thereafter. 5. Results of the audits will be presented to the QAPI committee for review and analysis for continued monitoring.
Penalty
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility did not maintain required documentation showing that annual NFPA 99-compliant testing (including physical integrity, resistance, leakage current, and touch current tests) was performed on electrical equipment used for patient care. During record review with the Maintenance Director, no records could be produced to verify that this testing had been completed as required, and the Maintenance Director acknowledged the lack of documentation.
Surveyors found that patient-care related electrical equipment was not inspected and maintained in accordance with NFPA 99 requirements. Biomedical inspection records showed that inspections were not current, and an observation in the gym revealed two microwaves, a toaster oven, and an "E Stem" device with overdue inspection stickers from 2024. During an interview, an assistant reported that this equipment was supplied by the corporate office and maintained by a different company, yet the items remained in use in a patient-care area without up-to-date inspections, affecting one of seven smoke compartments.
A portable blood pressure machine in the facility was found to be in use without undergoing the required Bio-Medical testing. The machine had been used daily for over two months, as confirmed by a staff nurse and the Director of Maintenance. This deficiency was acknowledged by the facility's administration during the exit conference.
The facility did not conduct the required annual inspection of electrical receptacles in resident care areas, affecting all resident bed locations. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
The facility did not ensure proper maintenance of electric beds as per the manufacturer's guidelines. During a survey, it was found that electrically operated beds were not inspected at the required intervals, and there was no documentation of formal inspections or maintenance. The Environmental Services Director acknowledged the lack of unique identifiers for beds and stated that beds were checked annually using a room audit form, but specific beds were not identified. This failure to adhere to maintenance requirements constituted a deficiency in compliance with NFPA 99 standards.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Failure to Maintain Annual Testing Documentation for Patient-Care Electrical Equipment
Penalty
Summary
The deficiency involves the facility’s failure to comply with NFPA 99 requirements for testing and maintenance of patient-care-related electrical equipment (PCREE). During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that physical integrity, resistance, leakage current, and touch current tests were performed on electrical equipment used for patient care. The facility was unable to provide documentation that this electrical testing was completed on an annual basis as required by NFPA 99. The Maintenance Director acknowledged that the facility failed to provide documentation demonstrating that annual electrical testing of equipment used for patient care had been completed. The deficiency was cited under NFPA 99 (referencing sections 10.3, 10.5.2.1, and 10.5.2.5, among others) and was noted as affecting all occupants in the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were described in the report.
Plan Of Correction
The testing of electrical equipment was performed by DESCO throughout the building. A report has been provided and work was 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 testing of electrical equipment was performed by DESCO throughout the building. A report has been provided and work was completed onThe 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 Maintain and Inspect Patient-Care Electrical Equipment per NFPA 99
Penalty
Summary
Surveyors identified a deficiency in the facility’s inspection and maintenance of patient-care related electrical equipment (PCREE) as required by NFPA 99. During record review at 10:40 AM, biomedical inspection records showed that patient electrical equipment inspections were not current, indicating that required testing and maintenance had not been performed in accordance with established intervals. The report notes that the facility failed to inspect PCREE in accordance with NFPA 99, which governs testing, maintenance, and documentation of such equipment. During an observation at 2:45 PM in the gym, surveyors found multiple pieces of patient-care related electrical equipment with overdue inspection stickers from 2024, including two microwaves, one toaster oven, and an "E Stem" device. In a concurrent staff interview, the Assistant stated that this equipment was outsourced from the corporate office and that a different company, not the facility, was responsible for the equipment. The deficiency was cited as affecting one of seven smoke compartments and was linked to noncompliance with NFPA 99 (2012 Edition) sections 10.3 and 10.5.2.1.
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 K0921 and assure continued compliance, the following plan has been put in place. K0921 - Electrical Equipment Testing & Stickers Immediate Correction: Non-compliant items (microwaves, toaster, E-Stim machine) were removed and inspected by a licensed Biomedical vendor. All items passed and now bear current 2026 inspection stickers. Identification of Others: A "Wall-to-Wall" audit of all electrical equipment was conducted. Any item found with an expired or missing sticker was sequestered for testing and repair. Systemic Changes: The Master Equipment Inventory (MEI) was updated to track Last Test and Next Due dates. Staff were re-educated on checking for stickers before use and "Red Tagging" expiring equipment. Monitoring (QA): The Maintenance Director will perform monthly spot checks of 10 random electrical items. Results will be presented at the monthly Safety Committee and quarterly QAPI meetings.
Failure to Test Electrical Equipment Before Use
Penalty
Summary
The facility failed to provide documentation for the electrical testing of fixed and portable medical equipment, specifically a portable blood pressure machine. During a tour of the facility, it was observed that the machine was connected to an electrical outlet for charging and was ready for use without having undergone the required Bio-Medical testing before being placed into service. This oversight was confirmed by the Director of Maintenance during the tour. Interviews conducted during the tour revealed that the portable blood pressure machine had been in use daily for over two months without the necessary testing. The staff nurse confirmed the machine's usage, and the Director of Maintenance acknowledged the lack of testing documentation. These findings were discussed and acknowledged by the Administrator and the Director of Maintenance during the exit conference.
Failure to Perform Annual Electrical Inspections
Penalty
Summary
The facility failed to maintain the required inspections of electrical wiring and receptacle systems, which affected all resident bed locations. During a documentation review on March 12, 2025, it was revealed that the annual inspection of receptacles in resident care areas was not performed. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
Facility will conduct annual receptacle testing in resident care areas. 4/28/25 Maintenance staff educated on receptacle testing. The Director of maintenance will conduct random facility audits.
Failure to Maintain Electric Beds as per Manufacturer's Guidelines
Penalty
Summary
The facility failed to ensure that patient care-related electrical equipment, specifically electric beds, was properly maintained according to the manufacturer's specifications. During the Life Safety Code Survey, it was observed that electrically operated beds were in use throughout the facility without documented formal inspections or maintenance. The facility's policy on medical equipment management required that all medical and electrical patient care equipment be evaluated prior to use and maintained according to specific criteria. However, there was no inventory or unique identification for the electrically operated beds, and no preventative maintenance forms were available to indicate that electrical safety checks were conducted routinely as required by the manufacturer. The survey revealed that the M.C. Rexx brand bed manual specified that each bed should be inspected at least once a year by qualified technicians, with a detailed checklist provided for the inspection. Despite this, the facility did not maintain records of such inspections. The Environmental Services Director confirmed that beds were checked annually using a room audit form, but there were no unique identifiers for the beds, and specific beds were not identified during these audits. This lack of documentation and adherence to the manufacturer's maintenance requirements constituted a deficiency in the facility's compliance with the 2012 edition of NFPA 99, Health Care Facilities Code, which mandates the establishment of policies and protocols for testing patient care-related electrical equipment.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K921 Corrective Action- To ensure the facility meets all the requirements for NFPA 101 Electrical Equipment Testing and Maintenance in regards to the testing of portable patient care related electrical equipment (PCREE), specifically patient electric beds. 1. The Maintenance Director has obtained manufacturers recommendations for each type of in-house electrical bed, and created an auditing system to monitor testing of each type of bed per manufacturer recommendations. 2. The Maintenance Director will complete a full house audit of resident beds to ensure all bed types are inspected per manufacturer recommendations, and documented as required by the NFPA 101. 3. The Administrator will oversee in-services to all maintenance department staff in regard to the NFPA 101 guidelines for patient care related electrical equipment testing and maintenance requirements. 4. To prevent future deficit in this practice, the Maintenance Director will perform 1 audit per month for 3 months to ensure bed inspections have been performed and documented according to the manufacturers recommendations. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K921.
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