Electrical System Deficiencies in Facility
Penalty
Summary
The facility failed to maintain and inspect its electrical systems in accordance with NFPA 70, Article 314, resulting in several deficiencies across different areas. During an observation on December 16, 2024, between 10:30 a.m. and 12:30 p.m., surveyors identified multiple issues. In the B wing Shower Room, a broken optical sensor light switch was found at 10:40 a.m. At 11:35 a.m., an unsecured junction box was observed above the B wing Lining closet. Additionally, at 12:15 p.m., a missing cover on an electrical receptacle was noted inside the C wing Day Room. These deficiencies were confirmed during an exit interview with the Administrator and Regional Maintenance Director. Further inspection on the same day at 11:00 a.m. revealed additional electrical system issues in the A/E Wing. Above the drop ceiling outside of Clean Storage, several free-hanging electrical junction boxes were discovered. This finding was also confirmed during the exit interview with the facility's Administrator and Regional Maintenance Director. These observations indicate a failure to adhere to the required standards for electrical system maintenance and inspection, affecting the safety and compliance of the facility.
Plan Of Correction
This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The broken electrical sensor in B-Wing Shower has been fixed, the unsecure junction box in B-Wing linen closet has been anchored, and the missing outlet cover in C-Wing Day Room has been replaced. 2. Maintenance Director, or designee, will conduct an initial audit throughout the facility to look for other electrical sensors that are broken, unsecure junction boxes, and missing outlet covers and will fix or replace them. 3. Maintenance Director will educate maintenance staff on checking for broken, unsecure, or missing electrical components while making maintenance rounds. 4. Maintenance Director, or designee, will conduct audits, weekly x 4 weeks then monthly x 2 months, to ensure that all electrical components such as broken sensors, unsecured junction boxes, and missing outlet covers are in place and secured properly. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action. This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The free-hanging electrical junction boxes located above the drop ceiling in A/E Clean Storage Room have been securely anchored. 2. Maintenance Director, or designee, will conduct an initial audit of all Clean Storage Rooms to ensure all electrical junction boxes are securely anchored. 3. Maintenance Director will educate maintenance staff on the need to ensure all electrical junction boxes are securely anchored. 4. Maintenance Director, or designee, will conduct audits, weekly x 4 weeks then monthly x 2 months, of junction boxes in Clean Utility Rooms to ensure they are securely anchored. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action.