Deficient Nurse Call System Maintenance
Penalty
Summary
The facility failed to maintain its nurse call system in accordance with NFPA 99 standards. During a fire safety tour conducted on March 19, 2025, between 12:55 PM and 2:25 PM, it was observed that the nurse call systems in both the Galilee and Masada wings were deficient. Specifically, the Galilee wing had two corridor lights that did not illuminate, and the Masada wing had three corridor lights that failed to illuminate when tested. These observations were made in the presence of the Maintenance Director, who acknowledged the deficiencies. The findings were subsequently reviewed with both the Administrator and the Maintenance Director during the exit conference on the same day at 3:15 PM.
Plan Of Correction
K900 NFPA 99 HEALTH CARE FACILITIES CODE OTHER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation that the Galilee wing nurse call system having two corridor lights that were allegedly not illuminating and the Masada wing nurse call system having three corridor lights that were allegedly not illuminating. The maintenance staff will check those nurse call light corridor lights allegedly not working and do any necessary repairs to ensure they are illuminating properly. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will check those nurse call light corridor light allegedly not working and do any necessary repairs to ensure they are illuminating properly. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25