Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 standards. During a fire safety tour conducted on March 19, 2025, it was observed that the facility did not have a supply of generator replacement parts for high mortality items on the premises. This deficiency was identified in the presence of the Maintenance Director, who acknowledged the findings during the inspection. The lack of generator replacement parts was discussed with both the Maintenance Director and the Administrator during the exit conference on the same day. The report cites specific sections of NFPA 99, NFPA 101, and NFPA 110 that were not adhered to, indicating a failure to comply with the required maintenance and testing protocols for the facility's essential electrical systems.
Plan Of Correction
K918 NFPA 99 ELECTRICAL SYSTEMS -- ESSENTIAL ELECTRICAL SYSTEM 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the facility not having a supply of generator parts for high mortality items on premises. Maintenance staff will obtain and keep on site generator parts that have a high mortality rate. 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 obtain and keep on site generator parts that have a high mortality rate. 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 K918 ELECTRICAL SYSTEMS - ESSENTIAL ELECTRICAL SYSTEM 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the facility not having a supply of generator parts for high mortality items on premises. Maintenance staff will obtain and keep on site generator parts that have a high mortality rate. 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 obtain and keep on site generator parts that have a high mortality rate. 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