Annual Inspection of Receptacles Not Conducted
Penalty
Summary
During a life safety recertification survey conducted in early 2025, it was observed that there was no documentation to confirm that electrical receptacles in resident areas on the 6th Floor had been inspected annually as required. Specifically, inspection stickers on receptacles in resident rooms 601, 603, 605, and throughout the 6th Floor were dated January 2023, indicating that the required annual inspections had not been performed. Additionally, an outlet in the outdoor area outside of the Physical Therapy Room, which is part of the path of egress, showed signs of damage. The Director of Maintenance acknowledged the lack of inspections and noted that the outdoor outlet had been damaged prior to his tenure at the facility.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The maintenance staff completed the annual electrical receptacle inspection and testing on the 6th floor on 3/5/2025. The director of maintenance replaced the identified damaged outside electrical receptacle on the patio on 3/3/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents, visitors, and staff have the potential to be affected by this practice. The Director of maintenance inspected all areas throughout the facility for the same deficiency. No other deficiencies were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with the inspection and testing of electrical receptacles in compliance with NFPA 99: 6.3.4.1.3. An audit tool has been developed to inspect the electrical receptacle for damage and inspection. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all electrical receptacles for damage and inspection stickers if needed to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, for one quarter, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.