Deficient Nurse Call System Maintenance
Penalty
Summary
The facility failed to maintain its nurse call system in accordance with NFPA 99 standards, as observed during a fire safety tour conducted on March 14, 2025. At the West Nurse's Station, which serves rooms 1-20, the required nurse call visual signal was missing at the corridor intersection near the nurse's station, where individual resident room doors are not directly visible. Additionally, the annunciator panel for Room 14 did not light up, and there was no audible signal when tested. Similarly, at the East Nurse's Station, which serves rooms 21-35, the required nurse call visual signal was also missing at the corridor intersection. The annunciator panels for Rooms 29, 31, and 32 did not light up, and there was no audible signal for Rooms 31 and 32 when tested. These deficiencies were acknowledged by the Administrator and the Maintenance Director during the observations and were reviewed with them at the exit conference.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified nurse call system visual signal on West and East Nurses station; quotes obtained by an outside vendor 2/19/2025. Parts ordered 3/31/2025 for the nurse call system in accordance with NFPA 99 to be completed by 4/14/2025 based upon vendor availability for installation. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review completed by the ED/Maintenance designee r/t ensuring the nurse call light system is maintained according to NFPA 99 to be completed by 4/14/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Maintenance re-educated by the ED r/t ensuring the nurse call light system is maintained according to NFPA 99 to be completed by 4/14/2025. (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 in place; Ongoing quality monitoring to be completed by the ED/Maintenance/designee through visual observation to ensure the nurse call light system is maintained according to NFPA 99 weekly x 4 weeks, twice monthly x 2 weeks then monthly and PRN as indicated.