Deficient Nurse Call System Maintenance
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.
Penalty
The facility's nurse call systems in the Galilee and Masada wings were found deficient during a fire safety tour, with several corridor lights failing to illuminate as required by NFPA 99 standards. The Maintenance Director acknowledged these deficiencies.
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
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