Incomplete Fire Drill Records and Improper Use of Electrical Equipment
Penalty
Summary
The facility failed to maintain complete fire drill records, as evidenced by the absence of documentation for fire drills conducted during the AM shift in the fourth quarter of 2024. During a record review and interview, the Administrator was unable to provide the required fire drill records and could not locate them in the designated binders. The facility was given an opportunity to submit the missing records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. Additionally, the facility did not maintain electrical equipment in accordance with regulatory requirements. Observations revealed the use of extension cords and daisy-chained power strips in several areas, including the Main Entrance, Kaiser Room, and Dietary Supervisor's Office. Specifically, extension cords were used to power a wander guard detector and a portable air conditioning unit, while a power strip was found powering another power strip for computers and monitors. The Maintenance Director confirmed these setups were due to insufficient outlets and the need to power specific equipment.
Plan Of Correction
Systemic Changes As a new system, the safety committee monthly meeting will review the documentation to ensure the plan of correction is sustained and completed. Any discrepancy will be addressed to the maintenance supervisor and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025. Corrective Action Maintenance director removed the yellow extension cord at the main entrance. Wander guard system is directly connected to the main power. Facility immediately removed the power strip from the kaiser room. The maintenance director will make sure that all electrical equipment is connected directly to the power outlet in the wall. Maintenance director and dietary manager removed the extension cord from the dietary manager's office and the portable air conditioner connected directly to the wall outlet. Identify other residents Maintenance director will do walk through the facility to make sure that this deficiency is not repeating in any other rooms. Any similar violations will be corrected immediately. Safety committee members will assist the maintenance director to identify any similar violations at the facility. Systemic Changes As a systemic change, the DSD and maintenance director will conduct an in-service to housekeeping and maintenance staff to re-educate them about the importance of not having any extension cords in the rooms & hallway. Housekeeping will assist and report to the maintenance director if they see any similar violations anywhere in the facility, and maintenance will correct it immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025.