Electrical Panel Circuits Missing Required Identification
Penalty
Summary
Surveyors observed that the facility failed to maintain proper identification of electrical circuits in two separate electrical panels located in mechanical rooms. Specifically, Panel A was found to have two out of forty-two circuits (circuits 13 and 27) missing identifiers, and Panel F had three out of forty-two circuits (circuits 26, 28, and 30) without labels. During interviews, staff indicated that the unlabeled circuits in Panel A were considered spares, while for Panel F, staff were unaware of the purpose of the unlabeled circuits. These deficiencies were identified during a facility tour and staff interviews, affecting 23 of 103 residents in one of five smoke compartments. The lack of proper labeling on the electrical panels was found to be non-compliant with NFPA 70 National Electrical Code requirements, which mandate that each circuit be clearly and legibly identified as to its specific purpose or use.
Plan Of Correction
How does the facility plan to monitor its performance to make sure that the corrections are implemented and achieved, that solutions are sustained, and that the corrective actions taken are evaluated for effectiveness through integration into the facility's Quality Assurance system? The Facilities Maintenance Director will review the monthly fire drill reports to ensure compliance with varying times and shift compliance. Any findings will be corrected within the month by way of a separate drill if required. The Facilities Maintenance Director will report compliance and findings of fire drills to the Quality Assurance Committee monthly for 12 months for integration and recommendations if indicated. K 919: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? No residents were found to be affected by the deficient practice in regard to the unlabeled circuits. The Maintenance Lead inspected and identified that circuits 13 and 27 in Panel A and confirmed them to be "spares". They were correctly labeled as "SPARE" on 03/27/2025. The maintenance lead inspected and identified that circuits 26, 28, and 30 on Panel F and confirmed them to be "spares". They were correctly labeled as "SPARE" on 03/27/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other residents were found to have been affected by the deficient practice and the corrective action taken above ensures that no residents will be affected. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Facilities Maintenance Director in-serviced all Maintenance Personnel in regard to the requirements of K919, specifically ensuring all circuit breakers are labeled. The Facility Maintenance Lead will inspect the electrical panels for proper circuit labeling monthly for three months. After this, the Facilities Maintenance Director added an annual "Inspect and Document the Main and Feeder Circuit Breakers" task to the TELS system to