Deficient Maintenance of Sprinkler Systems and Improper Storage in Electrical Panel Room
Penalty
Summary
Surveyors observed multiple deficiencies related to the maintenance of fire safety equipment and electrical panel access. During several walkthroughs with the maintenance supervisor (MS), it was noted that sprinkler deflectors in various rooms, including resident rooms, a restroom, and a shower room, had significant buildups of dust and, in one case, a green mildew-like substance. The MS acknowledged these findings during the observations. The facility's maintenance policy states that the maintenance department is responsible for keeping the building and equipment in a safe and operable manner and in compliance with applicable regulations. Additionally, the electrical panel room was found to be used for storage and as an office space for the case manager. Items such as binders, blank paper, and a floor polishing machine were stored within three inches of the electrical panel, which is not compliant with NFPA 70 requirements for clear working space around electrical panels. The MS confirmed that the room had been used in this manner for years due to limited space in the building and acknowledged the findings during the survey.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding electrical safety requirements as specified in NFPA 101 Life Safety Code (2012 Edition) and NFPA 70 National Electrical Code (2011 Edition), specifically regarding maintaining clear working spaces around electrical panels. Corrective Action Taken: On 05/20/2025, the Maintenance Supervisor immediately removed all stored items, including binders, paper, and floor polishing machine from the electrical panel room. The Case Manager's office was relocated to an alternative space within the facility. The electrical panel room was secured with appropriate signage indicating "Electrical Room - No Storage Permitted." The Maintenance Supervisor conducted a complete inspection of all electrical panel rooms facility-wide to ensure compliance with NFPA requirements for clear working spaces. Identification of Other Areas with Potential to be Affected: The Maintenance Supervisor, in conjunction with the Safety Committee, completed a facility-wide assessment on 05/20/2025 to identify any other electrical panels or utility rooms that could potentially be affected by improper storage or space utilization. This assessment included all four smoke compartments and documentation of current space utilization near all electrical equipment. Systemic Changes and Measures Implemented: 1. The facility's Maintenance Service Policy and Procedure has been revised to specifically address electrical room safety requirements, including: • Prohibition of storage within 36 inches of electrical panels • Required monthly inspections of all electrical rooms and panels 2. Implementation of a facility-wide space utilization assessment to ensure appropriate allocation of office and storage areas. Monitoring and Quality Assurance: The Maintenance Director will conduct weekly inspections of all electrical rooms for the first month, then monthly thereafter. The Director of Maintenance will conduct independent monthly audits to ensure continued compliance. Results will be documented and reviewed during monthly Safety Committee meetings and quarterly QAPI meetings. The QAPI Committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive quarters. Any identified issues will