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K0920
F

Unapproved Power Strip Causes Electrical Fire at Bedside

San Jose, California Survey Completed on 12-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a power strip was found in use at a patient bedside location that did not meet the required approval standards. During a facility tour, it was observed that a power strip was located approximately one foot away from a resident's bed on the ground in Resident Room 34. The Maintenance Supervisor confirmed that an electrical fire had occurred at this location in the early morning hours, and the resident occupying the bed reported that the power strip had been brought in by a family member for charging a phone. The facility was unable to verify whether the power strip in question met the necessary UL 1363A or UL 60601-1 standards required for use with patient-care-related electrical equipment in a patient care vicinity. This deficiency affected 47 out of 116 residents and one of four smoke compartments, as noted during the survey. The report does not provide additional details regarding the medical history or condition of the resident at the time of the incident.

Plan Of Correction

How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: A: Power strips and extension cords were immediately removed from the rooms. Both family and resident were notified of power cord safety and the importance of using medical-grade approved cords and safety of surroundings around the power cords. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A: All residents have the potential to be affected by the deficient practice. Facility-wide audit conducted on 12/08/25 and all other power cords identified were noted and removed. Education was provided on 12/08/25 to the Maintenance Director on appropriate power cords within the facility. Facility-wide audit to be completed weekly for 12 weeks and then PRN as needed. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A: 1) Resident education on proper equipment usage (i.e., hospital graded extension cords only) 2) Staff In-Serviced on fire safety and prevention in regards to outlets and proper power cord identification—importance of keeping residents' belongings away from outlets and bringing concerns related to storage of belongings to facility leadership team 3) Daily resident room round sheet updated and to be conducted by assigned department managers. Weekly facility rounds will be conducted and every room and common area checked to ensure approved hospital grade extension cords are in place and outlet integrity is compliant by the maintenance supervisor or designee. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: A: Room round sheets will be turned in weekly. The Maintenance Director or designee will complete a facility-wide audit weekly for 12 weeks and report the results of the audit to the Safety Committee and QA meeting for compliance evaluation x4 months and then PRN as needed. Include dates when corrective action will be completed. The corrective action completion dates must be acceptable by the State Agency: Completion date: 12/11/2025

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