Improper Fastening of Circuit Breaker Panel Cover with Sheet Metal Screws
Summary
Surveyors identified a deficiency in the facility’s maintenance of electrical utility equipment in accordance with NFPA 70. During an observation at 3:15 PM, they noted that the cover of a circuit breaker panel was fastened using sheet metal screws instead of appropriate fasteners. This condition was found in 1 of 7 smoke compartments. The facility’s maintenance director, present during the observation, acknowledged that sheet metal screws were being used on the circuit breaker panel cover. The report states that this failure to comply with NFPA 70 could result in electric or fire hazards. No residents or specific patient conditions were mentioned in the report, and no additional events beyond the improper fastening of the circuit breaker panel cover were described.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0511 and assure continued compliance, the following plan has been put in place. K0511 - Electrical Panel Fasteners Immediate Correction: Unauthorized sheet metal screws were removed from the cited circuit breaker panel and replaced with OEM-approved, blunt-end machine screws to prevent internal wire damage. Identification of Others: A facility-wide audit of all electrical panels, sub-panels, and pull boxes was conducted. Any non-compliant fasteners found were immediately replaced with blunt-end hardware. Systemic Changes: The Electrical Safety Policy was updated to prohibit self-tapping or pointed screws. Maintenance staff were trained on NFPA 70 hardware requirements to maintain equipment integrity. Monitoring (QA): "Panel Fastener Integrity" was added to the Monthly Life Safety Walkthrough. Audit logs will be reviewed during quarterly QAPI meetings.
Penalty
Surveyors identified that the facility’s electrical system was not maintained according to NFPA 101 and NFPA 70. In the kitchen electrical panel, breakers labeled for the dishwasher were in the off position while the dishwasher continued to run with power. In generator sub panel B, a breaker was labeled for a sprinkler pump even though no sprinkler pump existed, and there was an open breaker position without a blank cover. These issues were confirmed by the Maintenance Director and had the potential to affect all residents.
Improperly Labeled and Maintained Electrical Panels
Penalty
Summary
Surveyors found that the facility failed to maintain its electrical system in accordance with NFPA 101-2012 and NFPA 70-2011, potentially affecting all 69 residents. During a tour of the facility, surveyors observed in the kitchen electrical panel that the breakers labeled for the facility’s dishwasher were in the off position while the dishwasher itself was running and had power. Later, in generator sub panel B, surveyors noted a breaker labeled as a sprinkler pump even though the facility did not have a sprinkler pump, as well as an open breaker space without a blank installed. The Maintenance Director confirmed these findings at the time they were discovered. No specific residents, medical histories, or clinical conditions were mentioned in relation to these deficiencies.
Plan Of Correction
1.Based on observation and staff interview, no residents experienced negative outcomes related to electrical system deficiencies. The facility's kitchen dishwasher breakers were in the off position; the dishwasher was running and had power. It was also noted that in generator sub panel B there was a breaker listed as sprinkler pump as well as an open breaker that has no blank, while the facility has no sprinkler pump. 2.The Medical Director was notified by LNHA on 03/26/2026 of deficiencies including improper breaker configuration and labeling. 3.Electrical deficiencies will be corrected by licensed electrician on or before 04/30/2026. 4.Monthly inspections will be conducted and compliance reviewed in QAPI. 5.LNHA educated 03/26/2026 regarding the requirements for maintaining the facility's electrical equipment, including the requirements for the facility's kitchen dishwasher breakers' requirements in power being active and breaker reflecting that it is on, and vice versa. Also, Maintenance Direct was educated in the importance of ensuring the appropriate labeling of breakers.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
