Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911
Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on three of three levels.
Findings include:
Observation on January 23, 2024, between 11:15 a.m. and 12:34 p.m., revealed the following electrical deficiencies: A. (11:15 a.m.) on the second floor, above the smoke barrier doors next to resident room 202, had an unsecured junction box; B. (11:28 a.m.) second floor, next to resident room 233, had exposed wiring on the light fixture; C. (11:35 a.m.) on the second floor, beautician room, had two GFCI's with visual signs of burnt markings, an indication of overheating; D. (11:42 a.m.) on the first floor, above the elevators, had open/ exposed splices; E. (12:15 p.m.) basement, industrial fan cord, had a damaged cord with a non-rated splice and tape repairs; F. (12:25 p.m.) in the basement, boiler/ mechanical room, had an unused cord that was hard wired into a junction box, with an exposed plug end; G. (12:26 p.m.) in the basement, boiler/ mechanical room, had a non-terminated section of flexible metal conduit above the hot water tank; H. (12:34 p.m.) in the basement, kitchen, hot plate cart, had a damaged section of insulation on the cord.
Reference: NFPA 70-400.9, NFPA 70-300.12, NFPA 70-200.3, NFPA 314.23 and NFPA 70-400.2
Exit interview with the Administrator and Maintenance Supervisor on January 23, 2024, at 12:34 p.m., confirmed the above electrical system deficiencies.
| | Plan of Correction - To be completed: 02/20/2024
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
1. Facility completed the following: a. Secured junction box on 2nd floor located next to room 202 b. Removed exposed wire on light fixture on 2nd floor located next to room 233 c. Replaced two GFCI outlets in 2nd floor beautician room on 01/25/24 d. Secured wire in electrical box on 1st floor above the elevators e. Placed lock out tag out on industrial fan. Fan was removed from basement area. f. Removed cord in basement boiler room disconnect cord from outlet. Removed outlet. g. Removed flexible metal conduit from junction box in basement boiler room h. Repaired cord on hot plate cart located in basement kitchen
2. To identify other areas with the potential to be affected, Maintenance Director completed house audit of outlets, junction boxes, and equipment cords
3. To prevent this from reoccurring, Administrator/designee educated Maintenance Department on electrical system requirements per NFPA 70 and NFPA 99
4. For ongoing monitoring for compliance, Administrator/designee will audit for junction boxes, light fixtures, outlets, and equipment cords weekly for 4 weeks then monthly for 2 months.
5. Audit results will be reviewed by QAPI committee.
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