Sprinkler Head Installed Too Close to Light Fixture
Summary
Surveyors observed that the facility failed to provide a sprinkler system installed in accordance with NFPA 13 requirements. Specifically, during an inspection, it was found that the sprinkler head located in the main lobby near the front egress door was positioned too close to a light fixture. This proximity was determined to be within a few inches, which does not comply with NFPA 13, 8.3.2.5, Table 8.3.2.5(c), as it could alter the water flow pattern and prevent proper sprinkler protection. These findings were confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of observation.
Plan Of Correction
Element 2: An audit of the facility determined that 3 additional light fixtures are located too close to the sprinkler heads. Element 3: Electrician is scheduled to move overhead lights to be completed by 7/24/2025. Element 4: EVS Director or designee will audit sprinkler heads weekly to ensure that they are not blocked and provide proper sprinkler protection. Results will be brought to weekly QA for review and recommendations. EVS Director is responsible for compliance.
Penalty
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors found that the facility did not have documentation showing that the essential electrical system’s main and feeder circuit breakers were exercised annually in accordance with manufacturer recommendations and NFPA 99 requirements. During record review with the Maintenance Director, no records could be produced to verify that these breakers had been properly exercised, and the Maintenance Director acknowledged this failure. This deficiency was cited as affecting all occupants due to noncompliance with required essential electrical system maintenance and testing standards.
Surveyors found that the facility failed to perform and document required testing of backup generator batteries in accordance with NFPA 110. During record review, no documentation of generator battery testing was available, and the Maintenance Director acknowledged both the lack of records and a lack of knowledge of the NFPA 110 battery testing requirements. The report notes that this failure could result in loss of power affecting life support and life safety features for occupants.
Surveyors identified a deficiency when the facility could not provide documentation that backup generator batteries were being tested in accordance with NFPA 110 and NFPA 99 requirements. During record review, no records of generator battery testing were available, and the Maintenance Director confirmed he was unable to locate the requested documentation. This failure concerns the essential electrical system that supports life safety and critical functions during power loss.
Surveyors found that the facility failed to maintain its Essential Electrical System (EES) in accordance with NFPA 99 and related standards when record review showed that conductance testing was not performed for 2 of 2 sealed generator batteries over a defined period, and only one generator battery was tested during that time. During an interview, the Maintenance Director acknowledged that required testing had not been completed for both batteries. This lapse in required emergency power system maintenance affected the facility’s single EES and all residents and staff relying on it.
Surveyors found that the facility failed to maintain required documentation showing that its three generators were tested monthly and inspected and tested annually in accordance with NFPA 99 and NFPA 110. Despite multiple requests, no records of these tests or inspections were provided. During the facility tour, surveyors also observed that none of the three generators were equipped with remote manual stop buttons, and this was confirmed by the Maintenance Director. This deficient practice had the potential to affect all residents in the facility.
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Exercise and Document Main and Feeder Breaker Maintenance per NFPA 99
Penalty
Summary
The deficiency involves the facility’s failure to maintain and document required maintenance and testing of the essential electrical system’s main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that the main and feeder breakers had been exercised annually as required. The facility was unable to provide records demonstrating that these breakers were exercised per the manufacturer’s recommendations. The Maintenance Director acknowledged that the facility failed to provide documentation that the main and feeder breakers were exercised according to the manufacturer’s recommendations. This lack of documentation and evidence of required exercising of the breakers was cited as noncompliance with NFPA 99 (referencing sections 6.4.4, 6.5.4, 6.6.4/6.5.4 Class III) and related standards governing essential electrical system maintenance and testing. The deficiency was noted as having the potential to affect all occupants in the facility in the event of a fire or other emergency.
Plan Of Correction
A generator load test was performed on . Documentation of work performed is in the record book and print out from machine is also onThe facility has determined that all residents have the potential to be affected.An in-service education program will be conducted by the administrator.The administrator will conduct for a period of three months a random audit of completed documentation. K0918 A generator load test was performed on [R] Documentation of work performed is in the record book, and print out from machine is also on [R] The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Perform and Document Required Generator Battery Testing
Penalty
Summary
The deficiency involves the facility’s failure to maintain and inspect the backup generator batteries in accordance with NFPA 110 requirements. During a record review, surveyors requested documentation of generator battery testing and the facility was unable to provide any records demonstrating that such testing had been performed. The cited standards require testing of generator batteries to ensure the reliability of the prime mover starting system, but no evidence of compliance with these testing requirements was available in the facility’s maintenance records. During an interview conducted at the same time as the record review, the Maintenance Director acknowledged the absence of generator battery testing documentation and stated that she did not know the requirements for battery testing under NFPA 110. The report notes that failure to conduct these tests could result in the loss of power to the facility, which would endanger occupants due to loss of power to life support and life safety features. No specific residents or individual patient conditions are mentioned in the report.
Failure to Maintain Required Generator Battery Testing Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain and inspect the backup generator batteries in accordance with NFPA 110 requirements. During a record review, surveyors requested documentation of generator battery testing, which is required to ensure the reliability of the prime mover starting system. At the time of review, no documentation was provided to demonstrate that these battery tests had been performed as required. Concurrently, during an interview, the Maintenance Director acknowledged the issue and stated that he could not locate the requested documentation of generator battery testing. The cited regulations include NFPA 99 (2012 Edition) sections 6.4.4.1.3 and 6.4.4.2, and NFPA 110 (2010 Edition) section 8.3.7, which govern maintenance and testing of essential electrical systems, including generator batteries. The report notes that failure to conduct these tests could result in the loss of power to the facility, affecting life support and life safety features.
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 K0918 and assure continued compliance, the following plan has been put in place. K0918 - Generator Battery Testing Immediate Correction: A comprehensive generator battery test, including specific gravity and conductance testing, was performed and recorded in the EPSS Log to ensure peak cranking capacity. Identification of Others: The EPSS was audited to ensure all maintenance components were documented. The Life Safety binder was reorganized to house these records separately for easy retrieval. Systemic Changes: The Generator Maintenance Log was revised to include specific fields for weekly visual checks and monthly battery conductance/voltage testing. Staff were re-trained on NFPA 110 battery maintenance standards. Monitoring (QA): The Maintenance Director will conduct a monthly audit of the generator log. These audits will be presented to the QAPI Committee quarterly to identify any trends in battery degradation.
Failure to Perform Required Generator Battery Conductance Testing for Essential Electrical System
Penalty
Summary
The deficiency involves the facility’s failure to maintain the Essential Electrical System (EES) in accordance with NFPA 99 and related NFPA standards for its emergency power system. During a record review conducted with the Maintenance Director at 12:15 PM on the survey date, surveyors found that generator battery conductance testing was not performed for 2 of 2 sealed generator batteries over a specified period. The records showed that, during that same period, only one generator battery was conductance tested, leaving the second sealed battery untested. These findings applied to the facility’s single EES and therefore affected all residents and staff. The Maintenance Director, during the concurrent interview, acknowledged that the conductance testing had not been completed as required for both sealed batteries. The surveyors cited noncompliance with multiple NFPA 99, NFPA 101, and NFPA 110 provisions, which require proper maintenance and testing of emergency power sources, including generator batteries, to ensure the EES functions as intended. The findings were formally reviewed with the Administrator and the Maintenance Director at the exit conference, confirming that the lapse in required conductance testing constituted a failure to meet the applicable life safety and licensure requirements for the EES.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K918 Electrical Systems - Essential Electric Systems It is the practice of this facility to maintain the Essential Electrical System (EES). Immediate Corrective Action: The Maintenance Director was in-services on completing monthly generator battery conductance testing on both batteries. The Generator Monthly Load Test was completed on both batteries on [R]. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants on completing monthly generator battery conductance testing on both batteries. Monitoring: Maintenance Director and/or designee will do random monthly audits of the Generator battery conductance testing to ensure compliance, for 3 months. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance. K0918 The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K918 Electrical Systems - Essential Electric Systems It is the practice of this facility to maintain the Essential Electrical System (EES). Immediate Corrective Action: The Maintenance Director was in-services on completing monthly generator battery conductance testing on both batteries. The Generator Monthly Load Test was completed on both batteries on [R] . Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants on completing monthly generator battery conductance testing on both batteries. Monitoring: Maintenance Director and/or designee will do random monthly audits of the Generator battery conductance testing to ensure compliance, for 3 months. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance.
Failure to Maintain and Document Required Generator Testing and Safety Features
Penalty
Summary
Surveyors identified a deficiency related to the testing and maintenance of the facility’s essential electrical system and generators. During record review, they found no documentation to verify that the facility’s three generators were tested monthly as required by NFPA 99 and NFPA 110. Additionally, there was no documentation provided to show that the three generators were inspected and tested annually as required by code. Documentation of these tests and inspections was requested at the entrance conference and again later in the morning, but no records were produced by the time of survey exit. During the physical tour of the facility, surveyors observed that none of the three generators had remote manual stop buttons. An interview with the Maintenance Director confirmed the absence of these remote manual stop buttons at the time of observation. These findings were determined to be out of compliance with NFPA 99 – 2012 Edition, Section 6.4.4 through 6.5.4.2 and NFPA 110 – 2010 Edition 5.6.5, and the deficient practice had the potential to affect all 69 residents in the facility.
Plan Of Correction
1.Based on record review, observation, and staff interview, no residents experienced negative outcomes related to the facility's failure to test and maintain the essential electrical system in accordance with NFPA requirements. Findings identified during the survey included: • The facility failed to provide documentation verifying that the three generators were tested monthly as required. • The facility failed to provide documentation verifying that the three generators were inspected and tested annually as required. • During observation on 03/25/2026, it was identified that the facility's three generators did not have remote manual stop buttons installed. 2.The Medical Director was notified by LNHA on 03/26/2026 of the deficiency, including failure to perform and document required generator testing, lack of annual inspection documentation, and absence of required remote manual stop devices. 3.Generator system inspection, testing, and maintenance will be completed by a contracted generator service provider and/or Maintenance Director/designee on or before 04/30/2026. Corrective actions will include: • Completion of monthly generator testing under load conditions, including verification of automatic transfer within 10 seconds. • Completion of annual generator inspection and testing, including full system evaluation in accordance with NFPA 110 requirements. • Installation of remote manual stop buttons for all three generators in accordance with code requirements. • Verification that all generator components, transfer switches, and associated equipment are functioning properly. • Establishment of a comprehensive generator testing and maintenance program, including weekly inspections, monthly load testing (20–40 day intervals), and required periodic extended testing. • All generator testing, inspection, and maintenance activities will be placed on an automatically recurring schedule by Administrator/designee on or before 04/30/2026. Documentation logs will be implemented and maintained onsite. 4.Documentation of all generator inspections, testing, and maintenance will be maintained onsite and readily available. The Maintenance Director/designee will conduct weekly and monthly audits to ensure compliance with NFPA 99 and NFPA 110 requirements. Compliance will be reviewed in QAPI every quarter and as needed to ensure ongoing systemic compliance 5.LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining the facility's generators, including inspection and testing.
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