Failure to Perform Essential Electrical System Maintenance
Penalty
Summary
The facility failed to perform the required monthly and annual inspections and testing of its Essential Electrical System (EES), which is crucial for maintaining power supply in critical situations. During a document review and interview conducted on March 13, 2025, it was revealed that the facility did not conduct the necessary monthly 30-minute load bank test using the transfer switches, nor did it perform the annual 90-minute load bank test and the annual fuel quality test. These tests are essential to ensure the generator and associated equipment can supply power within 10 seconds, as required by NFPA standards. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director, where it was acknowledged that the facility had not adhered to the maintenance and testing schedule mandated by NFPA 101, NFPA 110, and NFPA 111. The lack of compliance with these standards indicates a failure to ensure the reliability of the emergency power system, which is critical for the safety and well-being of the residents in the event of a power outage.
Plan Of Correction
The generator will be run for 30 minute load bank using the transfer switches monthly and will be run for 90 minute load bank annually. An annual fuel quality test will be performed on the generator on April 3, 2025 and the fuel sample will be taken on the same date. The Maintenance Director was re-educated on the need to run the generator 30 minutes monthly under load and annually for 90 minutes under load as well as have a fuel quality test performed annually. The NHA or designee will audit the generator logs monthly 30-minute testing and semi-annually for the 90 minute testing and that all documentation is filed in the Life Safety Book.