Failure to Document Essential Electrical System Maintenance
Summary
The facility failed to maintain and test their essential electrical system in accordance with NFPA standards. During a record review conducted on April 15, 2025, between 10:00 AM and 2:00 PM, it was discovered that there was no documentation available for the performance of the main and feeder circuit breaker exercise. Additionally, there was no documentation provided for the generator's annual fuel quality test. These deficiencies were identified during a review with the Director of Continuum and the Maintenance Supervisor. The Director of Continuum and the Maintenance Supervisor acknowledged the findings during an interview conducted concurrently with the record review. The lack of documentation for these critical maintenance activities indicates a failure to adhere to the required standards for maintaining the essential electrical system, which is crucial for ensuring the safety and reliability of power in the facility. The findings were reviewed with the Director of Continuum and the Maintenance Supervisor at the exit meeting on the same day.
Penalty
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.
The facility did not complete the required four-hour load bank test of its diesel generator within the mandated 36-month period and failed to properly document engine hours during monthly tests, as confirmed by the Maintenance Director. This lapse affected the reliability of the essential electrical system for all residents.
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.
Failure to Complete Required Generator Load Bank Testing and Documentation
Penalty
Summary
The facility failed to maintain its diesel generator in accordance with NFPA 110-2010 requirements. During a review of the life safety documentation, it was found that the last four-hour load bank test of the generator had not been completed within the required 36-month interval, with the most recent test occurring several years prior. Additionally, the monthly test records did not document the engine hours as required, instead only noting the start and end times of the test. These findings were confirmed by the Maintenance Director, who was unaware of the specific requirements for generator testing and documentation. This deficiency had the potential to affect all 46 residents in the facility, as the generator is a critical component of the essential electrical system. The lack of proper testing and documentation means the facility could not ensure the generator's reliability in supplying emergency power within the required timeframe, as outlined by NFPA 110 standards. No specific resident medical histories or conditions were mentioned in relation to this deficiency.
Plan Of Correction
K918 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that the 4-hour 36-month load test was completed on the generator and written record of maintenance and testing was logged incorrectly. Step 1: Facility Administrator obtained the 4-hour bank test documentation from 6/9/2023. Step 2: NHA audited the generator testing log for the time meter reading—start and end—ensuring that it would include hours of the engine, not the test start and end time. Maintenance Director corrected log entry for the month of July 2025. Step 3: NHA educated Maintenance Director on the correct way to log generator testing entries 7/15/25.
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