Failure to Document Monthly Generator Conductance Test
Penalty
Summary
The facility failed to maintain and test their Essential Electrical System (EES) in accordance with NFPA 99 standards. During a record review conducted on April 8, 2025, between 10:00 AM and 1:30 PM, it was found that there was no documentation available for the monthly generator conductance test. This deficiency was identified for 1 of 1 monthly generator conductance test, indicating a lapse in the required maintenance and testing procedures. The Maintenance Director was present during the record review and acknowledged the findings. The absence of documentation for the generator conductance test suggests that the facility did not perform or properly record the necessary monthly test to ensure the generator's capability to supply service within the required 10 seconds. This oversight was discussed with the Maintenance Director during the exit conference on the same day.
Plan Of Correction
CFR(s) NFPA 110, 99 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: Maintenance Director conducted a test on 4/8/2025, 4/16/2025, & 4/21/2025 to ensure the battery conductance test is at the correct voltage and by IPS TAW Generator Company on 4/21/2025. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE WILL BE IDENTIFIED: The facility conduct a full house audit to identify all residents with the potential to be affected. The potential for harm is minimum. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT RECUR: The Maintenance Director will complete the Generator Conductance test on a monthly basis. Findings and the conductance test log will be brought to QAPI for 6 months and then annually thereafter. HOW THE CORRECTIVE ACTION WILL BE MONITORED: All findings will be brought to QAPI for six months and Annually thereafter.