Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to perform the required maintenance and testing of its Essential Electrical System (EES), which is crucial for ensuring the safety and functionality of the power supply in emergency situations. Specifically, the facility did not conduct the necessary weekly, monthly, and annual inspections and testing of the generator and associated equipment. This includes the failure to perform a monthly 30-minute load test using the transfer switches and an annual 90-minute load bank test. During a document review and interview conducted on April 16, 2025, it was confirmed by the Assistant Director of Nursing and the Maintenance Director that these essential maintenance activities were not carried out as required. The lack of adherence to the maintenance schedule outlined in NFPA 101 and related standards indicates a significant oversight in the facility's operational procedures, potentially compromising the reliability of the emergency power system.
Plan Of Correction
1 and 2. 4 hour building load test performed 3/8/2024 by GenServ. Maintenance Director has performed the monthly 30 min. test and will complete the annual 90 minute load bank inspection and testing of the facilities generator. 3. Maintenance department will be educated on the standards of completing weekly, monthly and annual inspections and testing of generator. 4. Maintenance or facility designee will audit facilities generator weekly for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.