Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its emergency generator and associated systems, as observed during a Life Safety Code survey. Specifically, the facility did not conduct monthly load tests, annual inspections of the main and feeder circuit breakers, or monthly and annual testing of emergency lighting associated with the emergency power supply equipment. During an observation in the basement, the transfer switch for the emergency generator was found in the Electrical room, and the emergency battery backup lighting fixture did not illuminate when tested. The Maintenance Supervisor was unaware of the requirement to test the battery backup lighting fixture monthly for 30 seconds and annually for 90 minutes. Review of logs from 2023 and 2024 showed no documentation of these tests being conducted. Additionally, the Maintenance Supervisor confirmed that there was no documentation of inspections for the main and feeder circuit breakers in 2023 and 2024. The contractor responsible for inspecting, testing, and maintaining the facility's emergency generator also did not conduct these inspections. Furthermore, the emergency generator was not run under load in a specific month of 2024 due to staffing issues, and the transfer switch was not exercised. These deficiencies affected both resident use floors and the basement, indicating a lack of compliance with the required safety standards.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 The following items noted during survey as being deficient: conducting monthly generator load tests, annual inspection of the main and feeder circuits breakers, monthly and annual testing of emergency lighting associated with emergency power supply equipment, and proper function of emergency lighting associated with emergency power supply equipment have all been completed and repaired to meet the life safety code standards. The emergency light fixture is scheduled to be replaced. The facility will complete a facility-wide audit to ensure there are no other battery-powered emergency light fixtures that require testing. The 30 second and 90 minute testing of the emergency light fixtures will occur with the routinely scheduled generator load tests. A contractor has been hired to complete the inspection of the main and feeder circuits breakers and annually going forward. An audit of all generator inspection documents will be completed to assure that routine load tests are completed within the standards of the life safety code. These inspections will be added to existing schedules. A review of the facilities policy related to generator inspections will be completed to assure it contains language that outlines the procedures for proper inspection. The audit documents used for generator inspections will also include the language specific to the monthly generator load tests and testing of the emergency light fixtures. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of generator inspection documents to include the main and feeder circuits breakers, the annual testing of emergency lighting associated with emergency power supply equipment, and emergency lighting associated with emergency power supply equipment, monthly generator load tests, and the monthly 30-second testing, will be completed and documented monthly, for three months to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.