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NY State Tag
F

Deficiencies in Emergency Generator Maintenance

Morrisville, New York Survey Completed on 01-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly maintain its 500-kilowatt diesel emergency generator in accordance with National Fire Protection Association (NFPA) 99 standards. The deficiencies included the lack of documentation for the transfer time from main power to the generator, which was not recorded in the monthly generator test log from April 2023 to July 2024. The Maintenance Director admitted to being unaware of the requirement for documenting transfer time until reviewing the regulations in 2024. Additionally, the facility did not complete the annual fuel test for 2023, and the 2024 fuel test failed to meet the necessary requirements. The Maintenance Director acknowledged not knowing the importance of testing the diesel fuel annually to prevent generator failure due to contaminants. Furthermore, the facility did not conduct the required three-year four-hour load test or the annual load bank tests for 2023 and 2024. Although a generator test log indicated a four-hour run on March 4, 2024, the actual load could not be calculated, and the recorded amperage was below the required 30 percent load. The Maintenance Director was unaware of the specific amperage value needed to achieve the 30 percent load and assumed incorrectly that the monthly load tests were sufficient. This lack of awareness led to the omission of the necessary annual 1.5-hour load bank test when monthly load values were under 30 percent.

Plan Of Correction

Plan of Correction: Approved March 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. **Generator Transfer Time** Transfer times are now being recorded on the generator log since 1/13/2025. All Maintenance staff were educated on the importance of properly recording generator transfer times. 2. **Annual Fuel Test** In discussing with the fuel testing company, our fuel did not “fail” because of hi [MEDICATION NAME]. It showed “failed” because the test measures for [MEDICATION NAME] due to an EPA regulation for “on-the-road” fuel. Our generator takes residential fuel that is “low [MEDICATION NAME]” and will never meet the “on the road” standard with an “ultra-low” formula. This part of the report is NOT-APPLICABLE since the generator and the “low [MEDICATION NAME]” fuel it uses is not for an “on the road” use. 3. **Three-Year Four-Hour Load Test** Crouse Community Center has scheduled a load bank test with the generator vendor on 3/19/2025 to ensure proper load requirement and will conduct the four-hour load test on 3/19/2025 once proper load is confirmed. 4. **Annual Load Bank Test** Crouse Community Center has scheduled a load bank test on 3/19/2025 to ensure compliance with proper load requirement. All Maintenance Staff were educated on the importance of accurate readings to reflect that the generator is running at 30%. They were also educated on the importance of the four-hour load test as well as the annual load bank testing. The Director of Environmental Services will monitor compliance with a generator testing that includes transfer time and load amount during testing, both with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.

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