Failure to Maintain Emergency Generator Fuel Reserve
Penalty
Summary
The facility failed to maintain its emergency generator fuel reserve according to the National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3. Specifically, there was no documented evidence that the emergency generator fuel reserve was tested in 2023. A Fuel Analysis Report dated June 24, 2024, indicated that the fuel reserve failed analysis due to excessive particle count and water contamination. The report suggested using portable filtration or a more aggressive approach to filtration and investigating the source of water contamination. However, there was no documented evidence that these suggestions were followed or that the fuel reserve was treated to reduce contamination levels. During a Life Safety Code Post-Survey Review survey, it was found that the facility did not provide evidence of retesting the emergency generator fuel reserve until it passed the fuel quality test. The facility's Electronic Plan of Correction stated that corrective actions would be taken if the fuel reserve failed retesting, but the facility did not ensure the plan was fully implemented by the Credible Allegation Date. An interview with the administrator revealed that the results of the retesting were not yet available, indicating a lack of timely follow-up on the deficiency.
Plan Of Correction
Plan of Correction: Approved February 14, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) Per the vendor suggestions, the facility will use portable filtration or a more aggressive approach to filtration to address the high particle count in the fuel reserve and will investigate and resolve the source of the water contamination in the fuel reserve. Should the fuel reserve fail retesting, corrective actions will be taken with additional retesting until the fuel reserve passes the fuel quality test as required by the National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 2010 edition 8.3. The facility maintenance director scheduled the vendor to test the generator fuel reserve and treat for contamination as needed. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The facility audit for other emergency generator fuel reserves found that there was another emergency generator fuel reserve tank on the grounds. This tank will be drained as the generator is not connected to the building in any way and is not needed. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Facility Maintenance Director was educated by the administrator on having the generator fuel reserve tested annually and to complete recommendations given by the vendor. The generator fuel reserve testing has been added to the preventative maintenance schedule to be completed annually. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) Findings of the annual fuel reserve testing will be reviewed by the Quality Assurance Performance Improvement Committee annually and additional recommendations for interventions will be given as needed. Responsible Party: Director of Maintenance