Deficiency in Emergency Generator Testing Records
Penalty
Summary
The facility failed to maintain emergency generator testing records in compliance with the National Fire Protection Association (NFPA) standards and federal regulations. Specifically, the emergency generator monthly test records did not document the load percentage of the nameplate under which the tests were conducted, nor did they record the generator transfer times. Additionally, the 4-hour load test records lacked documentation of engine performance during each hour of the test, including transfer time, percent of load, amperage, oil pressure, and water pressure. This deficiency was identified across multiple buildings within the facility, including Buildings #2, #3, #4, #5, #6, #7, #8, #10, #12, #14, #16, #19, #21, #22, #24, and #31 (House #1). The lack of proper documentation was consistent throughout these buildings, indicating a systemic issue in maintaining accurate and complete records for emergency generator testing. The absence of detailed records as required by NFPA 99 and NFPA 110 standards suggests a failure in the facility's processes for ensuring compliance with life safety code requirements. During the survey, the Facilities Manager acknowledged the deficiencies in the generator testing records and indicated plans to update the records to include the necessary information. However, the report focuses on the existing deficiencies and the lack of compliance with the required standards, without detailing any corrective actions or plans for future compliance.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 Element 1: Generator vendor was contacted to complete the 4-hour load test by (MONTH) 13, 2025, including engine performance during each hour of the test, including transfer time, percent of load, amperage, oil pressure, and water pressure. Generator testing records were amended to the load and generator testing times. Element 2: All residents have potential to be impacted. Element 3: Maintenance staff will be educated by facilities manager on the updated generator test log to ensure staff are aware of the required elements of generator testing. Education will be completed by (MONTH) 13, 2025. Element 4: Generator Test logs will be reviewed by facility manager or designee after all any generator testing to ensure all required elements were documented. Completed log will be brought to the monthly Quality Assurance committee to ensure compliance. Audits will be an ongoing part of the monthly Quality Assurance Committee. Committee will make recommendations for changes in plan as appropriate based on audit results. Facility Manager responsible for ongoing compliance.