Failure to Maintain Essential Electrical System Documentation
Penalty
Summary
The facility failed to maintain and test their Essential Electrical System (EES) in accordance with NFPA 99 standards. During a record review conducted on April 29, 2025, between 10:00 AM and 1:00 PM, it was found that there was no documentation available for two of the generator's monthly conductance tests. This lack of documentation was identified during a review with the Director of Property Management. The absence of these records indicates a failure to comply with the required maintenance and testing protocols for the facility's emergency power systems. An interview with the Administrator and the Director of Property Management confirmed the findings, and they acknowledged the deficiency. The review highlighted that the facility did not have the necessary records to demonstrate compliance with the NFPA 99 and NFPA 110 standards, which require regular testing and maintenance of generator sets and associated equipment. The findings were discussed with the facility's management at the exit meeting on the same day.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K918 Electrical Systems- Essential Electric System Maintenance and Testing Immediate Corrective Action: On 4/30/2025, an Ancel BST500 electronic battery tester was purchased to test the generator battery. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. No other generator was identified out of compliance. Measures: On 04/29/2025 the Director of Property management and maintenance assistance were re-educated on ensuring the generator battery tests are completed monthly by using the electronic battery tester and to record the conductance measurement on the log. On 5/07/2025, TAW Service Representative provided training and education to Director of Property management and maintenance assistance on using the electronic battery system tester to conduct cold cranking amps conductance test and documenting information on the monthly generator test log. Monitoring: The Director of Maintenance and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure compliance with NFPA 99 (2012 edition) and NFPA 110 (2010 Edition) standards. The Director of Maintenance will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.