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K0918
F

Failure to Perform Annual Diesel Fuel Quality Test for Emergency Generator

Clare, Michigan Survey Completed on 03-06-2025

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 provide documentation that an annual diesel fuel quality test was performed for the essential electrical system (EES) generator, as required by NFPA 110. During record reviews on two separate dates, surveyors found that the last available vendor report for diesel fuel testing was dated over a year prior, and there was no evidence that a fuel quality test had been conducted within the last 12 months. Additionally, the most recent diesel fuel quality test report provided by the vendor indicated that the fuel did not meet ASTM standards. This deficiency pertains to the maintenance and testing requirements for the emergency generator system, which is critical for supplying power in the event of an electrical failure. The lack of current and compliant diesel fuel testing documentation means the facility did not meet the required standards for ensuring the reliability of its emergency power source. No specific residents or patient conditions were mentioned in relation to this deficiency.

Plan Of Correction

No specific residents were identified. The fuel sample was taken during generator repair on 2/10/2025. Fuel sample was analyzed by lab for Number 1 Diesel when we run Number 2 Diesel. Lab was contacted to re-analyze fuel sample for correct fuel type. Cummins reanalyzed previous fuel sample for Diesel number 2 with passing results. NHA and Senior Maintenance Director reviewed the Generator Testing policy, which was deemed appropriate on 2/10/2025. Administrator provided re-education regarding proper maintenance and testing of the generator to the Senior Maintenance Director and Maintenance crew on 2/10/2025. If maintenance of the generator coincides with fuel sample testing, it will be done regardless of the repairs to be made to ensure compliance. NHA/designee will audit monthly. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. NHA is responsible for compliance.

See complete original report
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