Failure to Perform Annual Fuel Quality Test on Emergency Generator
Penalty
Summary
The facility failed to maintain compliance with requirements for the Emergency Power Supply System (EPSS) as outlined in NFPA 101 and NFPA 110. Specifically, the facility did not conduct the required annual fuel quality test for its 400-kilowatt diesel generator. During a document review and staff interview, it was confirmed that the last fuel quality test was performed over a year prior, and no recent test had been conducted. Staff indicated that the generator's fuel reserves required contaminant filtering before a test could be performed, which contributed to the lapse in testing. This deficiency affected all 43 residents and both smoke compartments within the facility. The failure to perform the annual fuel quality test was identified through a review of generator testing records and direct staff interviews, confirming that the required maintenance and testing protocols were not followed as mandated by regulatory standards.
Plan Of Correction
The facility failed to conduct the annual diesel generator fuel quality test in 2025. On April 15, 2025, the diesel generator fuel testing vendor was contacted, and a service is scheduled for May 2nd, 2025, for the diesel to be sampled and tested by the certified vendor. The testing requirement was added to the facility's emergency preparedness checklist and calendar. The maintenance lead will be responsible for contacting and scheduling the timely inspections with the vendor.