Failure to Label Generator Fuel Tank with Required NFPA 704 Placard
Summary
The facility failed to comply with requirements for labeling the generator's above ground diesel fuel tank with an NFPA 704 placard. During an observation on April 23, 2025, it was noted that the fuel tank was not marked with the required placard in a location visible upon approach, as mandated by NFPA 30, 21.7.2.1. This deficiency was identified during a survey and confirmed by the Acting Maintenance Director at the time of discovery. The report specifies that this failure to label the fuel tank properly is not in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. The deficiency could potentially affect all occupants in the event of a fire, as the lack of proper labeling may hinder emergency response or safety procedures. No specific residents or patient conditions are mentioned in the report.
Penalty
The facility did not complete the required four-hour load bank test of its diesel generator within the mandated 36-month period and failed to properly document engine hours during monthly tests, as confirmed by the Maintenance Director. This lapse affected the reliability of the essential electrical system for all residents.
Failure to Complete Required Generator Load Bank Testing and Documentation
Penalty
Summary
The facility failed to maintain its diesel generator in accordance with NFPA 110-2010 requirements. During a review of the life safety documentation, it was found that the last four-hour load bank test of the generator had not been completed within the required 36-month interval, with the most recent test occurring several years prior. Additionally, the monthly test records did not document the engine hours as required, instead only noting the start and end times of the test. These findings were confirmed by the Maintenance Director, who was unaware of the specific requirements for generator testing and documentation. This deficiency had the potential to affect all 46 residents in the facility, as the generator is a critical component of the essential electrical system. The lack of proper testing and documentation means the facility could not ensure the generator's reliability in supplying emergency power within the required timeframe, as outlined by NFPA 110 standards. No specific resident medical histories or conditions were mentioned in relation to this deficiency.
Plan Of Correction
K918 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that the 4-hour 36-month load test was completed on the generator and written record of maintenance and testing was logged incorrectly. Step 1: Facility Administrator obtained the 4-hour bank test documentation from 6/9/2023. Step 2: NHA audited the generator testing log for the time meter reading—start and end—ensuring that it would include hours of the engine, not the test start and end time. Maintenance Director corrected log entry for the month of July 2025. Step 3: NHA educated Maintenance Director on the correct way to log generator testing entries 7/15/25.
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