Deficient Emergency Generator Maintenance and Documentation
Penalty
Summary
The facility failed to maintain compliance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 requirements for emergency electrical systems. During observation, both of the facility's emergency backup power generators were found with unsecured access panels, lacking the required handle locks or other devices to prevent unauthorized access. This was confirmed by the Maintenance Director at the time of observation. Additionally, the facility was unable to provide documentation of the required annual servicing date and annual 90-minute load bank test for the emergency generator set, despite the generator's initial service date being recorded. Further record review revealed that the facility did not have evidence of the required monthly load tests for the generator set from February 2024 onward. The facility also failed to provide documentation of the annual fuel analysis for the stored diesel fuel used by the emergency backup power generators. No compliance documentation was presented to the surveyor by the time of exit, and these findings were confirmed with the Maintenance Director during the record review process.
Plan Of Correction
K918 – Electrical Systems- Essential 1. The facility failed to ensure generators or other alternative power sources are in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70. a. The installed emergency backup power generators were supplied with lock/denying devices. b. The new emergency back-up power generator has had its annual 90-minute load back test and inspection scheduled. c. The monthly load run test and inspection has been performed and documented on the new generator. d. The annual fuel analysis for the stored diesel fuel for the emergency back-up power generator has been completed. 2. The maintenance director and staff were educated on weekly, monthly, and annually required generator tests as well as proper documentation according to NFPA standards. 3. To maintain continued compliance, the Maintenance Director or designee will complete a random audit week for 4 weeks to ensure the NFPA standards are being met. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.