Failure to Maintain and Test Emergency Power Supply System
Penalty
Summary
The facility failed to maintain its Emergency Power Supply System (EPSS) as required by NFPA 101, NFPA 110, and related standards. Specifically, the facility did not conduct the required weekly visual inspections for both its 10-kW and 25-kW propane generators, missing 10 out of 52 inspections for each generator. Additionally, the facility did not perform three of the required 12 monthly load tests for each generator, with missing records for March, April, and September of the specified year. Staff interviewed during the survey were unable to confirm whether these inspections and tests had been completed, citing lack of employment at the facility during the relevant periods and uncertainty regarding missing records. The facility also failed to conduct three of the required 12 monthly conductance tests for the batteries of both generators, with missing documentation for the same months as the load tests. Staff were again unable to verify if these tests had been performed, and no explanation was provided for the missing records. Furthermore, the facility did not provide evidence of having conducted the mandatory four-hour load tests for either generator, which are required every three years. The date of the last such test was unknown, and no records were submitted by the deadline given by surveyors. These deficiencies affected all 92 residents and all six smoke compartments in the facility. The lack of required inspections, testing, and documentation for the emergency generators and their batteries was confirmed through document review, staff interviews, and the absence of records during the survey. No information was provided regarding the medical history or condition of individual residents at the time of the deficiency.
Plan Of Correction
K 918 - Essential Electrical Systems How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Finding 1: On 3/18/25, the current EVS Director performed and documented a visual inspection of the 10kW generator to confirm it is functional. No issues were found. • Finding 2: On 3/20/25, the EVS Director inspected the 25kW generator. No issues were found. • Finding 3: Load test completed on 10kW generator on 3/28/25. • Finding 4: Load test completed on 25kW generator on 3/28/25. • Finding 5: Conductance test completed for 10kW generator on 3/18/25; batteries confirmed to be within operational parameters. • Finding 6: Conductance test completed for 25kW generator on 3/20/25; batteries confirmed to be within operational parameters. • Finding 7: Facility contracted with vendor to conduct 4-hour load test for the 10kW generator on 1/8/25. • Finding 8: Facility contracted with vendor to conduct 4-hour load test for the 25kW generator on 1/8/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected. The EVS Director conducted a full generator inspection on 3/18/25 to verify the emergency power system's functionality. No other issues were identified. The EVS Director conducted an additional inspection on 3/27/25 to verify the emergency power system's functionality. No other issues were identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • EVS Director will conduct a weekly non-load test for both the 10kW and 25kW generators. • EVS Director will conduct a monthly load test for both the 10kW and 25kW generators. • EVS Director will conduct battery conductance tests on both the 10kW and 25kW generators. • Our vendor will conduct a 4-hour load test for both the 10kW and 25kW generators. • A new EVS Director has been hired, and we will continue to monitor and support ongoing compliance. • The EVS Director was trained by the administrator on 3/9/25 on the importance of proper testing, documentation, and reporting of generator inspections and load tests. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • EVS Director will conduct weekly and monthly tests for both the 10kW and 25kW generators. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance: 4/18/25 K 919 Electrical Equipment - Other How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • The circuit breaker filler plate was ordered on 3/31/25 and is scheduled to arrive 4/10/25. • The missing cover for the breaker space labeled "24" will be replaced on the arrival of the breaker cover by 4/11/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: • EVS director conducted a facility-wide inspection on 3/19/25 of all electrical breaker panels to ensure all available spaces are sealed and covered properly. • Did not find any other open breaker slots. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • The facility will conduct quarterly inspections of all electrical panels and wiring to ensure compliance. These inspections will be documented, and corrective actions will be taken as necessary.