Failure to Maintain Emergency Power Supply System
Penalty
Summary
The facility failed to maintain its Emergency Power Supply System (EPSS) in accordance with regulatory requirements. During a tour and review of records, it was observed that the facility did not have a remote manual stop station for its five-kilowatt propane EPSS. The absence of this stop station was confirmed through observation and interview with the Maintenance Staff, who stated they were unaware of the requirement for such a device. Additionally, the facility was unable to provide documentation of a required four-hour load test for the EPSS when requested. The Maintenance Staff confirmed that no such documentation was available for review. This indicates that the facility did not perform or could not verify the performance of the four-hour load test as required by NFPA 110 standards. These deficiencies affected all 57 residents and three smoke compartments within the facility. The lack of a remote manual stop station and the absence of documentation for the four-hour load test were directly observed and confirmed through staff interviews and record review.
Plan Of Correction
K 918 - Electrical Systems - Essential Electric System. Continue A. 1. C. Bates Electric company installed the remote manual stop station for the five-kilowatt propane EPSS on 4/11/25. 2. The annual service and the four-hour load bank test for the generator is scheduled on 4/18/25 by the C and D Power company. B. There is only one generator in the building. No other concerns with this deficient practice. C. The Administrator provided an in-service on 4/14/25 to the Maintenance Staff regarding the requirements of the Life and Safety findings K 918 Electrical Systems - Essential Electric System including but not limited to: 1. Remote manual stop station for the five-kilowatt propane EPSS. 2. The Administrator provided an in-service to the Maintenance Staff regarding the annual service and the four-hour load bank test for the facility generator. D. Monitoring 1. Maintenance Staff will monitor and test the remote manual stop station for the five-kilowatt propane EPSS once a month during generator test and by the facility contracted vendor that provides service to do the four-hour load bank test for the generator. It will be recorded on the "Generator Log." 2. The Maintenance Staff and Administrator will monitor to make sure that the annual service and the four-hour load bank test for the generator is conducted annually by the facility contracted vendor for the generator preventative maintenance. A log will be maintained to record the annual generator service on the "Generator Log." The log will be kept by the Maintenance Staff and is available for inspection when requested. E. QUALITY ASSURANCE: The Administrator and the Quality Assurance Performance Improvement (QAPI) team members will discuss system effectiveness of the plan of correction for this deficient practice of K 918 Electrical Systems and Essential Electric System; remote manual stop for the generator is maintained and the four-hour generator load test is performed annually. Completion Date: April 18, 2025