Failure to Provide Required Emergency Lighting in Generator ATS Room
Summary
The facility failed to maintain its generator in accordance with NFPA 110 requirements. During an observation, it was found that there was no battery back-up light installed in the electrical room containing the generator Automatic Transfer Switch (ATS), as required by NFPA 110, section 7.3. This deficiency was identified through direct observation and confirmed in an interview with the Maintenance Technician at the time of discovery. The lack of a battery back-up light in the generator ATS room could potentially affect all occupants of the facility, as it would result in no emergency lighting in the event of a generator failure, leaving no lighted access to emergency equipment. The report does not mention any specific residents or staff affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Penalty
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors identified that the facility did not maintain required documentation for 1.5-hour load bank testing, monthly generator load testing, weekly voltage checks, or monthly conductance testing for generator batteries. These omissions were confirmed during a record review and acknowledged by facility leadership.
A deficiency was identified when the facility did not provide documentation that the main control board of one emergency generator, flagged for replacement during annual maintenance, had been corrected. This issue was confirmed by the maintenance supervisor.
The facility did not maintain the emergency generator annunciator panel, which was found to be without power and nonfunctional during testing at the first floor Nurses Station. This deficiency was confirmed by the Administrator and Maintenance Director, impacting the facility's ability to monitor emergency power systems as required.
Surveyors found that the facility did not provide documentation verifying that required weekly inspections, monthly testing, and annual testing of the emergency generator were performed in the past year. The Administrator confirmed the absence of these records, affecting the entire emergency electrical system.
Surveyors found that the facility did not have documentation showing its emergency generator had undergone a required four-hour continuous load test within the past 36 months. Administrative and maintenance staff were unable to provide evidence of compliance, and the only available service report showed a test duration of just over three hours, not meeting regulatory standards.
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Maintain and Document Essential Electrical System Testing
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 requirements, as evidenced by missing documentation and incomplete testing records. During a record review with the Regional Director of Plant Operations, surveyors found that there was no documentation for the required 1.5-hour load bank testing for 2024, nor was there evidence of monthly testing under a thirty percent load. This testing is necessary to ensure the generator can supply emergency power as required by regulation. Additionally, the facility did not provide documentation of weekly voltage checks for the two generator batteries. Regular monitoring of battery voltage is essential to confirm that the generator will function properly in the event of a power outage. The absence of these records indicates that the facility did not consistently monitor the generator batteries as required. Furthermore, there was no documentation of monthly conductance testing for the generator's two sealed batteries prior to 2025. Conductance testing is a standard procedure to assess the health and reliability of the batteries that support the emergency power system. The Regional Maintenance Director acknowledged these findings during the survey, and the deficiencies were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. An unannounced Fire & Life Safety Recertification survey was conducted on at Nspire Healthcare Tamarac, a nursing home in Tamarac, Florida. Nspire Healthcare Tamarac is not in compliance with 42 CFR 483 Subpart B, 42 CFR 488.307, and National Fire Protection Association (NFPA) 101 (2012 Edition), NFPA 99 (2012 Edition) requirements for nursing homes. Initial Plan Review. 1994 Existing NFPA 220 Construction Type: II (111) Number of beds: 151 Census: 122 The following is a description of the noncompliance. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. [Repeated sections with placeholders such as [R] and incomplete dates are included as in the original text.]
Failure to Maintain Emergency Generator Control Board
Penalty
Summary
The facility failed to maintain the emergency generator as required by NFPA standards. During a document review, it was found that the annual planned maintenance inspection report for the 35 kW generator indicated that the unit's main control board needed to be replaced to prevent a possible no start condition. However, there was no documentation available to show that this issue had been corrected. This deficiency was confirmed during an interview with the maintenance supervisor, who acknowledged the lack of corrective documentation for the emergency generator. The report specifically notes that this failure affected one of two generators at the facility, and the required maintenance action was not completed or recorded as resolved.
Plan Of Correction
The systematic change will be to contact vendor to get the unit main control board replaced. The Director of Maintenance will monitor service needs to generator and have vendor repair onsite as needed. The Director of Maintenance will report this findings to the Administrator and Monthly Quality Assurance meeting.
Failure to Maintain Emergency Generator Annunciator Panel
Penalty
Summary
The facility failed to maintain the emergency generator system as required by NFPA standards. During an observation on July 30, 2025, at 11:50 a.m., it was found that the annunciator panel, located at the first floor Nurses Station, was not supplied with electricity and did not function when tested. This panel is a critical component for monitoring the status of the emergency generator system. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. The lack of a functioning annunciator panel affected the entire facility, as it compromised the ability to monitor and respond to emergency power needs as outlined in regulatory requirements.
Plan Of Correction
Vendor out on 8/13/25 to replace annunciator panel. Maintenance director was reeducated by NHA/Designee on K0918 with focus on proper maintenance of emergency generator. Maintenance director/designee will monitor the monthly generator log for four months to ensure compliance. Results of the audits to be reviewed at the QAA committee to determine the need for further follow-up/monitoring.
Failure to Document Emergency Generator Maintenance and Testing
Penalty
Summary
The facility failed to provide documentation verifying that weekly inspections, monthly testing, and annual testing of the emergency generator were conducted within the previous twelve months. During a document review, surveyors were unable to locate records confirming that these required maintenance and testing activities had taken place as specified by NFPA 101, NFPA 110, and related standards. An interview with the Administrator confirmed the absence of documentation for the emergency generator's weekly inspections, monthly testing, and annual testing for the past year. This lack of records affected the entire emergency electrical system component, as there was no evidence to demonstrate compliance with the required maintenance and testing protocols.
Plan Of Correction
1) The facility cannot retroactively complete an annual, monthly, and weekly generator check. 2) The weekly generator check was completed, the monthly generator check was completed, and the annual generator was completed by Penn Power on 8/8/2025. Records were placed in the life safety binder. 3) The maintenance director was re-educated on monthly, weekly, and annual generator inspections. 4) The NHA or designee will conduct a quarterly audit for 1 year monthly, then for 3 years, to ensure generator inspections are completed. The results will be submitted to the QAPI committee for review and analysis of the need for continued monitoring.
Failure to Document Four-Hour Emergency Generator Load Test
Penalty
Summary
The facility failed to provide documentation that its emergency generator underwent a required four-hour continuous load test within the past 36 months, as mandated by NFPA 110 standards. During the survey, the Administrator and DON were unable to produce written documentation of the most recent four-hour generator load test when requested. The Administrator indicated that the Maintenance Supervisor (MS) might have the documentation, but he was unavailable at the time due to being on vacation. Upon the MS's return, a generator service report dated 9/21/2021 was provided, which indicated that the emergency generator was tested for only 3 hours and 15 minutes, falling short of the required four-hour duration. No other documentation was available to demonstrate compliance with the four-hour continuous load test requirement within the last 36 months. The MS acknowledged the absence of a four-hour load test during an interview with the surveyor. The deficiency was identified through observation, interviews, and record review, and it affected all three smoke compartments of the facility. The lack of proper documentation and completion of the four-hour generator load test was confirmed by both administrative and maintenance staff during the survey process.
Plan Of Correction
has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be put into place to ensure that this deficiency does not recur: has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. On 07/28/2025, the Administrator provided a 1:1 in-service to the Maintenance Supervisor to ensure a continuous four-hour emergency generator load test is conducted every 36 months. The Maintenance Supervisor will conduct an annual maintenance record review to ensure a continuous four-hour emergency generator load test is conducted within 36 months. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025.
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