Lack of Four-Hour Generator Load Test Documentation
Penalty
Summary
The facility failed to provide documentation that its emergency generator underwent a required four-hour continuous exercise within the past 36 months. During an interview, the Administrator and Maintenance Supervisor were unable to produce written records of the most recent four-hour generator load test when requested by the surveyor. A review of the facility's generator service reports confirmed that there was no indication of a four-hour continuous exercise or test having been performed. Further inquiry with the Maintenance Supervisor and Regional Maintenance Director revealed that they could not locate any documented evidence that the generator had been tested continuously for at least four hours within the required timeframe. This deficiency affected all three smoke compartments in the facility, as the lack of proper generator testing could impact the emergency power system's reliability during a power loss.
Plan Of Correction
K918 Electrical Systems - Essential Electric Systems Correct Deficient Practice: On 03/10/2025, MS scheduled Bay City Electric to perform a four-hour continuous exercise under load condition on 04/08/2025. Identify Others: The deficient practice has the potential to affect all residents, staff, and visitors in the event of a power failure. Systemic Changes: In-service education was provided by the Administrator on 03/10/2025 to MS regarding NFPA 110 and Life Safety Code requirements to ensure the facility's generator is being tested appropriately. MS and the Administrator will create a yearly calendar for testing the generator. MS will perform the generator tests and complete the Mesa Glen Generator Testing Log on an as-needed basis to ensure the facility's generator is functioning appropriately. Monitoring: Findings and trends from inspection rounds will be brought to the Quarterly Safety Committee meeting by MS until the Safety Committee has determined compliance has been sustained. The facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/25