Deficient Maintenance of Emergency Power System
Penalty
Summary
The facility failed to ensure that generators and their components, or other alternative power sources, were maintained as required by regulatory standards. During observations on two separate occasions, both generator annunciator panels displayed an illuminated "battery voltage" light, indicating a high voltage level. Despite this alert, the generator contractor was unable to determine the cause, although they confirmed that the battery levels were within normal range. This issue was identified through direct observation and interview with the Maintenance Director. The deficiency was noted because the facility did not meet the requirements for maintenance and testing of the essential electrical system, as outlined by NFPA standards. Specifically, the presence of the high voltage indicator on the generator annunciator panels was not resolved, and the underlying cause remained undetermined at the time of the survey. This failure could potentially affect all occupants in the event of a power failure, as the reliability of the emergency power system was not assured.
Plan Of Correction
Bay Bluffs maintains compliance with NFPA 101 requirements related to maintenance of emergency generator and other essential electrical systems. All residents and staff have the potential to be impacted if essential electrical systems are not functioning properly. On May 2, 2025, Cummins Bridgeway completed maintenance on the generator and attempted to complete work to address the generator battery voltage light on the annunciator panels. Unfortunately, due to a faulty panel, work could not be completed at that time. New panels were ordered, and a temporary waiver was requested of LARA on May 15, 2025, via email. On June 18, 2025, Cummins Bridgeway was able to complete repairs on the annunciator panels, which eliminated the error message on both panels and on the generator itself. Monitoring of the generator annunciator panels will take place during monthly safety rounds by the Plant Operations Director or designee. The Plant Operations Director is responsible for coordination and monitoring of this plan of correction.