Failure to Perform and Document Annual Fuel Quality Testing for Emergency Generators
Penalty
Summary
The facility failed to maintain the Emergency Power Supply System (EPSS) as required by NFPA 101 and NFPA 110 standards. During a facility tour, record review, and interviews with facility leadership, it was found that documentation was not provided to show that a fuel quality test had been performed at least annually on the 200-kilowatt diesel generator for the subacute area and the 125-kilowatt diesel generator for the annex building. The last available documentation for the subacute generator was from nearly two years prior, and no current or previous year's report was provided by the deadline set by surveyors. The Plant Operations Manager stated that a recent fuel quality test had been performed, but the report was not available for review at the time of the survey. This deficiency affected all 59 residents and four smoke compartments within the facility. The lack of current fuel quality testing documentation could impact the operational reliability of the emergency power system. This issue had also been previously cited during a prior Life Safety Code Recertification Survey, indicating a repeated failure to comply with required maintenance and testing protocols for the facility's emergency generators.
Plan Of Correction
The contracted company to take samples for fuel quality testing on 5/15/25. The Director of Plant Operations contacted the company for the results. Both generators will be tested for fuel quality on an annual basis. Action plans are generated with findings and deadlines for completion. The Plant Operations Manager or qualified designee will be maintaining the record of preventive maintenance of the electrical system, including the generator fuel quality test. The Director of Plant Operations will do a random record review and inspection of the process at least annually or as needed to check compliance. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.