Failure to Conduct Required Four-Hour Generator Load Test
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 and NFPA 110 requirements for emergency power systems by not conducting the required four-hour load test on its 15-kilowatt propane generator. During a facility tour, surveyors requested and reviewed generator testing records and found that there was no documentation of a four-hour load test, as required to be performed at least once every 36 months. Instead, only records of two-hour load tests were available for review. The Environmental Supervisor confirmed during an interview that the vendor had only conducted two-hour load tests for the generator. This deficiency affected all 35 residents in the facility and both smoke compartments, as the generator is responsible for supplying essential electrical service in the event of a power outage. The lack of a four-hour load test could result in the malfunction of the emergency generator, as the facility could not demonstrate that the generator would operate under load for the required duration. No specific medical history or condition of the residents was mentioned in the report.
Plan Of Correction
Corrective Action: The facility conducted the 4-hour load test for the 15-kilowatt propane generator on 06/12/2025. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: The four-hour load test for the 15-kilowatt propane generator will be done every 3 years by the facility. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of Correction: 06/12/2025