Lack of Documentation for 4-Hour Emergency Generator Exercise
Penalty
Summary
The facility failed to provide documentation verifying that a continuous 4-hour exercise of the emergency generator had occurred within the previous 36 months. During a document review, surveyors were unable to locate records confirming that this required test had been completed as mandated by NFPA 110 standards. The absence of this documentation was confirmed during an interview with the Director of Maintenance, who acknowledged that there was no record available to demonstrate compliance with the 4-hour generator exercise requirement. This deficiency affects the entire emergency electrical system component, as the required maintenance and testing procedures are essential for ensuring the generator's reliability in supplying power during emergencies. The lack of documentation means there is no evidence that the generator's performance and endurance have been adequately tested within the specified timeframe.
Plan Of Correction
The 4-hour generator load test has been completed as of 7/2/25. The 4-hour generator load test will be conducted every 36 months. The 4-hour generator load test will be scheduled through the work order system to maintain compliance. The scheduled load tests will be monitored through the work order system for compliance and reported to QAPI as completed. An annual audit will be completed and filed in the Life Safety Book to ensure compliance. The completion date is 8/24/25.