Failure to Document Four-Hour Emergency Generator Load Test
Penalty
Summary
The facility failed to provide documentation that its emergency generator underwent a required four-hour continuous load test within the past 36 months, as mandated by NFPA 110 standards. During the survey, the Administrator and DON were unable to produce written documentation of the most recent four-hour generator load test when requested. The Administrator indicated that the Maintenance Supervisor (MS) might have the documentation, but he was unavailable at the time due to being on vacation. Upon the MS's return, a generator service report dated 9/21/2021 was provided, which indicated that the emergency generator was tested for only 3 hours and 15 minutes, falling short of the required four-hour duration. No other documentation was available to demonstrate compliance with the four-hour continuous load test requirement within the last 36 months. The MS acknowledged the absence of a four-hour load test during an interview with the surveyor. The deficiency was identified through observation, interviews, and record review, and it affected all three smoke compartments of the facility. The lack of proper documentation and completion of the four-hour generator load test was confirmed by both administrative and maintenance staff during the survey process.
Plan Of Correction
has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be put into place to ensure that this deficiency does not recur: has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. On 07/28/2025, the Administrator provided a 1:1 in-service to the Maintenance Supervisor to ensure a continuous four-hour emergency generator load test is conducted every 36 months. The Maintenance Supervisor will conduct an annual maintenance record review to ensure a continuous four-hour emergency generator load test is conducted within 36 months. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025.