Failure to Conduct and Document Monthly Generator Load Test
Penalty
Summary
The facility failed to maintain the emergency power supply system as required by NFPA 101 and NFPA 110 standards. Specifically, the facility did not conduct the required monthly 30-minute load test of the emergency generator for one month, as evidenced by the absence of documentation for the test in August 2024. This deficiency was identified during a document review and interview with the Assistant Administrator and Maintenance Director, who confirmed that the facility was between Maintenance Directors at the time, resulting in the missed test. The generator in question is a 4 kilowatt gasoline-powered unit with a 25-gallon backup fuel supply. The lack of a monthly load test meant that the facility could not demonstrate that the generator and associated equipment were capable of supplying emergency power within the required 10 seconds, as stipulated by regulatory standards. The deficiency affected both smoke compartments and all 51 residents in the facility, as the emergency power system is essential for maintaining critical services during a loss of normal utility power. Surveyors found that the facility was unable to provide written records of the required monthly generator load test for the specified period. The absence of this documentation indicated non-compliance with the operational inspection and testing requirements outlined in NFPA 110, which mandates that emergency power supply systems be inspected weekly and exercised under load at least monthly. No issues were identified with the residents at the time of the survey, and the deficiency was limited to the failure to perform and document the required generator test.
Plan Of Correction
K 918 Ontario Grove Healthcare and Wellness Centre Plan of Correction for Life and Safety June 17, 2025 Submitted by: Belinda Busuego, RN DON Submitted on: 6/24/2025 Ontario Grove Healthcare & Wellness submits this response and Plan of Correction as part of the requirements under state and federal law. The Plan of Correction is submitted in accordance with specific regulatory requirements. It shall not be construed as admission of any alleged deficiency cited or any liability. The provider submits this plan of correction with the intention that it is inadmissible by any third party to any civil, criminal action or proceedings against the provider or its employees, agents, officers, directors, or stakeholders. The facility reserves the right to challenge the cited findings if at any time the provider determines that the disputed findings are relied upon in a manner adverse to the interests of the provider either by the governmental agencies or third parties. The facility desires that this plan of correction be considered the facility's allegation of compliance. "Preparation, submission and or execution of the Plan of Correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of Correction is prepared, submitted and/or executed solely because it is required by the provisions of federal and state law." K324 Cooking Facilities 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 6/17/2025, Maintenance Supervisor conducted the annual kitchen equipment inspection to ensure no malfunction of the fuel-fired kitchen cooking equipment in the kitchen. No issues identified. 2. How the facility will identify other residents having the potential to be affected by the same deficient and what corrective action will be taken. On 6/17/2025, Maintenance Supervisor conducted the annual kitchen equipment inspection to ensure no malfunction of the fuel-fired kitchen cooking equipment in the kitchen. No issues identified. 3. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. On 6/17/2025, Assistant Administrator conducted a one-to-one in-service with Maintenance Supervisor to ensure that the annual kitchen equipment inspection is conducted as required. Maintenance Supervisor will conduct annual kitchen appliance inspection to ensure that kitchen cooking equipment is functioning and protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. The Maintenance Supervisor will report identified issues to the Administrator or Assistant Administrator for corrective actions. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance process. Maintenance Supervisor will present kitchen inspection findings on QA&A meeting for further evaluation and recommendations for 3 months. 5. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance process. Maintenance Supervisor will present monthly load test results to the QA&A meeting for further evaluation and recommendations for 3 months.