Failure to Complete Required 30-Minute Generator Load Testing
Penalty
Summary
The facility failed to maintain compliance with essential electrical system maintenance and testing requirements as specified by NFPA 101 and related standards. During a review of records and interviews with the Administrator and Maintenance Director, it was found that the emergency generator was not exercised under load for the required 30 minutes each month. Instead, the generator was only tested under load for 20 minutes monthly, as indicated by the facility's "Emergency Generator Log." The Maintenance Director stated during the interview that they were unaware of the 30-minute requirement for the monthly load test. This deficiency affected all 93 residents in four smoke compartments, as the generator's operability during an emergency situation or fire could not be assured based on the incomplete testing. The findings were based solely on documentation and staff interviews, with no mention of any specific resident medical history or condition at the time of the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Environmental services director held a 30-minute load test on 6/26/25 with no negative findings. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All patients have the ability to be affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Environmental services director is required to test the generator backup system for 30 minutes each month, was given a 1:1 by the administrator on 6/26/25 explaining the 30-minute monthly requirement, and has agreed to perform the test each month for the full, required 30 minutes. How the facility plans to monitor its performance to make sure that solutions are sustained: Environmental services director will be responsible for scheduling and verifying all inspections are completed on a timely basis. Maintenance generator load testing log sheet will be brought to QA on a monthly basis for review until reaching 3 consecutive months with no concerns. Include dates when corrective action will be completed: Inspection completed 6/26/25.