Failure to Maintain and Document Essential Electrical System Testing
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 requirements, as evidenced by missing documentation and incomplete testing records. During a record review with the Regional Director of Plant Operations, surveyors found that there was no documentation for the required 1.5-hour load bank testing for 2024, nor was there evidence of monthly testing under a thirty percent load. This testing is necessary to ensure the generator can supply emergency power as required by regulation. Additionally, the facility did not provide documentation of weekly voltage checks for the two generator batteries. Regular monitoring of battery voltage is essential to confirm that the generator will function properly in the event of a power outage. The absence of these records indicates that the facility did not consistently monitor the generator batteries as required. Furthermore, there was no documentation of monthly conductance testing for the generator's two sealed batteries prior to 2025. Conductance testing is a standard procedure to assess the health and reliability of the batteries that support the emergency power system. The Regional Maintenance Director acknowledged these findings during the survey, and the deficiencies were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. An unannounced Fire & Life Safety Recertification survey was conducted on at Nspire Healthcare Tamarac, a nursing home in Tamarac, Florida. Nspire Healthcare Tamarac is not in compliance with 42 CFR 483 Subpart B, 42 CFR 488.307, and National Fire Protection Association (NFPA) 101 (2012 Edition), NFPA 99 (2012 Edition) requirements for nursing homes. Initial Plan Review. 1994 Existing NFPA 220 Construction Type: II (111) Number of beds: 151 Census: 122 The following is a description of the noncompliance. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. [Repeated sections with placeholders such as [R] and incomplete dates are included as in the original text.]