Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918
Based on document review and interview, the facility failed to maintain, inspect, and test the essential electric system for one of one emergency generator.
Findings include:
Document review on March 18, 2025, at 9:38 a.m., revealed the annual fuel analysis report for the emergency generator, dated January 10, 2025, noted "Particle count results exceed acceptable limits."
Interview with the maintenance director on March 18, 2025, at 9:38 a.m., confirmed the annual fuel report noted the sample did not meet specifications for the emergency generator.
| | Plan of Correction - To be completed: 04/30/2025
Maintenance Director was educated on Generator Fuel Testing Protocol. Maintenance Director or designee will schedule a test to have fuel tank sample completed and cleaned. This process will be repeated until the fuel sample result is "normal". Maintenance Director or designee will continue to audit the generator fuel tank annually and will be recorded in TELS for annual compliance. Results of audits will be reported to quality assurance for review and recommendations.
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