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: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0918
Based on document review and interview, it was determined the facility failed to maintain the emergency generators, affecting the entire facility.
Findings include:
1. Document review on January 24, 2024, at 9:30 a.m., revealed 5 of 12 monthly generator load tests were documented less than the required 30 minutes.
Exit Interview with the Maintenance Director on January 24, 2024, at 11:45 a.m., confirmed the partial load tests.
2. Document review on January 24, 2024, at 9:35 a.m., revealed the March 23, 2023, generator fuel quality report indicated Total Sulfur levels above the maximum allowable quantity. Evidence of corrective action/resampling was unavailable at time of survey.
Exit Interview with the Maintenance Director on January 24, 2024, at 11:45 a.m., confirmed the generator fuel deficiency.
| | Plan of Correction - To be completed: 02/13/2024
Staff have been reeducated on fuel testing and load bank testing requirements. A new fuel test was conducted on 2/1/2024 and results were released on 2/6/2024 showing the facility meets all the requirements. A monthly audit will be conducted to ensure load bank testing meets the time requirements for compliance.
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