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 perform emergency generator maintenance and testing in three instances, affecting the entire facility.
Findings include:
Document review on July 20, 2026, revealed the facility lacked documentation for the following:
a) 9:15 a.m., Annual preventative maintenance;
b) 9:20 a.m., Annual load bank test;
c) 9:30 a.m., Annual fuel quality test.
Interview with the facility administrator on July 20, 2026, at 8:15 a.m., confirmed the annual generator testing documentation was unavailable at the time of the survey.
| | Plan of Correction - To be completed: 08/07/2026
1. The generator inspection vendor under contract with St. Anne Home did not respond timely to the facility after repeated calls to schedule an inspection for the cited areas. A contract with a new vendor was established by the Director of Plant Operations to inspect the Annual Preventative Maintenance Test, Annual Load Bank Test, and the Annual Fuel Quality Test.
2. The inspection for the Annual Preventative Maintenance Test, Annual Load Bank Test, and Annual Fuel Quality Test was scheduled for August 5 and 6 by the Director of Plant Operations.
3. The Nursing Home Administrator educated the Director of Plant Operations to obtain a back-up contract with another generator inspection vendor to prevent this situation from recurring.
4. The schedule for these facility annual tests with due dates for the tests will be reviewed by the Director of Plant Operations at the monthly QAPI meeting on 7/31/26, to add generator audits as a standing agenda item in the QAPI meetings.
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