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, it was determined the facility failed to maintain and inspect the emergency generator, affecting one of nine generator reports.
Findings include:
1. Document review on March 25, 2026, at 9:00 a.m., revealed the facility could not produce documentation of the 3-year, 4-hour load bank test.
Exit interview with the Administrator and Maintenance Director on March 25, 2026, at 12:30 p.m., confirmed that the lack of documentation.
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Based on an onsite revisit conducted on May 27, 2026, the following was determined:
Item 1 was not completed. The 3-year, 4-hour load test was not completed.
Exit interview with the Administrator and Maintenance Director on May 27, 2026, at 11:00 a.m., confirmed that item 1 was not completed.
| | Plan of Correction - To be completed: 06/15/2026
Plan of Correction:
1. A time limited waiver was submitted for repairs on April 9, 2026.
2. The facility will correct the identified concern. A qualified generator vendor will be scheduled to perform the required 36-month, 4-hour load bank test of the emergency generator in accordance with NFPA 110. A quote was received and accepted. The installation plan will be submitted to the Department of Health, Life Safety. Documentation of the completed test will be maintained on-site and readily available.
3. Systematic changes will be implemented to prevent recurrence. The facility established a life safety compliance calendar to track required generator testing, including weekly inspections, monthly load testing, and the 36-month, 4-hour load bank test. The Maintenance Director or designee will be responsible for scheduling required testing and maintaining documentation in the life safety compliance binder.
4. The Maintenance Director or designee will continue to review the generator testing log and life safety compliance calendar monthly for three months to ensure required testing is completed and documented. The log is ongoing.
5. The results of monitoring will be reviewed through the facility's QAPI program monthly for three months.
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