Failure to Maintain and Test Emergency Power Supply System
Summary
The facility failed to maintain its Emergency Power Supply System (EPSS) as required by NFPA 101, NFPA 110, and related standards. Specifically, the facility did not conduct the required weekly visual inspections for both its 10-kW and 25-kW propane generators, missing 10 out of 52 inspections for each generator. Additionally, the facility did not perform three of the required 12 monthly load tests for each generator, with missing records for March, April, and September of the specified year. Staff interviewed during the survey were unable to confirm whether these inspections and tests had been completed, citing lack of employment at the facility during the relevant periods and uncertainty regarding missing records. The facility also failed to conduct three of the required 12 monthly conductance tests for the batteries of both generators, with missing documentation for the same months as the load tests. Staff were again unable to verify if these tests had been performed, and no explanation was provided for the missing records. Furthermore, the facility did not provide evidence of having conducted the mandatory four-hour load tests for either generator, which are required every three years. The date of the last such test was unknown, and no records were submitted by the deadline given by surveyors. These deficiencies affected all 92 residents and all six smoke compartments in the facility. The lack of required inspections, testing, and documentation for the emergency generators and their batteries was confirmed through document review, staff interviews, and the absence of records during the survey. No information was provided regarding the medical history or condition of individual residents at the time of the deficiency.
Plan Of Correction
K 918 - Essential Electrical Systems How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Finding 1: On 3/18/25, the current EVS Director performed and documented a visual inspection of the 10kW generator to confirm it is functional. No issues were found. • Finding 2: On 3/20/25, the EVS Director inspected the 25kW generator. No issues were found. • Finding 3: Load test completed on 10kW generator on 3/28/25. • Finding 4: Load test completed on 25kW generator on 3/28/25. • Finding 5: Conductance test completed for 10kW generator on 3/18/25; batteries confirmed to be within operational parameters. • Finding 6: Conductance test completed for 25kW generator on 3/20/25; batteries confirmed to be within operational parameters. • Finding 7: Facility contracted with vendor to conduct 4-hour load test for the 10kW generator on 1/8/25. • Finding 8: Facility contracted with vendor to conduct 4-hour load test for the 25kW generator on 1/8/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected. The EVS Director conducted a full generator inspection on 3/18/25 to verify the emergency power system's functionality. No other issues were identified. The EVS Director conducted an additional inspection on 3/27/25 to verify the emergency power system's functionality. No other issues were identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • EVS Director will conduct a weekly non-load test for both the 10kW and 25kW generators. • EVS Director will conduct a monthly load test for both the 10kW and 25kW generators. • EVS Director will conduct battery conductance tests on both the 10kW and 25kW generators. • Our vendor will conduct a 4-hour load test for both the 10kW and 25kW generators. • A new EVS Director has been hired, and we will continue to monitor and support ongoing compliance. • The EVS Director was trained by the administrator on 3/9/25 on the importance of proper testing, documentation, and reporting of generator inspections and load tests. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • EVS Director will conduct weekly and monthly tests for both the 10kW and 25kW generators. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance: 4/18/25 K 919 Electrical Equipment - Other How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • The circuit breaker filler plate was ordered on 3/31/25 and is scheduled to arrive 4/10/25. • The missing cover for the breaker space labeled "24" will be replaced on the arrival of the breaker cover by 4/11/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: • EVS director conducted a facility-wide inspection on 3/19/25 of all electrical breaker panels to ensure all available spaces are sealed and covered properly. • Did not find any other open breaker slots. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • The facility will conduct quarterly inspections of all electrical panels and wiring to ensure compliance. These inspections will be documented, and corrective actions will be taken as necessary.
Penalty
Surveyors found that the facility failed to maintain required documentation showing that its three generators were tested monthly and inspected and tested annually in accordance with NFPA 99 and NFPA 110. Despite multiple requests, no records of these tests or inspections were provided. During the facility tour, surveyors also observed that none of the three generators were equipped with remote manual stop buttons, and this was confirmed by the Maintenance Director. This deficient practice had the potential to affect all residents in the facility.
The facility did not complete the required four-hour load bank test of its diesel generator within the mandated 36-month period and failed to properly document engine hours during monthly tests, as confirmed by the Maintenance Director. This lapse affected the reliability of the essential electrical system for all residents.
Failure to Maintain and Document Required Generator Testing and Safety Features
Penalty
Summary
Surveyors identified a deficiency related to the testing and maintenance of the facility’s essential electrical system and generators. During record review, they found no documentation to verify that the facility’s three generators were tested monthly as required by NFPA 99 and NFPA 110. Additionally, there was no documentation provided to show that the three generators were inspected and tested annually as required by code. Documentation of these tests and inspections was requested at the entrance conference and again later in the morning, but no records were produced by the time of survey exit. During the physical tour of the facility, surveyors observed that none of the three generators had remote manual stop buttons. An interview with the Maintenance Director confirmed the absence of these remote manual stop buttons at the time of observation. These findings were determined to be out of compliance with NFPA 99 – 2012 Edition, Section 6.4.4 through 6.5.4.2 and NFPA 110 – 2010 Edition 5.6.5, and the deficient practice had the potential to affect all 69 residents in the facility.
Plan Of Correction
1.Based on record review, observation, and staff interview, no residents experienced negative outcomes related to the facility's failure to test and maintain the essential electrical system in accordance with NFPA requirements. Findings identified during the survey included: • The facility failed to provide documentation verifying that the three generators were tested monthly as required. • The facility failed to provide documentation verifying that the three generators were inspected and tested annually as required. • During observation on 03/25/2026, it was identified that the facility's three generators did not have remote manual stop buttons installed. 2.The Medical Director was notified by LNHA on 03/26/2026 of the deficiency, including failure to perform and document required generator testing, lack of annual inspection documentation, and absence of required remote manual stop devices. 3.Generator system inspection, testing, and maintenance will be completed by a contracted generator service provider and/or Maintenance Director/designee on or before 04/30/2026. Corrective actions will include: • Completion of monthly generator testing under load conditions, including verification of automatic transfer within 10 seconds. • Completion of annual generator inspection and testing, including full system evaluation in accordance with NFPA 110 requirements. • Installation of remote manual stop buttons for all three generators in accordance with code requirements. • Verification that all generator components, transfer switches, and associated equipment are functioning properly. • Establishment of a comprehensive generator testing and maintenance program, including weekly inspections, monthly load testing (20–40 day intervals), and required periodic extended testing. • All generator testing, inspection, and maintenance activities will be placed on an automatically recurring schedule by Administrator/designee on or before 04/30/2026. Documentation logs will be implemented and maintained onsite. 4.Documentation of all generator inspections, testing, and maintenance will be maintained onsite and readily available. The Maintenance Director/designee will conduct weekly and monthly audits to ensure compliance with NFPA 99 and NFPA 110 requirements. Compliance will be reviewed in QAPI every quarter and as needed to ensure ongoing systemic compliance 5.LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining the facility's generators, including inspection and testing.
Failure to Complete Required Generator Load Bank Testing and Documentation
Penalty
Summary
The facility failed to maintain its diesel generator in accordance with NFPA 110-2010 requirements. During a review of the life safety documentation, it was found that the last four-hour load bank test of the generator had not been completed within the required 36-month interval, with the most recent test occurring several years prior. Additionally, the monthly test records did not document the engine hours as required, instead only noting the start and end times of the test. These findings were confirmed by the Maintenance Director, who was unaware of the specific requirements for generator testing and documentation. This deficiency had the potential to affect all 46 residents in the facility, as the generator is a critical component of the essential electrical system. The lack of proper testing and documentation means the facility could not ensure the generator's reliability in supplying emergency power within the required timeframe, as outlined by NFPA 110 standards. No specific resident medical histories or conditions were mentioned in relation to this deficiency.
Plan Of Correction
K918 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that the 4-hour 36-month load test was completed on the generator and written record of maintenance and testing was logged incorrectly. Step 1: Facility Administrator obtained the 4-hour bank test documentation from 6/9/2023. Step 2: NHA audited the generator testing log for the time meter reading—start and end—ensuring that it would include hours of the engine, not the test start and end time. Maintenance Director corrected log entry for the month of July 2025. Step 3: NHA educated Maintenance Director on the correct way to log generator testing entries 7/15/25.
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