Health inspection·December 2, 2021

Title 22 Article 6 Physical Plant 72641. Emergency Lighting and Power System, (e) Emergency generators shall be tested at least every 14 days under full load condition for a minimum of 30 minutes. (f) A written record of inspection, performance, exercising period and repair of the emergency electrical system shall be regularly maintained on the premises and available for inspection by the Department. On 11/9/2021, during a Life and Safety Code (LSC) Recertification survey the emergency and standby power systems (generator) procedures were evaluated. The facility failed to conduct and document testing of the emergency and standby power system (generator) under full load condition every 14 days for a minimum of 30 minutes and failed to conduct and document monthly testing. As a result, all residents residing in the facility were placed at risk of burns from fire. On 11/9/2021, at 11:20 a.m., during an interview, Director of Nursing (DON) stated the administrator (ADM) was not physically present in the facility but could be contacted by telephone. On 11/10/2021, at 8:42 p.m., during an interview and concurrent review of the Annual Generator Service/Inspection, ADM stated the last service was conducted on 7/27/2020. ADM was unable to provide documentation the emergency generator and its battery were tested monthly by Maintenance Supervisor (MS). ADM explained the facility’s MS left on 9/17/2021 and since then, nobody conducted routine inspection, testing, and maintenance of the emergency generator. On 11/10/2021, at 10 a.m., during an interview, ADM provided documentation of monthly generator load tests dated 2/26/2021 and 3/26/2021. ADM stated there was no other documentation of generator load testing and that there was no record of monthly battery testing. On 11/10/2021, at 11:18 a.m., during an interview, ADM confirmed since MS left the facility, there was no one in the facility knowledgeable or competent to conduct a test of the facility’s generator under load condition. During an interview with the IMS on 11/10/2021, at 11:50 a.m., he stated that he was not comfortable testing the emergency generator because he did not how to do it. On 11/10/2021, at 1:14 p.m., during an interview, ADM stated the generator provided power to every fourth light in the hallway, all red emergency outlets, and the kitchen refrigerator and freezer. ADM stated that in case of a power loss, all resident equipment that operates on electricity, would be plugged into the red emergency outlets. A review of the facility’s Emergency Preparedness Manual titled, “Inspection and Testing of Emergency Generators”, reviewed and approved on 2/5/2021, indicated “certification requirements NFPA 101 (00), Sec. 7.9.2.3 required that emergency generators be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Chapter 2 of NFPA 101 references the 1999 edition of NFPA 110. This facility follows those standards for installation, testing, and maintenance.”. On 11/10/2021, at 1:18 p.m., during an interview, ADM stated the facility did not have additional policies and procedures related to the emergency generator. A review of the National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 Edition, indicated that the generator set or other alternate power source and associated equipment shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. A review of the National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2012 Edition, indicated that routine maintenance and operational testing program of emergency and standby power systems (EPSS) shall be overseen by a properly instructed individual. EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer’s specifications. Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. The routine maintenance and operational testing program shall be overseen by a properly instructed individual. The facility failed to conduct and document testing of the emergency and standby power system (generator) under full load condition every 14 days for a minimum of 30 minutes and failed to conduct and document monthly testing. As a result, all residents residing in the facility were placed at risk of burns from fire. The above violation had a direct relationship to the health, safety, and security of all residents in the facility.