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Based Generator Log review, Generator policy and procedure review and interview it was determined there was no evidence one of one (Generator #4) generator serving Building 2 was run under load for 30 minutes each month beginning in May 2012 through 11/06/13. The failed practice had the potential to affect the health and safety of all patients, visitors, and staff because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 8 patients on 11/05/13. The findings follow:

A. Review of the Generator Logs on 11/06/13 at 1515 revealed missing monthly load test documentation as follows: On Generator #4, monthly load test documentation was missing between May 2012 and October 2013.
B. In an interview on 11/06/13 at 1540, the Safety/Emergency Management Director verified the missing monthly load test documentation and verified there was no further documentation available for review.
C. Review of the Maintenance Policy and Procedure Manual on 11/07/13 at 1000 revealed a policy. "Maintenance-Electrical Distribution System and Generator" that stated "a generator test will be performed under actual load and operating temperature conditions for at least 30 minutes monthly.

Based Generator Log review, Generator policy and procedure review and interview, it was determined there was no evidence three of three (#1-#3) generators serving Building 1 were run under load for 30 minutes each month beginning in May 2012 through 11/06/13. The failed practice had the potential to affect the health and safety of all patients, visitors, and staff because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 8 patients on 11/05/13. The findings follow:

A. Review of the Generator Logs on 11/06/13 at 1515 revealed missing monthly load test documentation as follows:
1) On Generator #1, monthly load test documentation was missing between January 2013 and September 2013. The generator was run for only 10 minutes on 10/02/13.
2) On Generator #2, monthly load test documentation was missing between January 2013 and September 2013. The generator was run for only 15 minutes on 10/17/13.
3) On Generator #3, monthly load test documentation was missing between March 2013 and September 2013. The generator was run for only 20 minutes on 10/07/13.
B. In an interview on 11/06/13 at 1540, the Safety/Emergency Management Director verified the missing monthly load test documentation and verified there was no further documentation available for review.
C. Review of the Maintenance Policy and Procedure Manual on 11/07/13 at 1000 revealed a policy. "Maintenance-Electrical Distribution System and Generator" that stated "a generator test will be performed under actual load and operating temperature conditions for at least 30 minutes monthly. "

Based Generator Log review, Generator policy and procedure review and interview it was determined there was no evidence one of one (Generator #4) generator serving Building 2 was run under load for 30 minutes each month beginning in May 2012 through 11/06/13. The failed practice had the potential to affect the health and safety of all patients, visitors, and staff because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 8 patients on 11/05/13. The findings follow:

A. Review of the Generator Logs on 11/06/13 at 1515 revealed missing monthly load test documentation as follows: On Generator #4, monthly load test documentation was missing between May 2012 and October 2013.
B. In an interview on 11/06/13 at 1540, the Safety/Emergency Management Director verified the missing monthly load test documentation and verified there was no further documentation available for review.
C. Review of the Maintenance Policy and Procedure Manual on 11/07/13 at 1000 revealed a policy. "Maintenance-Electrical Distribution System and Generator" that stated "a generator test will be performed under actual load and operating temperature conditions for at least 30 minutes monthly.

Based Generator Log review, Generator policy and procedure review and interview, it was determined there was no evidence three of three (#1-#3) generators serving Building 1 were run under load for 30 minutes each month beginning in May 2012 through 11/06/13. The failed practice had the potential to affect the health and safety of all patients, visitors, and staff because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 8 patients on 11/05/13. The findings follow:

A. Review of the Generator Logs on 11/06/13 at 1515 revealed missing monthly load test documentation as follows:
1) On Generator #1, monthly load test documentation was missing between January 2013 and September 2013. The generator was run for only 10 minutes on 10/02/13.
2) On Generator #2, monthly load test documentation was missing between January 2013 and September 2013. The generator was run for only 15 minutes on 10/17/13.
3) On Generator #3, monthly load test documentation was missing between March 2013 and September 2013. The generator was run for only 20 minutes on 10/07/13.
B. In an interview on 11/06/13 at 1540, the Safety/Emergency Management Director verified the missing monthly load test documentation and verified there was no further documentation available for review.
C. Review of the Maintenance Policy and Procedure Manual on 11/07/13 at 1000 revealed a policy. "Maintenance-Electrical Distribution System and Generator" that stated "a generator test will be performed under actual load and operating temperature conditions for at least 30 minutes monthly. "