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Based on record review and staff interview, the facility failed to inspect the emergency electrical system (EES) main and feeder breakers annually, and failed to exercise these circuit breakers periodically. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 5/7/24 at 11:19 am revealed documentation was not provided to verify emergency electrical system (EES) main and feeder circuit breakers were inspected annually and exercised periodically.

In an interview on 5/7/24 at 11:19 am, Maintenance A confirmed the testing was not documented, but stated majority of the breakers are exercised monthly to start generator testing.

NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.

Based on record review and staff interview, the facility failed to conduct fire drills under varying times and conditions. This practice did not provide training for staff to respond to a fire emergency during various activities and staffing levels.

Findings are:

Record review on 5/7/24 at 11:07 am of fire drills revealed:
1. Fire drill times were not varied by one hour for the 1st shift in 2023: 1/24 at 1:45 pm, 4/18 at 2:05 pm, 6/12 at 10:05 am, 10/20 at 1:25 pm and 12/8 at 10:30 am.
2. Fire drill times were not varied by one hour for the 2nd shift in 2023: 1/31 at 11:05 pm, 3/23 at 8:10 pm, 5/10 10:15 pm, 9/13 at 8:35 pm.

In an interview on 5/7/24 at 11:07 am, Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to inspect the emergency electrical system (EES) main and feeder breakers annually, and failed to exercise these circuit breakers periodically. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 5/7/24 at 11:19 am revealed documentation was not provided to verify emergency electrical system (EES) main and feeder circuit breakers were inspected annually and exercised periodically.

In an interview on 5/7/24 at 11:19 am, Maintenance A confirmed the testing was not documented, but stated majority of the breakers are exercised monthly to start generator testing.

NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.