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Based on record review and interview, this facility failed to test the emergency generator to either 30% of the nameplate rating or an annual load bank test. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator does not ensure proper operation and prompt repair and affected all occupants.

Findings Are:

Record review conducted on 05-25-16, at 10:40 a.m. of the facility's generator inspection, testing, and maintenance records revealed the documentation did not indicate the generator was tested monthly at 30% of the nameplate rating for at least 30 minutes with an additional cool-down period. The facility was also unable to provide evidence of an annual load bank test in lieu of the 30% monthly test.
The deficient practice was confirmed by Maintenance Staff A during interview at 10:42 a.m. on 05-25-16.

Record review of the following NFPA Standard revealed: Level 1 and level 2 Emergency Power Supply Sources (EPSS)s, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes using one of the following methods: Under operating temperature conditions or at not less than 30% of the EPS nameplate rating or loading that maintains the minimum exhaust temperatures as recommended by the manufacturer. 1999 NFPA 110, 6-4.1 and 6-4.2

Based on observation and interview, the facility allowed the installation of an alcohol based hand rub dispenser within the required separation distance from an ignition source. The deficient practice increased the potential of a fire from an adjacent ingnition source.

Findings Are:

Observation on 05-25-16, at 11:58 A.M., revealed an alcohol-based hand rub dispenser in the O.B. corridor that was installed directly above an electrical receptacle, which is an ignition source.

Interview with Maintenance "A" on 5-25-16 at 11:58 A.M. confirmed the findings

Based on record review and interview, this facility failed to test the emergency generator to either 30% of the nameplate rating or an annual load bank test. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator does not ensure proper operation and prompt repair and affected all occupants.

Findings Are:

Record review conducted on 05-25-16, at 10:40 a.m. of the facility's generator inspection, testing, and maintenance records revealed the documentation did not indicate the generator was tested monthly at 30% of the nameplate rating for at least 30 minutes with an additional cool-down period. The facility was also unable to provide evidence of an annual load bank test in lieu of the 30% monthly test.
The deficient practice was confirmed by Maintenance Staff A during interview at 10:42 a.m. on 05-25-16.

Record review of the following NFPA Standard revealed: Level 1 and level 2 Emergency Power Supply Sources (EPSS)s, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes using one of the following methods: Under operating temperature conditions or at not less than 30% of the EPS nameplate rating or loading that maintains the minimum exhaust temperatures as recommended by the manufacturer. 1999 NFPA 110, 6-4.1 and 6-4.2