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Based on record review and staff interview the facility failed to assure the generator is properly tested under load monthly. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all patients in 11 of 11 smoke zones on 5 level/floors . The facility has a capacity of 25 and a census of 6.

Findings Include:

During the survey conducted on 5/12/14 and 5/13/14 between 9:00 A.M. and 4:30 P.M. the following was observed:

1.) At approximately 11:07 A.M. on 5/12/14 it is discovered that the monthly load testing of the diesel generator is not with sufficient load to be within 30% of the 300 kilowatts on the data plate on the generator, nor has an annual load bank test been performed within the last 12 months.

2.) At approximately 11:30 A.M. on 5/12/14 it is discovered that the facility is unable to produce documentation of what life safety systems are powered by which of their two emergency generators.

The Plant Operations Supervisor and Plant Operations Specialist A were present and acknowledged the findings. The Plant Operations Supervisor indicated the generator is operated under load for 30 minutes monthly and logs indicate that the amperage has been less than required on all load tests. Immediately after reviewing the generator logs and determining that sufficient load capacities had not been reached nor had load bank testing been performed, the Surveyor contacted via telephone his immediate Field Supervisor with the KSFMO, who in turn contacted his supervisor, the [Chief of Fire Prevention Division] in Topeka, KS. After discussion with the Surveyors supervisors, the Surveyor indicated to the Plant Operations Supervisor the allegation of Immediate Jeopardy. After further discussion with his Field Supervisor via Telephone and Email, the Surveyor directed the Facility to draft up a document stating that the Facility would cease all surgeries until further notice by the KSFMO. Facility Staff immediately began to contact contractors and technicians and reported that Foley Equipment Co. was enroute at 4:00 P.M. on 5/12/14 to perform a load bank test on the diesel generator.

NFPA Standard: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110 Standard for Emergency and Standby Power Systems, Section 6 4.2.

Based on record review and staff interview the facility failed to assure the generator is properly tested under load monthly. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all patients in 11 of 11 smoke zones on 5 level/floors . The facility has a capacity of 25 and a census of 6.

Findings Include:

During the survey conducted on 5/12/14 and 5/13/14 between 9:00 A.M. and 4:30 P.M. the following was observed:

1.) At approximately 11:07 A.M. on 5/12/14 it is discovered that the monthly load testing of the diesel generator is not with sufficient load to be within 30% of the 300 kilowatts on the data plate on the generator, nor has an annual load bank test been performed within the last 12 months.

2.) At approximately 11:30 A.M. on 5/12/14 it is discovered that the facility is unable to produce documentation of what life safety systems are powered by which of their two emergency generators.

The Plant Operations Supervisor and Plant Operations Specialist A were present and acknowledged the findings. The Plant Operations Supervisor indicated the generator is operated under load for 30 minutes monthly and logs indicate that the amperage has been less than required on all load tests. Immediately after reviewing the generator logs and determining that sufficient load capacities had not been reached nor had load bank testing been performed, the Surveyor contacted via telephone his immediate Field Supervisor with the KSFMO, who in turn contacted his supervisor, the [Chief of Fire Prevention Division] in Topeka, KS. After discussion with the Surveyors supervisors, the Surveyor indicated to the Plant Operations Supervisor the allegation of Immediate Jeopardy. After further discussion with his Field Supervisor via Telephone and Email, the Surveyor directed the Facility to draft up a document stating that the Facility would cease all surgeries until further notice by the KSFMO. Facility Staff immediately began to contact contractors and technicians and reported that Foley Equipment Co. was enroute at 4:00 P.M. on 5/12/14 to perform a load bank test on the diesel generator.

NFPA Standard: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
1999 NFPA 110 Standard for Emergency and Standby Power Systems, Section 6 4.2.