Emergency Generator Maintenance Deficiencies
Penalty
Summary
The emergency generator at the facility was not properly maintained, as evidenced by several deficiencies identified during a Life Safety Code survey. The generator, which provides emergency backup power to all resident use floors and the basement, had undocumented monthly load tests and weekly checks. Additionally, there was no record of a four-hour continuous generator run within the last 36 months, and the main and feeder circuit breaker inspection was not completed annually. It was also unknown if the generator met 30 percent of its nameplate kilowatt rating during load tests, as required. Interviews revealed that the facility was without a Director of Plant Operations for a period in 2024, during which the responsibility for generator maintenance fell to the Administrator. However, the Administrator was unable to locate maintenance records for 2024, and the Director of Plant Operations from a sister facility, who assisted during this time, was not specifically assigned generator maintenance duties. The Director of Long Term Care Facilities mentioned that an outside contractor had postponed the circuit breaker inspection, and a new date had not been scheduled. The facility did not have a specific policy for generator maintenance but followed the manufacturer's instructions.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 Corrective Action for Affected Area: Load test was completed (MONTH) 29, 2025, and weekly visual inspections began week of (MONTH) 20, 2025. The generator is scheduled to be run under load for four continuous hours on (MONTH) 13, 2025; at this time, the load bank test will reach its 30% as listed on the name plate. Inspection of the main and feeder circuit breakers is scheduled for (MONTH) 20, 2025. All residents have the potential to be affected by the same deficient practice. Steps to prevent recurrence include weekly visual inspection of the generator, a 30-minute load test occurred (MONTH) 29, 2025, and will occur monthly. The generator is scheduled to be run under load for four continuous hours on (MONTH) 13, 2025. Inspection of the main and feeder circuit breakers is scheduled for (MONTH) 20, 2025. Steps to Prevent Recurrence: Weekly and monthly generator audit/log forms which include weekly inspection and monthly load are being utilized. Maintenance staff will be educated to ensure monthly generator load tests are completed and documented, weekly generator checks are completed and documented, the generator is run under load for four continuous hours every 36 months and documented, an annual load bank test is completed on the generator and documented, and main and feeder circuit breaker inspection is completed annually if the generator does meet 30 percent of its nameplate kilowatt rating during load tests. How Corrective Action Will be Monitored: The audits will be completed to ensure the generator is run under load for four continuous hours every 36 months and documented, an annual load bank test is completed on the generator and documented, and main and feeder circuit breaker inspection is completed annually if the generator does meet 30 percent of its nameplate kilowatt rating during load tests. Audits will be reviewed by Administration and reported to the Quality Assurance committee. The Plant Operations Director will be responsible to ensure compliance.