Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 Emergency Power and Standby Power Systems (2010 Edition), specifically Section 8.3.8. During a record review, it was discovered that the facility did not provide documentation of the annual fuel quality test for the diesel generator. This documentation was requested multiple times, including at the entrance conference, during the record review, and before the exit conference, but was not provided. An interview conducted on the same day confirmed the finding, with a staff member acknowledging the facility's inability to locate the missing documentation. This deficiency had the potential to affect all 131 residents in the facility, as the generator is a critical component of the facility's emergency power system.
Plan Of Correction
Element 1 This deficiency was corrected by performing the fuel quality test of the diesel generator. Element 2 This deficiency has the potential to affect all residents. Element 3 A Generator audit is being conducted by the Maintenance Director to ensure the facility remains in compliance with K918. This audit is being completed by reviewing the inspection book. Element 4 The Generator audit is being monitored by the Administrator or designee every three months for the next twelve months to ensure that this test is being performed annually. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for twelve months to the Quality Assurance Performance Improvement team for review and action as necessary.