Failure to Perform Annual Emergency Generator Maintenance Testing
Penalty
Summary
The facility failed to perform the required emergency generator maintenance testing over the past 12 months. During a documentation review on January 28, 2025, it was discovered that the facility did not have records of an annual preventive maintenance (PM) test for the emergency generator. This lack of documentation indicates that the facility did not conduct the necessary testing to ensure the generator's functionality and compliance with NFPA standards. An interview with the Facility Administrator and Maintenance Director confirmed that the documentation for the annual generator testing was not available at the time of the survey. This deficiency highlights a lapse in the facility's adherence to the maintenance and testing protocols required for emergency power systems, as outlined by NFPA 101, NFPA 110, and NFPA 111 standards.
Plan Of Correction
The facility will perform emergency generator maintenance testing annually as required. The facility will schedule and complete annual emergency generator PM. Documentation of the PM will be stored and maintained by the facility. The administrator will audit emergency generator PM logs to ensure PM is being completed as required. Maintenance director will be educated on federal tag F0918.