Failure to Maintain Emergency Generator Testing
Penalty
Summary
The facility failed to maintain the required testing of emergency generator components, specifically affecting one generator. During a document review on December 3, 2024, it was discovered that the facility did not have verifying documentation for monthly battery conductance testing and the 3-year 4-hour load test. These tests are essential to ensure the generator's capability to supply service within 10 seconds, as required by NFPA standards. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation. This lack of documentation indicates that the facility did not adhere to the maintenance and testing protocols outlined in NFPA 101, NFPA 110, and NFPA 111, which are critical for the proper functioning of the emergency power systems in the facility.
Plan Of Correction
Monthly battery conductance testing completed. 3 year 4 hour generator load test completed. Maintenance staff educated that a 3 year 4 hour load test must be completed on the generator. Maintenance will schedule the next 3yr 4 hour load test with vendor immediately following the completion of load test.