Failure to Maintain Emergency Generator Documentation
Penalty
Summary
The facility failed to maintain the emergency generator as required, affecting the entire facility. During a document review, it was found that the facility did not provide documentation for several critical tests. These included the weekly visual inspection and battery voltage/electrolyte levels, the monthly 30-minute load run and transfer switch operation, and the annual fuel sample. This lack of documentation indicates that the facility did not perform or record these essential maintenance activities, which are crucial for ensuring the reliability of the emergency power system. An interview with the maintenance supervisor confirmed that the documentation for these tests was unavailable at the time of the survey. This deficiency suggests a lapse in the facility's adherence to the National Fire Protection Association (NFPA) standards, specifically NFPA 101, NFPA 110, and NFPA 111, which outline the requirements for maintaining and testing emergency power systems. The absence of these records raises concerns about the facility's ability to provide a reliable power source in emergencies, potentially impacting the safety and well-being of residents.
Plan Of Correction
Weekly visual inspection and battery voltage/electrolyte levels and a monthly 30-minute load run and transfer switch operation was completed February 5, 2025. The annual fuel sample was taken January 30, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025 regarding the requirement for weekly visual inspection and battery voltage/electrolyte levels and a monthly 30-minute load run and transfer switch operation of the emergency generator, as well as an annual fuel sample. An audit will be conducted by the Maintenance Director to ensure that weekly visual inspection and battery voltage/electrolyte levels and a monthly 30-minute load run and transfer switch operation of the emergency generator, as well as an annual fuel sample is completed. A weekly audit will be conducted for visual inspection and battery voltage/electrolyte levels and a monthly audit will be conducted for 4 months for a 30-minute load run and transfer switch operation of the emergency generator. An annual audit will be conducted to ensure that a fuel sample is completed. These audits will be monitored by the Administrator. Results of the audits will be presented at the quarterly QAPI meeting and recommendations will be implemented.