Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the generator set as required, which was evidenced by the lack of weekly battery voltage readings. This deficiency was observed during a documentation review and interview process, affecting both floors of the facility. The absence of these readings indicates a failure to comply with the maintenance and testing protocols outlined in NFPA 101 and NFPA 110, which require regular inspections and testing to ensure the generator's functionality. During an observation on December 10, 2024, at 11:28 a.m., it was noted that the facility did not have the necessary documentation for weekly battery voltage readings. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager later that day. The lack of these readings suggests that the facility did not adhere to the required maintenance schedule, potentially impacting the reliability of the emergency power system.
Plan Of Correction
- Unable to correct missing generator battery voltage readings. - Battery voltage reading will be conducted weekly. - Maintenance Director will be educated on generator battery voltage readings and documentation of same. - Generator battery voltage readings will be audited monthly by maintenance director/designee to ensure voltage is accurate and documented. Trends will be reviewed at QAPI meeting monthly.