Generator Documentation Deficiency
Penalty
Summary
The facility failed to meet the electrical system requirements for its generator, as evidenced by the absence of necessary documentation. During a document review and interview conducted on February 6, 2025, it was revealed that the facility could not provide annual generator documentation for a 90-minute load bank test and a fuel quality test. This deficiency was confirmed during an interview with the maintenance supervisor, who acknowledged the unavailability of the required documentation at the time of the survey. The generator and associated equipment are required to supply service within 10 seconds, and maintenance and testing must be performed in accordance with NFPA 110. The generator sets should be inspected weekly, exercised under load for 30 minutes 12 times a year, and exercised once every 36 months for 4 continuous hours. Additionally, written records of maintenance and testing must be maintained and readily available. The facility's failure to provide documentation for the 90-minute load bank test and fuel quality test indicates non-compliance with these requirements.
Plan Of Correction
The maintenance director provided supporting documentation to the inspector on 02/10/2025. The maintenance director contacted Cleveland Brothers and obtained copies of the documentation for the fuel quality testing completed. Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting.