Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the emergency generator as required, which affected the entire facility. During an observation on January 30, 2025, at 9:55 a.m., it was noted that the emergency generator annunciator panel located at the ground floor main entrance displayed a warning lamp illuminated with a "Not in Auto" trouble code. This indicates that the generator was not set to automatically engage in the event of a power failure, which is a critical requirement for ensuring the safety and functionality of the facility's essential electrical systems. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m. The failure to maintain the generator in a state of readiness as per the NFPA 101 and NFPA 110 standards, which require the generator to be capable of supplying service within 10 seconds, represents a significant oversight in the facility's maintenance protocols. This oversight could potentially compromise the facility's ability to provide continuous care and safety to its residents in the event of a power outage.
Plan Of Correction
Step 1 The emergency generator was reset to auto. Step 2 The maintenance team educated on the requirement to ensure that the emergency generator is set to auto to ensure that service can be automatically provided within 10 seconds as required. Step 3 The maintenance director will audit the generator setting weekly and ensure that the annunciator panel is set on auto. Findings will be reviewed during QAPI meeting.