Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect its emergency generator, which is crucial for the safety and operation of the entire facility. During a document review on December 23, 2024, it was found that the facility could not provide documentation for several required tests and inspections. These included weekly visual inspections, weekly battery electrolyte level or battery voltage checks, an annual 90-minute load bank test, a 3-year 4-hour load test, and an annual fuel quality test. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the absence of these critical documents. This lack of documentation indicates that the facility did not adhere to the necessary maintenance and testing protocols for its emergency generator, as outlined by NFPA standards. This deficiency affects the entire facility, as the generator is essential for maintaining power during emergencies.
Plan Of Correction
The generator will be visually inspected weekly. Battery voltage will be weekly inspected. Annual 90 min load bank and fuel quality has been completed. 3 year, 4 hour load test will be completed timely. Maintenance Dir/designee will re-educate maintenance staff on proper maintenance of the generator. NHA/designee will complete weekly audits x 3 and monthly audits x 1 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.